INITIAL COMMENTS
|
This report is a result of an on-site inspection conducted on August 10, 2007, as a result of an incident report regarding the death of a client, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Harwood House 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 October 10, 2007.
|
Plan of Correction
|
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
|
Observations
709.23 (a)
Based on a review of the facility's policies and procedures, the project director failed to annually update a written manual delineating project policies and procedures. Several conflicting administrative and clinical policies and procedures were documented in the manual. The executive director and sixteen other staff members signed and dated the manual in June 2007. The signatures indicated that all staff reviewed the manual in its entirety at this time.
Two conflicting policies regarding the completion of the client's psychosocial history and assessment were documented in the manual. A policy dated 10/96 entitled "Program implementation" stated "Within five days of admission the primary counselor meets with the resident to complete the psychosocial history and assessment." A policy dated 6/07 entitled "Psychosocial history and assessment" stated "...each resident and their counselor shall complete a detailed Psychosocial History and Assessment ...within fourteen (14) days of admission." The "Initial 21-day Treatment Plan" form stated "Complete psychosocial process in the first 14 days."
A policy dated 10/96 entitled "Program Implementation" stated "Case conferences are held on a weekly basis with staff and client present ..." A second policy dated 12/96 entitled Case consultations/case conferences stated "All clients shall be the subject of a case conference every 30 days when the treatment plan is updated ..."
Two conflicting policies regarding medical emergencies were documented in the manual. A policy dated 6/03 entitled "Crisis Management - Medical Emergencies" and a policy dated 7/03 entitled "Medical Emergencies" addressed different procedures for staff in the event of a medical emergency.
Two conflicting policies regarding psychiatric emergencies were documented in the manual. A policy dated 6/93 entitled "Crisis Management - Psychiatric Emergencies" and a policy dated 7/03 entitled "Psychiatric Emergencies" addressed different procedures for staff in the event of a psychiatric emergency.
Two conflicting forms regarding the removal of possessions were included in the manual. A form dated 3/04 entitled "Resident Acknowledgement of Responsibility to remove possessions and Medications" stated "Harwood House will hold, and store, personal belongings, such as clothes, personal care items ...for no more than Seven (7) days ...After Seven (7) days Harwood House may dispose of these items as they see fit." A form dated 11/04 entitled "Client acknowledgement of resident information" stated "...I understand that any and all clothing and personal property left at Harwood for more than 14 days after my discharge becomes the property of Harwood House."
Two copies of a typed memo regarding the "List of Unapproved Medications" that was faxed from the psychiatrist to the Executive Director on May 10, 2007 contained conflicting information. The original typed memo was in the policy and procedure manual. A copy of this memo was in the staff log book with a handwritten note not on the original faxed version. The handwritten note stated "We are not going to Advertise this but if you do get a referral on these meds, we can interview them." The handwritten note was not signed. This note indicated that although a policy was in place, the facility would not abide by it.
Three conflicting policies regarding client compliance with his/her medication were documented in the manual. Three policies, "Dispensing Medications", "Clients admitted who only have prescriptions for medications" and "Taking medications", dated 7/00, 8/03 and 2/07 respectively contained inconsistencies as to whether or not a client who does not take his/her medication would or would not be discharged from the facility.
|
Plan of Correction
Full compliance by 10/4/07. The Policy and Procedure manual has been updated and all conflicting policies have been removed. New Policies have been written to reflect current procedures.
The policy program implementation from 10/96 has been updated to match the phychosocial history and assessment policy. All psychosocials will be completed in 14 days. All initial treatment plans will be completed in 21 days, according to policy.
Program implementation from 10/96 has been updated to match the updated case consult/case conference policy. Case conferences will be done at a minimum every 30 days.
Destroyed 7/03 policy entitled medical emergencies and psychiatric emergencies. Crisis management -psychiatric emergencies and crisis management - medical emergencies have been updated. Policies are no longer conflicting.
The form dated 3/4 was changed to match the form dated on 11/4. All staff will be responsible for compliance.
The policy for unapproved medications will be followed by all staff.
Policies dated 7/00 and 2/07 have been revised and the policy dated 8/03 has been omitted. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
|
Observations
Based on a review of the facility's policies and procedures and the client record for client #1, the facility failed to document clinical information as stated in the facility's policy and procedure.
