INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 18, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, White Deer Run of York was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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709.53(a)(3) LICENSURE Records of Service
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a complete chronological listing of the various specific services provided to each individual.
The findings include:
Four inpatient records were reviewed for documentation of a record of service on April 18, 2013. The facility failed to document services as provided to the clients in one out of four inpatient client records, specifically # 4.
Client #4 was admitted to treatment on December 4, 2012 and discharged on December 18, 2012. Progress notes were completed for individual sessions occurring on 12/4/12, 12/12/12, and 12/18/12 as well as group sessions occurring on 12/12/12, 12/13/12, 12/17/12, and 12/18/12; however, none of these sessions were documented in the record of services.
The lack of documentation was confirmed with the facility director and regional director during the exit interview.
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Plan of Correction
To ensure a complete and accurate chronological listing of the serv ices provided to each individual, the facility will implement the following:
1) All clinical staff will be provided with training on the requirement to document record of services form in chronological order with each clinical service provided for each individual served. Training will be provided no later than May 1, 2013.
Responsible Party: Campus Director
2) Internal audits of open records will be conducted by the medical records technician on a weekly basis to verify that all services documented on progress notes are accurately documented on the record of service Audits will begin no later than May 18, 2013. Results of the audits will be provided to the Lead Counselor for timely correction of incomplete record of services. Responsible Party: Lead Counselor
3) Audits of a representative sample of closed charts will be conducted on a monthly basis by the Campus Director and Lead Counselor to verify proper documentation of the record of services. Responsible Party: Campus Director and Lead Counselor |
709.53(a)(5) LICENSURE Progress Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to document progress notes after each significant client contact in two of four client records.
The findings include:
Four inpatient client records were reviewed for documentation of progress notes on April 18, 2013. Progress notes completed after each significant client contact were required in all four client records reviewed. Client records # 2 and 3 did not include progress notes after each significant contact.
Client #2 was admitted to treatment on April 1, 2013 and was still active as of the date of inspection. According to the record of services, group sessions took place on 4/2/13, 4/4/13, 4/15/13, 4/16/13 and 4/17/13 and an individual session was conducted on 4/3/13; however, there were no corresponding progress notes for these sessions in client record #2.
Client #3 was admitted to treatment on February 7, 2013 and discharged on February 28, 2013. According to the record of services, group sessions took place on 2/18/13 and 2/20/13 and an individual session was conducted on 2/18/13; however, there were no corresponding progress notes for these sessions in client record #3.
The findings were reviewed with the facility director and regional director during the exit interview.
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Plan of Correction
To ensure that all significant client contacts are documented in a progress note for all individuals served, the facility will implement the following:
1) Clinical staff will be trained on the requirement to document significant client contacts to include group and individual counseling sessions within 24 hours of contact with the client. Training will be provided no later than May 20, 2013. Responsible Party: Campus Director
2) Internal audits of open records will be conducted by the medical records technician on a weekly basis to verify that all services documented on the record of service have a corresponding progress note in the chart. Each chart will be audited for a minimum of four group progress notes and one individual progress note in each seven day period. Audits will begin no later than May 18, 2013. Results of the audits will be provided to the Lead Counselor for timely correction of incomplete progress notes. Responsible Party: Lead Counselor
3) Audits of a representative sample of closed charts will be conducted on a monthly basis by the Campus Director and Lead Counselor to verify all significant client contacts reflected on the record of service have a corresponding progress note in the chart. Audits of closed charts will begin no later than June 5, 2013. Responsible Party: Campus Director and Lead Counselor |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on the review of inpatient client records and the facility's policies and procedures, the facility failed to document follow-ups in accordance with the facility's policies and procedures.
The findings include:
The facility ' s policy regarding follow-ups states:
If a client is referred to another agency, with client consent, the provider is contacted within 7 business days following the client ' s scheduled aftercare appointment.
Two inpatient client records were reviewed on April 18, 2013 for documentation of a follow-up. The facility failed to document follow-ups in accordance with the their policy in two out of two inpatient client records, specifically client records # 3 and 4.
Client #3 was admitted on February 7, 2013 and discharged on February 28, 2013. The client was referred to another agency, with an appointment date of March 12, 2013. As of the date of inspection there was no documentation of a follow-up call made for client #3.
Client #4 was admitted on December 4, 2012 and discharged on December 18, 2012. The client was referred to another agency, with an appointment date of December 26, 2012. As of the date of inspection there was no documentation of a follow-up call made for client #4.
The findings were confirmed with the regional director and facility director during the exit interview.
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Plan of Correction
To ensure full compliance with the company policy regarding follow ups, the facility will implement the following:
1) Clinical staff will be trained on the company follow up policy and thier responsibility to submit a follow up form to the Office Manager no later than the date of discharge to conduct the follow up contact.
2) The Office Manager will implement a system to include a complete list of all clients discharged from the program and the results of thier follow up contacts. The Office Manager will notify the Campus Director if a client has discharged in the last 24 hours and a follow up form was not received from the clinical staff. Campus Director will assist in obtaining the proper documentation from the clinical staff so that the follow up contact is made. System will be implemented no later than 5/18/2013. Responsible Party: Office Manager, Campus Director
3) Monthly internal audits will be conducted by the Campus Director to ensure follow up forms are present in all charts in accordance with company policy. Audits will begin no later than May 18, 2013. Responsible Party: Campus Director |