INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 19-21, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, St. Joseph's Institute 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 and a plan of correction is due on November 16, 2010.
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Plan of Correction
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704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on the review of the administrative manuals and a discussion with the Clinical Director, the facility failed to document an overall training plan for the current training year which identified topics, trainers and dates of proposed training.
The findings included:
The Clinical Director presented documentation of the facility training materials for the current training year during the onsite inspection. An assessment was documented. A list of proposed training topics was documented. No identification of proposed trainers or dates for training proposed were included as part of the text of the overall training plan. The Clinical director was in agreement that the materials requested were not available.
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Plan of Correction
The Project Director will develop a more specific overall plan to address facility training needs, based on the training assessment, that will include training subjects, trainers, and proposed dates of training for the training year. This will be completed by 11/30/10. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on the review of facility training logs and personnel records, and a discussion with the Clinical Director, the facility failed to document an individual annual training plan for each employee.
The findings included:
Six personnel records and the facility training manual were reviewed during the onsite inspection. Five personnel records were required to include documentation of training plans.
No individual training plan was documented in five of five personnel records reviewed. The findings were reviewed with the Clinical Director and she was in agreement that the documents in the employee record filed under the training section were, in fact, training logs and not an individual training plan specific to the needs of the employee. The agency training log included documentation of internal training received by each employee and contained training feedback forms. The individual personnel records contained a training section which had documentation of training received prior to employment with the facility. The training section of the personnel record also contained a running training log of the training received during employment at the facility which was current.
Employee # 1 was hired 5/1/05 but had no documentation of an individual training plan at the time of the personnel record inspection on 10/20/2010.
Employee # 3 was hired 6/22/10 but had no documentation of an individual training plan at the time of the personnel record inspection on 10/20/2010.
Employee # 4 was hired 5/1/05 but had no documentation of an individual training plan at the time of the personnel record inspection on 10/20/2010.
Employee # 5 was hired 3/1/10 but had no documentation of an individual training plan at the time of the personnel record inspection on 10/20/2010.
Employee # 6 was hired 8/12/10 but had no documentation of an individual training plan at the time of the personnel record inspection on 10/20/2010.
All findings were discussed with the Clinical Director throughout the course of the inspection and opportunity was provided to present additional information or documentation if it was available. The Clinical Director did not dispute the findings.
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Plan of Correction
A written individualized training plan will be developed for each employee by the Project Director. The ITP will identify subject areas and potential resources for training which meet the requirements for the employee's position and which relate to the employee's skill level and interest. It will be developed with input from the employee and will be reviewed annually. This will be completed by 12/15/10. Bimonthly personnel record audits will be performed by the Project Director to ensure compliance. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of the fire drill logs during the onsite licensing inspection, the facility failed to document the preparation by staff to utilize alternate exits during fire drills.
The findings included:
Fire drill documentation was on file from the time the facility began operation. The drills were documented monthly as required. The fire drill form did not contain any information about which exits were used at each fire drill so it was impossible to determine that alternate exits were being utilized. The exit routes used need to be documented in the fire drill record.
All findings were discussed with the Clinical Director throughout the course of the inspection and opportunity was provided to present additional information or documentation if it was available. The Clinical Director did not dispute the findings.
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Plan of Correction
Fire drill report form will be modified to include documentation of which exit routes were used.
Plant Manager will be instructed, by President, to ensure that routine exit routes are blocked off and that alternate routes are used and documented at times during fire drills. This will take place on or before 11/15/10.
Facility will show full compliance with this standard by 11/30/10.
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709.28(c)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of client records during the onsite inspection , the facility failed to adhere to the limitations on disclosures of client identifying information mandated at 4 Pa. Code subsection 255.5(b). There were also instances noted in client records of consents to release information signed by the client which did not clearly identify the specific information which was to be released.
The findings included:
Six client records were reviewed and documentation from the utilization review department was reviewed for an additional three clients . All disclosures of information made on any client served by the facility were required to adhere to the limitations established at 4 Pa. Code subsection 255.5(b). Each consent to release information form in each client record was required to identify the specific information which could be released with the consent of the client.
Record # 1 - Documentation of disclosures from the client record kept by the Utilization Review department indicated that information was released which discussed specific individual treatment issues including boundaries, medications prescribed, Spiritual beliefs and details of incidents which occurred at the facility. All of this information exceeded the parameters permitted by the regulation.