Two conflicting policies regarding the completion of the client's psychosocial history and assessment were documented in the manual. A policy dated 10/96 entitled "Program implementation" stated "Within five days of admission the primary counselor meets with the resident to complete the psychosocial history and assessment." A policy dated 6/07 entitled "Psychosocial history and assessment" stated "...each resident and their counselor shall complete a detailed Psychosocial History and Assessment ...within fourteen (14) days of admission." The "Initial 21-day Treatment Plan" form stated "Complete psychosocial process in the first 14 days." A progress note regarding the completion of the history and assessment was dated 16 days after client #1 was admitted.
The facility's policy entitled "Record of Service", dated 5/97, stated that "It shall be the policy of Harwood House that all services a client is provided, receives, or is referred to shall be documented on the CLIENT SERVICE LOG ...The primary counselor, or staff person providing the service of referral, is responsible for documenting the service in the service log. The Clinical Supervisor is responsible for ensuring compliance to this policy through ongoing chart reviews. The Executive Director is responsible for overall compliance to this policy." Client #1 was referred to a psychiatrist on July 26, 2007 and this service was not documented on the client service log.
A policy dated 10/96 entitled "Program Implementation" stated "Case conferences are held on a weekly basis with staff and client present ..." A second policy dated 12/96 entitled "Case consultations/case conferences" stated "All clients shall be the subject of a case conference every 30 days when the treatment plan is updated ..." A case consultation/case conference was not documented for client #1 from July 2 through August 4, 2007.
A policy dated 10/96 entitled "Discharge Summary" stated "It shall be the policy of Harwood House that a discharge summary shall be completed for all residents when their treatment experience at Harwood ends. It shall be the policy of Harwood House that the discharge summary shall be completed within five (5) days. The primary counselor is responsible for completing the discharge summary within five (5) days and placing it in the client record. The clinical supervisor is responsible for ensuring overall compliance to this policy and procedure." Client #1 died at the facility on August 4, 2007. A review of the client record, for client #1, revealed that a discharge summary was not completed.
A policy and procedure dated 6/99 entitled "Thirty day (30) day (sic) resident evaluation" stated that "all individuals admitted to the halfway house shall be placed upon thirty (30) days probation to determine their commitment to recovery and seriousness about treatment...The primary counselor is responsible for documenting the staff decision in the clinical record." A form entitled "Client acknowledgement of resident information" signed by the client stated "I understand that after my first 30 days here that I will be re-evaluated by staff to make sure that Harwood House is the proper level of care for me at this time. If it is not, I may be asked to leave Harwood with or without another residential referral and in some cases, I also understand that I may be asked to leave Harwood the same day of this decision". A review of the client record for client #1 revealed that the facility failed to document a thirty day evaluation.
The facility had two policies regarding the maintenance of client records. The first policy dated 10/96 entitled "Maintenance of client records" stated "It shall be the policy of Harwood House that all client records shall be stored in a locked file cabinet in the supply room." A second policy dated 10/96 entitled "Retention of client records" stated "It shall be the policy of Harwood House that all inactive records shall be stored in a secure locked file cabinet." During the physical plant inspection conducted on August 10, 2007 at 11:00 a.m. and again at 12:45 p.m., several client records from 2001 through 2006 were observed in cardboard boxes in two unlocked hallway closets.
Based on a review of the facility's policy and procedure on incident reporting and the staff log book, the facility failed to document an incident as stated in policy and procedure. The facility's policy (no date) entitled "Incident Reporting" stated "The staff person on duty at the time of the incident is responsible for documenting the incident in the Staff Log Book. The documentation must include the name(s) of the individual(s) involved, the nature of the incident, the time and location of the incident, a detailed description of the incident, and what was done by the staff person on duty...The Executive Director is responsible for overall compliance with this policy." A review of the staff log book with regards to an incident that occurred on August 4, 2007 at the facility which resulted in the death of client #1 by suicide revealed that the staff person on duty at the time of the incident failed to document in the staff log book the name(s) of the individual(s) involved, the nature of the incident, a detailed description of the incident and what was done by the staff person on duty.
|
Plan of Correction
709.24 Treatment/Rehabilitation Management
The program director is responsible for ensuring that there are accurate policies for the implementation of treatment services. The policy and procedure manual has been updated. All psychosocials will be completed in 14 days. Case conferences will be done at a minimum or 45 days.
