INITIAL COMMENTS
|
This report is a result of an unannounced inspection conducted on May 24, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, St. Joseph Institute, Inc. 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.
|
Plan of Correction
|
709.26(d)(5)(ii) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(ii) The individual shall be informed, by written copy, of their annual evaluation.
|
Observations
Based on a review of personnel records, the facility failed to document performance ratings on employees in accordance with facility policy and procedure.
The findings included:
An onsite inspection was conducted on May 24, 2011. At that time six employee records were reviewed. Several of the staff were recently hired but in the case of three of the staff in the sample, performance evaluations were required. Based on an interview with the Clinical Director, facility policy required that a probationary performance evaluation be documented at 90 days and then that performance evaluations be completed annually.
Personnel record # 2- this employee was hired on 11/3/10. The 90 day probationary performance evaluation was due by 2/3/2011. At the time of the review on 5/24/11 no 90 day probationary evaluation was documented.
Personnel record # 4- this employee was hired on 6/4/10. The 90 day probationary performance evaluation was due by 9/4/2010. At the time of the review on 5/24/11, documentation in the record contained an employee evaluation dated 12/7/10, well past the employee's 90 day anniversary.
Personnel record # 6- this employee was hired on 10/7/10. The 90 day probationary performance evaluation was due by 1/7/2011. At the time of the review on 5/24/11 no 90 day probationary evaluation was documented.
The findings were reviewed with the Clinical Director and were not disputed.
|
Plan of Correction
Facility policy will by revised by 06/30/11 to ensure that all annual performance evaluations will be completed by Dec 15 of each year, probationary performance evaluations will be completed 90 days after date of hire.
HR will audit personnel files on a monthly basis beginning 07/01/11 to ensure compliance with performance evaluations and will report any issues to the President and Clinical Director. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
|
Observations
Based on a review of client records and an interview with the Clinical Director, the facility failed to ensure that staff physicians signed verbal orders in each client record within 24 hours of calling them in as required by this regulation.
The findings included:
On May 24, 2011, an unannounced, onsite plan of correction follow up inspection was conducted and three full client records were reviewed. Each client record which contained documentation of verbal medication orders was required to have the prescribing physician's signature affixed within 24 hours of calling the order in for the client. In 2 of 3 applicable records, the physician failed to affix his/her signature within 24 hours of calling in an order. Specific findings are addressed below:
Client record #2 - This client was admitted on March 4, 2011. Verbal medication orders were documented in the record on March 4, 2011 but the physician's signature was not documented until March 9, 2011. A second verbal order was documented in this record on March 15, 2011 but the physician's signature was not documented until March 19, 2011.
Client record # 3 - This client was admitted on February 19, 2011. Verbal medication orders were documented in the record on February 20, 2011 but the physician's signature was not documented until February 27, 2011.
An interview was conducted with the Clinical Director who acknowledged that this has been an ongoing issue with the physician in question. The facility is in the process of recruiting a new physician. The findings were not disputed.
|
Plan of Correction
Nursing and Physician staff will be retrained by Clinical Director on this policy by 06/30/11. Clinical Director/Nursing staff will audit charts on a weekly basis to ensure compliance beginning 07/15/11. |
709.51(b)(2)(i) LICENSURE Client Orientation to Project
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(i) Project policies.
|
Observations
Based on the review of client records and an interview with the Clinical Director, the facility failed to document that client orientation occurred in accordance with written facility policy in four of four client records reviewed.
The findings included:
During the onsite inspection of May 24, 2011, four client records were reviewed for documentation of client orientation to the project. Page 134 of the facility manual contains a written policy and procedure which directs that staff are to review the orientation checklist with each client and that the client is then to sign the checklist document. The checklists were incomplete in four of four client records reviewed.
Client record # 1- The client was admitted on 5/5/11 . The required areas of the checklist on the orientation document in the client record were not checked off and no signature was affixed to the document as required by facility policy.
Client record # 2- The client was admitted on 3/4/11 .The required areas of the checklist on the orientation document in the client record were not checked off and no signature was affixed to the document as required by facility policy.
Client record # 3- The client was admitted on 2/19/11 . The required areas of the checklist on the orientation document in the client record were not checked off and no signature was affixed to the document as required by facility policy.
Client record # 4- The client was admitted on 5/9/11 . The required areas of the checklist on the orientation document in the client record were not checked off and no signature was affixed to the document as required by facility policy.
The findings were reviewed with the Clinical Director and were not disputed.
|
Plan of Correction
Client orientation policy and process to be revised by 06/30/11. Clinical Director will complete monthly chart audits to ensure compliance beginning 07/15/11. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
|
Observations
Based on the review of client records and an interview with the Clinical Director, the facility failed to document intake physicals examinations at intake as required by written facility policy in two of three client records.