Record # 4 - Consents to release information to physicians who were treating the client were signed on May 27, 2010. These documents did not identify what specific information would be released to the treating physicians.
Record # 5- Consents to release information in the client record were documented on August 4, 2010 which did not identify the specific information to be released to the clients spouse . The information to be released was stated on the consent form only as "verbal communication" and did not identify specific components of the record which the client gave consent to release to the spouse. A second consent to release information dated the same day was to a friend and identified the specific information to be released only as "status on condition" for emergency purposes.
Record # 6- Consents to release information in the client record were documented which did not identify the specific information to be released. A consent to release information dated 8/18/10 to the client's spouse identified the specific information to be released only as " continued care and treatment". A consent to release information dated 8/18/10 to the client's physician identified the specific information to be released only as " continued care and treatment". A consent to release information dated 8/18/10 to the client's insurance payer identified the specific information to be released only as " continued care and treatment".
Record # 7- Documentation on the Utilization Review (UR) forms indicated that information regarding specific clinical aspects of the client's treatment were released to the insurance company paying for treatment. Specific components released included medications, family relationship history, employment history and cravings experienced .
Record # 7- Documentation of information released to the insurance company included specific topics discussed in a family treatment session, components of the client's family history and employment history.
Record # 8- Documentation included in the Utilization Review (UR) forms indicated that the information released to the insurance company included disclosures about the client's drugs of choice, the client's tendency toward violent /abusive behavior when using and clinical impressions of treatment staff.
The findings were reviewed with the Clinical Director and she was in agreement that they were accurate.
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Plan of Correction
The President will modify and revise the current consent forms to ensure that they are more "user-friendly". All patient care staff will be trained on Confidentiality by the Clinical Director and will demonstrate understanding of these regulations. This will take place by 11/30/10. Monthly chart audits will be completed by the Clinical Director to ensure compliance. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on the review of client records and a handbook issued to the client at intake, the facility failed to document that it informed clients of their rights as specified under this section of the regulations as required. These rights include: Retention of civil rights, non-discrimination on the basis of religion, gender, sexual orientation, ethnicity,etc., the right to inspect his/her client record and make corrections, the right to submit rebuttal information and appeal decisions limiting access to portions of the client record.
The findings included:
Six client records were reviewed. Each was required to include documentation that the client had been informed of his/her rights.
Record # 1 - The client was admitted on 9/16/10. No documentation was included in the client record or handbook which informed the client of his/her rights.
Record #2 - The client was admitted on 10/9/10. No documentation was included in the client record or handbook which informed the client of his/her rights.
Record # 3- The client was admitted on 10/7/10. No documentation was included in the client record or handbook which informed the client of his/her rights.
Record # 4 - The client was admitted on 5/26/10. No documentation was included in the client record or handbook which informed the client of his/her rights.
Record # 5- The client was admitted on 8/4/10. No documentation was included in the client record or handbook which informed the client of his/her rights.
Record # 6- The client was admitted on 8/18/10. No documentation was included in the client record or handbook which informed the client of his/her rights.
The findings were reviewed with the Clinical Director and she was in agreement that they were accurate.
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Plan of Correction
P&P to be modified and updated, Client Rights form to be modified, documentation of clients being informed of their rights will be added to the medical record ? Clinical Director will ensure completion of the process by 11/30/10. Documentation will be audited monthly to ensure compliance by 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.
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Observations
Based on the review of client records the facility failed to insure that the prescribing Doctor signed verbal medication orders in two client records within 24 hours as specified in agency policy and as required by this regulation .
The findings include:
Six client records were reviewed during the onsite inspection. The records were reviewed October 20 and 21, 2010. Two of the records reviewed contained documentation of verbal medication orders called in by the agency physician. Two of two applicable records failed to document the physician's signature within 24 hours of the verbal order.
Record # 1- This client was admitted on 9/16/10. The following verbal order dates and physician signature dates were documented in this record: A verbal order was telephoned in on 9/16/10 at 16:30. The physician signed and dated the order on 9/18/10 at 1200. A verbal order was telephoned in to nursing staff on 9/30/10 at 15:05. The physician signed for the order on 10/1/10 at 1600. A verbal order was telephoned in on 9/18/10 at 11:45. The physician signed the verbal order on 9/26/10 at 0900.
Record # 6 - This client was admitted on 8/18/10. The following verbal order dates and physician signature dates were documented in this record: A verbal order was telephoned in to nursing staff on 8/28/10 at 14:30. The physician signed for the order on 9/6/10 but the time was not recorded.