The Discharge Summary was extended to 7 days on policy, to allow time for typing. The service log will include individual and group sessions. All incedents will be properly documented.
The program director is responsible for ensuring overall compliance with this standard and will train all clinical staff in the policies.
Time frame for compliance: All clinical staff will be trained on proper clinical documentation and time frames by 10/31/2007. All staff will be trained in incedent reporting by 10/31/07
|
709.24(a)(4) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(4) Written procedures for referral outlining cooperation with other service providers.
|
Observations
Based on a review of facility policy and procedures and client records, the facility failed to document the results of the incoming referral process for client #1. A facility policy dated 12/96 entitled "Initial Contact and Referral" stated "...the staff person taking the referral shall complete an Initial Contact Form on the person being referred. This form must be filled out completely." An "Initial Contact Form" was not documented in the client record for client #1.
A second facility policy dated 4/97 entitled "Initial interview" stated that "an initial interview form" will be completed by the client and "any unanswered questions or blank spaces shall be filled in at this time." A form entitled "Harwood House Initial Interview Form" was in the client record for client #1, but was incomplete. The form was left blank in the "staff assessment, accepted, denied or interviewed by" fields.
A facility policy (no date) entitled "Policy and procedure for accepting and making referrals" stated that "An individual may be referred to Harwood House providing they ...have a primary diagnosis of alcohol/substance abuse ...be free of any mood altering or psychotropic medications ....If a referral is on medication the caller shall be informed of the policy on medications and advised that the person will not be accepted or interviewed until they are medication free." An assessment from the referral source diagnosed client #1 with significant Axis I mental health disorders. Client #1 was on four prescribed mood altering medications prior to entering Harwood House.
|
Plan of Correction
709.24 Treatment/rehabilitation management.written procedures for referrals.
The program director is responsible for overall compliance with this standard. Clinical staff are responsible for documenting the results of the incoming referral process in the clint chart. The clinical supervisor is responsible for accurate documentation through monthly chart reviews.
Time frame for compliance: The policy and procedure manual has been updated. All clinical staff will be trained in the referral process by the clinical supervisor before 10/31/07 |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
|
Observations
Based on a review of the staff log book and physical plant inspection, the facility failed to ensure the confidentiality of client identity. The front door to the facility located on West Chester Pike was unsecured and did not prevent persons from entering the facility at any time. Entries in the staff log book between July 14, 2007 and August 5, 2007 verified that anyone can enter the building at any time. A former client, a police officer and a friend of a former client all entered the building during this time period jeopardizing the confidentiality of client identity.
|
Plan of Correction
709.28 Confidentiality of client identity and records.
All staff are responsible for maintaining client identity and confidentiality. The program director is responsible for overall compliance with this standard.
The front door was repaired and is now locked at all times. The security system, including a camera, monitor and eletronic door release has been installed.The door will be kept locked and manually opened until the security system is in place.
Time frame for compliance: This plan of correction has already been implemented. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
|
Observations
Based on a review of the facility's policy and procedure, staff interview and a physical plant inspection conducted on August 10, 2007, the facility failed to maintain client records within locked storage containers.
The facility had two policies regarding the maintenance of client records. The first policy dated 10/96 entitled "Maintenance of client records" stated "It shall be the policy of Harwood House that all client records shall be stored in a locked file cabinet in the supply room." A second policy dated 10/96 entitled "Retention of client records" stated "It shall be the policy of Harwood House that all inactive records shall be stored in a secure locked file cabinet."
During the physical plant inspection conducted on August 10, 2007 at 11:00 a.m. and again at 12:45 p.m., client records from 2001 through 2006 were observed in cardboard boxes in two unlocked hallway closets. The Executive Director acknowledged that client records were stored in the closets, but the closets should have been padlocked. Neither policy identified this area as storage for client records.
|
Plan of Correction
Full compliance achieved 09/25/2007
Policies have been revised. Policies have been separated into maintenance of current records and retention of records. All current client records are stored in locked filing cabinet. All old records are stored in locked storage closet.
ALL storage area will be kept secure and locked at all times.
The clinical supervisor is responsible for securing all clinical charts. The program director is responsible for ensuring overall compliance regarding storage of clinical charts. |
709.32(c)(4) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
|
Observations
Based on a review of client records, the facility failed to document a clear account of medication in one of one record reviewed, #1.
