INITIAL COMMENTS
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This report identifies the findings of an on-site complaint investigation conducted on June 4, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on July 2, 2007.
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Plan of Correction
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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
Client # 4 was admitted to the facility on a medication that did not appear on the facility's 2000 year list of approved psychiatric medications. There was no admission note from the facility's psychiatrist to state that the medication the client was prescribed was appropriate for the treatment program.
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Plan of Correction
On June 5 the psychiatrist was contacted and told about the observation of the reviewer that an unapproved medication list would be as effective as an approved list. On June 6 an unapproved list was faxed over by the psychiatrist. The list was given to the Board for review on Monday June 11 and it was placed in the Policy and Procedure Manual on June 12. This list has been in force since June 11, 2007. Compliance was achieved on June 11, 2007. As part of the initial referral procedure the referring facility (person) is asked what medications a person is on. If a referral is on an unapproved medication the referring person shall be advised of this and the person shall not be interviewed or admitted. Any person who is taking an unapproved medication shall not be interviewed or admitted unless they are removed from the medication prior to the interview.There will be no exceptions to this procedure. There will be no exceptions. The Program Director will make sure that the list is followed. |
709.53(a)(4) LICENSURE Referral contact
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:
(4) Referral contact.
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Observations
The facility failed to document referral contact information including the nature and disposition of referrals made to hospitals in two client records reviewed, #3 and 4.
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Plan of Correction
Individuals who go to the hospital by their own choice or on a referral from staff have always been contacted to make sure they are all right or what their status is. This contact has not always been documented properly.
Effective June 5, 2007 all individuals who go to the hospital by choice or referral by staff are having the follow-yup contact documented in the client record.
The Program Director will ensure compliance to this by reading (which he normally does) the staff log and through monthly chart reviews done when the PCPC is completed. |
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
The facility failed to document the circumstances that led to two clients being therapeutically discharged, #4 and 6. Progress notes did not include information as to when the clients were therapeutically discharged.
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Plan of Correction
The reason for discharge is placed on the Notice of Involuntary Discharge. A discharge note is then made for each client who is discharged.
Effective immediately all clients who are discharged shall have the reason they are discharged and the date of the discharge documented in the discharge note. The reason(s) and/or incident which lead up to the discharge shall also be documented in the discharge note. After this the client will be given the Notice of Involuntary Discharge.
The Program Director will ensure compliance to this when doing the discharge PCPC. |