The findings were reviewed with the Clinical Director who agreed they were accurate.
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Plan of Correction
Nursing and Physician staff will be trained by Clinical Director on this policy by 11/30/10. Clinical Director will audit charts on a monthly basis to ensure compliance beginning 12/15/10. |
709.32(c)(1) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication.
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Observations
Based on the review of client records and the facility policy manual during the onsite inspection, the facility failed to document a policy describing how medications are to be administered. The facility also documented several medication errors in one client record reviewed in the sample.
The findings included:
The facility policy on medication administration was ambiguously written. The policy addressed both self administration of medication and staff administration of medication. In projects that permit the self-administration of drugs with abuse potential, there should be a written policy and procedure governing such activity. Project decisions to permit self-administration must be based on individual needs and be undertaken in a manner that complies with any laws and regulations applicable to such acts. The facility policy did not specify how self administration was to occur and instances where self administration would be permitted.
Six client records were reviewed. Four of these were clients who received prescribed medications. All six records documented supplements that clients were to be given as part of the holistic treatment regime practiced at the facility. Two of the four applicable records of clients who received prescribed medication were problematic. Specifics are listed below.
Record # 1 . This client was admitted on 9/16/10. The client was prescribed opiate medication and Valium. Documentation in the client record indicated that the client passed some of these pills to another client enrolled at the facility. The incident highlighted the need for a specific policy and procedure to insure that staff properly monitor how these medications are handled and administered.
Record # 5 - This client was admitted on 8/4/10. Documentation in the record indicated that the client was not given prescribed dosages of Librium at the recommended times . Specifically the following doses were omitted: 8/7/10 @ 17:15; 8/8/10 @ 07:45; 8/8/10 @ 13:45. Documentation in the record indicated that the client was given the wrong dosage of Paroxitine on 8/4/10 at 21:00 and on 8/5/10 at 07:45. The dose prescribed was 10 mg. but the client received 12.5 mg. on these occasions. The record also indicated that the client should have received Lexapro on these occasions instead of Paroxitene.
The findings were reviewed with the Clinical Director who agreed that they were accurate.
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Plan of Correction
All medication management policies will be reviewed and modified by 11/30/10 by Clinical Director. All Nursing and Clinical staff will be trained on the proper process by 12/15/10. Clinical Director will observe med passes on a weekly basis to ensure compliance with this regulation. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of client records, the facility failed to document personal histories which addressed family interrelationships, educational histories and sexual abuse histories in each record. Histories documented in the records were incomplete in six of six client records reviewed.
The findings included:
Six client records were reviewed on October 20 and 21, 2010. Each was required to include documentation of personal histories which addressed the clients' family history, sexual abuse history and education history.
Record # 1 - This client was admitted on 9/16/10. The documentation in the record failed to include details of the client's education such as the impact of drug and alcohol abuse issues on educational performance and educational goals. The history did not include comments as to whether the client had been sexually abused.
Record # 2. The client was admitted on 10/9/10. The record failed to include documentation of family interrelationships for both the family of origin and the current family constellation. Documentation in the record failed to include details of the client's education and the impact of substance abuse on educational performance and goals. The history did not include comments as to whether the client had been sexually abused.
Record # 3. The client was admitted on 10/7/10. The documentation in the record failed to include details of the client's education and the impact of substance abuse on educational performance and goals. The history did not include comments as to whether the client had been sexually abused. The record failed to document family interrelationships for both the family of origin and the current family constellation.
Record # 4 - The client was admitted on 5/26/10. The record failed to include documentation of family interrelationships for both the family of origin and the current family constellation. Documentation in the record failed to include details of the client's education and the impact of substance abuse issues on educational performance and goals. The history did not include comments as to whether the client had been sexually abused.
Client # 5 - The client was admitted on 8/4/10. The record failed to document family interrelationships for both the family of origin and the current family constellation The documentation in the record failed to include details of the client's education and the impact of substance abuse on educational performance and goals. The history did not include comments as to whether the client had been sexually abused.
Client # 6- The client was admitted on 8/18/10. The record failed to document family interrelationships for both the family of origin and the current family constellation. The history did not include comments as to whether the client had been sexually abused.
All findings were discussed with the Clinical Director throughout the course of the inspection and opportunity was provided to present additional information or documentation if it was available. The Clinical Director did not dispute the findings.