The medication order for client #1 from the referring facility listed the client's medications as follows: Lexapro 20 mg, QAM 6/8-7/22; Hydrodiuril (Hydrochlorothiazide) 25 mg QAM 6/8-7/22; Depakote 1250 mg QHS 6/18-9/15; and Seroquel 400 mg QHS 6/25-9/22.
Two conflicting doctor's appointment forms were documented in the client record of client #1 for the same date and time. The first doctor's appointment form dated Thursday, July 26 at 8:30 am indicated the client's current medications as: "Lexapro 20 mg. in a.m.; Depakote 1250 mg @ bed; Seroquel 400 mg at bed; Hydrochlorothiazide 25 mg in am". The "Psychiatrist Changes in medications" were listed as follows: continue Lexapro/Depakote; decrease Seroquel to 300 mg pd q HS; continue HCTZ 25 mg am. This form was signed by the psychiatrist. This form would indicate that the client should continue with his current dose of 1250 mgs. of Depakote and the dosage of Seroquel would be decreased to 300 mgs. A second doctor's appointment form dated Thursday, July 26 at 8:30 am indicated the client's current medications as: "Lexapro 20 mg 1 tab in am; Depakote 250 mg 1 tab @ bed w/other dose; Depakote 500 mg 2 tabs at Bed; Seroquel 400 mg 1 tab @ Bed". A statement "Medicine Dose is wrong" was written on this form. The psychiatrist did not sign this second form. This form would indicate that the client should receive a total of 1500 mgs. of Depakote and 400 mgs. of Seroquel.
The facility failed to document the dosages on the individual medication record for client #1. The dosages were stated as "1 tab, 2 tabs or 2 tabs" on each record versus the dosage of the medication.
Client #1 was admitted to the facility on July 2, 2007. The individual medication record for client #1 indicated that the client did not receive Seroquel July 2 through 21, 2007 or on August 2 or 3, 2007. Documentation in the client's record indicted that the client had been on Seroquel as prescribed "for 2 years". If "he can't sleep, he self medicates". He "hears voices if not on Seroquel".
The individual medication record for client #1 indicated that the client did not receive Hydrochlorothiazide (no dosage listed) July 2 through 13, 2007 or on August 2 or 3, 2007 as prescribed. A note in the staff log book dated 7/14/07 stated client #1 "got his med there was no med card for his hydrochlorothiazide. V ' ed the cardex twice for a card - no one made another card? Made a new card for him."
The individual medication record for client #1 indicated that the client did not receive Depakote as prescribed. Based on the documentation on the medication record and the lack of a dosage for the prescribed medication, the records indicate that the client did not receive the amount of Depakote prescribed fourteen of thirty-three days. The medication record indicated that the client received 2 1/2 tabs of 500 mg Depakote and 1 tab of 250 mg Depakote on July 5, 6, 10, 11, 12 and 13, 2007 for a total of 1500 mg of Depakote. The client was prescribed a total of only 1250 mgs. of Depakote during this time period. Client #1 did not receive 2 1/2 tabs of 500 mg Depakote as prescribed from July 25 through August 3, 2007. Client #1 did not receive 1 tab of 250 mg Depakote as prescribed from July 26 through August 3, 2007.
The individual medication record for client #1 indicated that the client did not receive Lexapro as prescribed for ten of thirty-three days. Lexapro was prescribed as 20 mg. in a.m. Client #1 did not receive Lexapro until 6:00 pm on July 4, 2007; 10:10 pm on July 8, 2007; 6:00 pm on July 10, 2007; Noon on July 14, 2007; 6:00 pm on July 17, 2007; and 10:00 pm on July 20, 2007. Client #1 did not receive Lexapro on July 19, 2007, August 2 or 3, 2007. There was no documentation in the medication or client record regarding why the client did not receive this medication as prescribed.
|
Plan of Correction
709.32 Medication control.
The program director is responsible for implementing policies and procedures regarding medication control. The policy book has been updated. The clinical supervisor and program director will train all staff on medication policies.
Time frame for compliance: All staff will be trained by 10/31/2007
A new policy was written to include bi-weekly medication checks, storage of medication and dispencing of medication.
Staff psychiatrist will do training on medication dosages, documentation, and information on the new medication group, once a month.
The Bi-weekly medication log check will ensure clients have their medication. If a client is out of medication, Harwood will purchase the medication for that client.Staff psychiatrist will do training on medication dosages, documentation, and information on medication group, once a month.