The findings included:
Three client records were reviewed during the onsite inspection of May 24, 2011. Each was required by regulation and facility policy to include documentation of physical examinations.
.
Client record # 1 - This client was admitted on 5/5/11. The physical examination documented in the client record was not completed until 5/17/11.
Client record # 3 - This client was admitted on 2/19/11 and discharged on 3/21/11 . The physical examination documented in the client record was not completed until 2/27/11.
The findings were reviewed with the Clinical Director and were not disputed.
|
Plan of Correction
Physician staff to be retrained by Clinical Director on facility policy by 06/30/11. Clinical Director/Nursing staff will audit charts weekly to ensure compliance beginning 07/15/11. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on the review of client records, the facility failed to document the type and frequency of treatment in the individual treatment and rehabilitation plan in two of three client records.
The findings include:
Three client records were reviewed on May 24, 2011. The type and frequency of treatment was required in the individual treatment and rehabilitation plan in three client records. The facility did not document the type and frequency of treatment in the individual treatment and rehabilitation plan in two of three client records reviewed .
Record # 2- the client was admitted on 3/4/11 and discharged on 3/17/11. The treatment plan was formulated on 3/14/11. The type and frequency of treatment to be offered was not documented on the record at the time of the review.
Record # 3 - the client was admitted on 2/19/11 and discharged on 3/21/11. The treatment plan was formulated on 2/23/11. The treatment plan documented the type of treatment to be offered but no frequency was recorded on the treatment plan.
The findings were reviewed with the Clinical Director and she did not dispute them.
|
Plan of Correction
TCP form update to include prompt for type and frequency of services by 06/30/11. Clinical staff to be trained on process and charts to be audited monthly by clinical director by 07/15/11. |
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.
|
Observations
Based on the review of client records, and an interview with the facility director, the facility failed to document a record of service on each client in three of three client records.
The findings included:
Three client records were reviewed on May 24, 2011. Each of these records was required to include documentation of a record of services that contained a chronological listing (separate from progress notes) of the various specific services provided to the individual client.
Client record #1- The client was admitted on 5/5/11. At the time of the record review on May 24, 2011 no documentation of a record of services was on file.
Client record # 2 - The client was admitted on 3/4/11 and discharged on 3/17/11. At the time of the record review on May 24, 2011 no documentation of a record of services was on file.
Client record # 3- The client was admitted on 2/19/11 and discharged on 3/21/11. At the time of the record review on May 24, 2011 no documentation of a record of services was on file.
.
The Clinical Director was informed of the findings and was given the opportunity to produce the documentation. No documentation was located to verify compliance with this requirement.
|
Plan of Correction
Records of service to be implemented on 06/30/11. Staff to be trained on proper procedure and charts to by audited by clinical director by 07/15/11. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
|
Observations
Based on the review of client records, and an interview with the facility director, the facility failed to document a discharge summary on each discharged client in two of three client records.
The findings included:
Three client records were reviewed onsite on May 24, 2011. Two of these were closed records and required documentation of a discharge summary. Written facility policy requires that discharge summary documentation occur for each client within 7 days from discharge. Discharge summaries were not documented in two of two client records.
Client record # 2 - the client was admitted on 3/4/11 and discharged on 3/17/11. At the time of the record review on May 24, 2011 no documentation of a discharge summary was recorded as required by written facility policy.
Client record # 3- the client was admitted on 2/19/11 and discharged on 3/21/11. At the time of the record review on May 24, 2011 no documentation of a discharge summary was recorded as required by written facility policy.
The Clinical Director was informed of the findings and was given the opportunity to produce the documentation. No documentation that discharge summaries were completed could be located for these clients.
|
Plan of Correction
Discharge summary form to be revised and clinical director to train clinical staff on policy by 06/30/11. Monthly chart audits by clinical director to ensure compliance to begin 07/15/11. |
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.
|
Observations
Based on the review of client records, and an interview with the facility director, the facility failed to document follow up on each discharged client in one of two client records.
The findings included:
Three client records were reviewed onsite on May 24, 2011. Two of these were closed records and required documentation of follow up contacts. Written facility policy requires that follow up occur for each client within 7 days from discharge. Follow up was not documented in one of two client records.
Client record # 2 - the client was admitted on 3/4/11 and discharged on 3/17/11. At the time of the client record review on May 24, 2011 no documentation of follow up was recorded in the follow up log as required by written facility policy.
The Clinical Director was informed of the findings and was given the opportunity to produce the documentation. No documentation that follow up was completed could be located for this client.
|
Plan of Correction
Clinical staff to be retrained by clinical director on follow-up process by 06/30/11. Monthly audits by clinical director to ensure compliance to begin by 07/15/11. |