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Plan of Correction
Intake/Nursing/Clinical Assessment form will be revised and modified to include questions that specifically address: family dynamics, educational histories, and sexual history by Clinical Director by 11/30/10. Staff will be trained and revised assessment form will be implemented by 12/15/10 by Clinical Director.
Clinical Director will ensure ongoing compliance through monthly chart audits.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document psychosocial evaluations which provided a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation in five of six records reviewed.
The findings included:
Six client records were reviewed during the onsite licensing inspection of 10/21-29/2010. Each of the records was required to include documentation of a psychosocial evaluation which included a clear description of the client's presenting and underlying problems, client needs or problems that can or cannot be resolved through treatment or that might inhibit treatment, client assets and strengths, the potential or available client support systems, the client's preferred coping mechanisms, conclusions regarding the client's appearance, behavior and reactions during the intake process, and conclusions regarding the client's attitude toward and ability to participate in the treatment process. Specific findings are noted below for each record:
Record #1 - The client was admitted on 9/16/10. The psychosocial evaluation was completed in a timely manner in the record. The documentation in the psychosocial evaluation did not address the client's coping mechanisms and did not identify possible relationships, conditions and causes leading to the client's current situation in the clinical impressions of the counselor.
Record #3 - The client was admitted on 10/7/10. The psychosocial evaluation was completed in a timely manner in the record. The documentation in the psychosocial evaluation did not address the counselor's observations about the client's needs or strengths and did not identify possible relationships, conditions and causes leading to the client's current situation in the clinical impressions of the counselor.
Record #4 - The client was admitted on 5/26/10. The psychosocial evaluation was completed in a timely manner in the record. The documentation in the psychosocial evaluation did not address the client's support systems or the counselor's impressions of the client's treatment needs and did not identify possible relationships, conditions and causes leading to the client's current situation in the clinical impressions of the counselor.
Record #5 - The client was admitted on 8/4/10. The psychosocial evaluation was completed in a timely manner in the record. The documentation in the psychosocial evaluation did not address the client's coping mechanisms or the counselor's impression of the client's attitude toward treatment or strengths and did not identify possible relationships, conditions and causes leading to the client's current situation in the clinical impressions of the counselor.
Record #6 - The client was admitted on 8/18/10. The psychosocial evaluation was completed in a timely manner in the record. The documentation in the psychosocial evaluation did not address the client's coping mechanisms and did not identify possible relationships, conditions and causes leading to the client's current situation in the clinical impressions of the counselor. The documentation also failed to include the counselor's assessment of the client's strengths and attitude toward treatment.
All findings were discussed with the Clinical Director throughout the course of the inspection and opportunity was provided to present additional information or documentation if it was available. The Clinical Director did not dispute the findings.
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Plan of Correction
Clinical staff will be trained on proper documentation of the psychosocial evaluation by 11/30/10. Clinical Director will perform monthly chart audits to ensure compliance with this regulation. |
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.
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Observations
Based on the review of client records during the onsite inspection, the facility failed to document the type and frequency of the services to be provided to the client on the treatment plans in five of six records reviewed.
The findings included:
Six client records were reviewed during the onsite inspection. Each was required to document a treatment plan which identified the type and/or frequency of services to be provided to the client during their course of treatment at the facility.
Record # 2- The client was admitted on 10/9/10. The treatment plan was formulated on 10/9/10. The treatment plan documented in the record failed to document the frequency of the services to be provided to the client.
Record # 3- The client was admitted on 10/7/10. The treatment plan was formulated on 10/7/10. The treatment plan documented in the record failed to document the frequency of the services to be provided to the client.
Record # 4- The client was admitted on 5/26/10. The treatment plan was formulated on 5/27/10. The treatment plan documented in the record failed to document the type or frequency of the services to be provided to the client.
Record # 5- The client was admitted on 8/4/10. The treatment plan was formulated on 8/6/10. The treatment plan documented in the record failed to document the type or frequency of the services to be provided to the client.
Record # 6- The client was admitted on 8/18/10. The treatment plan was formulated on 8/18/10. The treatment plan documented in the record failed to document the type or frequency of the services to be provided to the client.
All findings were discussed with the Clinical Director throughout the course of the inspection and opportunity was provided to present additional information or documentation if it was available. The Clinical Director did not dispute the findings.
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Plan of Correction
Clinical Director will train clinical staff to ensure that documentation of type and frequency of services are included consistently on the treatment plan. This will occur by 11/30/10 and will be monitored by monthly chart audits performed by the Clinical Director. |
709.53(a)(8) LICENSURE Case Consultation 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:
(8) Case consultation notes.
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Observations
Based on a review of the client records, the facility manual and a discussion with the clinical director, the facility failed to document case consultations in accordance with stated facility policy and procedure in six of six applicable records reviewed.
The findings included:
The procedure stated in the facility manual indicated that case consultations would be documented weekly for each client. Six records were applicable for this requirement. None of the six records had documentation of case consultations.
Record # 1- The client was admitted on 9/16/10. Record reviews were conducted on October 20 and 21, 2010. No case consultations were documented in the record at the time of the review.
Record # 2- The client was admitted on 10/9/10. Record reviews were conducted on October 20 and 21, 2010. No case consultations were documented in the record at the time of the review.
Record # 3- The client was admitted on 10/7/10. Record reviews were conducted on October 20 and 21, 2010. No case consultations were documented in the record at the time of the review.
Record # 4- The client was admitted on 5/26/10. Record reviews were conducted on October 20 and 21, 2010. No case consultations were documented in the record at the time of the review.
Record # 5- The client was admitted on 8/4/10. Record reviews were conducted on October 20 and 21, 2010. No case consultations were documented in the record at the time of the review.
Record # 6- The client was admitted on 8/18/10. Record reviews were conducted on October 20 and 21, 2010. No case consultations were documented in the record at the time of the review.
All findings were discussed with the Clinical Director throughout the course of the inspection and opportunity was provided to present additional information or documentation if it was available. The Clinical Director did not dispute the findings.
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Plan of Correction
Clinical Director will create a form to document case consultations and will train all patient care staff by 11/15/10. Monthly chart audits will be completed by the Clinical Director to ensure compliance with this process. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records and a discussion with the clinical director, the facility failed to document aftercare plans which identified timeframes for the completion of each goal and a statement on the process for re-entry into the program should the client be in need of further services in two of three applicable records.
The findings included:
Six client records were reviewed on October 20 and 21, 2010. Three client records were discharged clients and were required to include documentation of after care plans which included: the client's future goals with time frames, a description of the services that can be provided by the project after discharge, the method and frequency of continuing contact to provide client support, criteria for re-entry into the project, provision for the periodic re-evaluation and termination of the plan.
Record # 5-The client was admitted on 8/4/10 and discharged on 9/11/10. The aftercare plan on file in the client record did not include documentation of timeframes for each of the stated goals or the process for reentry into the project if needed.
Record # 6-The client was admitted on 8/18/10 and discharged on 9/17/10. The aftercare plan on file in the client record did not include documentation of timeframes for each of the stated goals or the process for reentry into the project if needed
All findings were discussed with the Clinical Director throughout the course of the inspection and opportunity was provided to present additional information or documentation if it was available. The Clinical Director did not dispute the findings.
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Plan of Correction
Aftercare plan form will be modified by Clinical Director to include timeframes for stated goals and the process for re-entry into the program. Modification and staff training to be completed by 11/30/10.
Clinical Director to audit charts monthly to ensure compliance. |
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 client records and the facility policy manual during the onsite inspection, the facility failed to document client follow up after discharge within the time frames specified in facility policy in three of three client records.
The findings included:
Six records were reviewed during the inspection on October 20 & 21, 2010. Three of those reviewed were required to include documentation of an attempt to follow up on the client. Facility policy and procedure required that follow up attempts be conducted at one week, one month, six months and one year.
Record # 4- The client was admitted on 5/26/10 and discharged on 6/23/10. Follow up in the record was documented on 8/10/10, 8/24/10, 9/3/10 and 9/12/10. The one week and one month follow up attempts were not documented or were documented late.
Record # 5 - The client was admitted on 8/4/10 and discharged on 9/11/10. Follow up in the record was documented on September 16, 21 and 24, 2010. The one month follow up was not documented.
Record # 6- The client was admitted on 8/18/10 and discharged on 9/17/10. Follow up in the record was documented on 9/21/10. The one month follow up was not documented.
All findings were discussed with the Clinical Director throughout the course of the inspection and opportunity was provided to present additional information or documentation if it was available. The Clinical Director did not dispute the findings.
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Plan of Correction
Aftercare follow-up process to be revised by Clinical Director and staff to be trained by 11/30/10. Monthly chart audits to ensure compliance will be completed by the Clinical Director. |