The Bi-weekly medication log check will ensure clients have their medication and take at directed times consistently.
|
709.51(a)(1) LICENSURE Criteria for Admission
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(1) Criteria for admission.
|
Observations
Based on a review of the facility's policy and procedure for admissions and client records, the facility failed to adhere to its policy and procedure regarding client admissions. A facility policy (no date) entitled "Policy and procedure for accepting and making referrals" stated that "An individual may be referred to Harwood House providing they ...have a primary diagnosis of alcohol/substance abuse ...be free of any mood altering or psychotropic medications ....If a referral is on medication the caller shall be informed of the policy on medications and advised that the person will not be accepted or interviewed until they are medication free." An assessment from the referral source diagnosed client #1 with significant Axis I mental health disorders. Client #1 was on four prescribed medications prior to entering Harwood House.
|
Plan of Correction
The program director is responsible for ensuring overall compliance with this standard. The program director and clinical supervisor will train all staff on new policy by 10/31/2007.
The policy on accepting and making referrals( no date) has been revised according to current admission criteria and acceptable medications approved by staff psychiatrist. New policy states Harwood House does accepts Axis I diagnosis as well as approved medications.
Time frame for compliance: Policies have been updated. All staff will be trained by 10/31/2007. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of facility policy and procedure and client records, the facility failed to document counseling services according to the individual treatment and rehabilitation plan in three of three records reviewed, #1, 2 and 3. The "Initial 21-day Treatment Plan" stated that clients will receive group sessions twice a week and one individual session per week. The facility's policy and procedure dated 10/95 entitled "Basic Program" stated that "three hours of group counseling and a minimum of one hour of individual counseling" would be provided each week.
Client #1 was in treatment for five weeks and did not receive one hour of individual counseling two of five weeks. There were no individual counseling sessions provided to the client during these two weeks. Client #1 did not receive any group counseling for three of five weeks and only one group counseling session (one for 1 hour and 1 for 1.5 hours) for two of five weeks.
Client #2 was in treatment for 22 weeks and did not receive one hour of individual counseling for 6 of 22 weeks reviewed. There were no individual counseling sessions provided to the client during these six weeks. Client #2 did not receive any group session for three weeks and only one group session for ten of 22 weeks reviewed.
Client #3 was in treatment for four weeks and did not receive one hour of individual counseling for one of four weeks reviewed. Client #3 did not receive two group counseling sessions for three of four weeks reviewed. Only one group session was provided during these three weeks.
|
Plan of Correction
709.52 Provision of Counseling services
It is the clinical staff responsibility to provide all clinical services documented on the treatment plan and to document in the client chart.. It is the clinical supervisors responsibility ensure that there is coverage for all clinical services and to ensure that all services are documented in the client chart. It is the program directors responsibility to ensure overall compliance
All clients will receive 3 hours of group and 1 hour of individual counseling a week.
Time frame for compliance: All clinical staff will be trained by the clinical supervisor regarding documentation of services by 10/31/2007
. |
709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
|
Observations
Based on a review of facility policy and procedure and client records, the facility failed to provide counseling on a regular and scheduled basis in three of three records reviewed, #1, 2 and 3.
Client #1 was in treatment for five weeks and did not receive one hour of individual counseling two of five weeks. There were no individual counseling sessions provided to the client during these two weeks. Client #1 did not receive any group counseling for three of five weeks and only one group counseling session (one for 1 hour and 1 for 1.5 hours) for two of five weeks.
Client #2 was in treatment for 22 weeks and did not receive one hour of individual counseling for 6 of 22 weeks reviewed. There were no individual counseling sessions provided to the client during these six weeks. Client #2 did not receive any group session for three weeks and only one group session for ten of 22 weeks reviewed.
Client #3 was in treatment for four weeks and did not receive one hour of individual counseling for one of four weeks reviewed. Client #3 did not receive two group counseling sessions for three of four weeks reviewed. Only one group session was provided during these three weeks.
|
Plan of Correction
709.52 Regularity of Counseling provided.
It is the clinial counselors responsibility to provide counseling on a regular and scheduled basis. It is the clinical supervisors responsibility to ensure that all residents are receiving group and individual counseling weekly through staff supervision. It is the program directors responsibility to ensure overall compliance.
Full Compliance achieved 9/25/2007.
All clinical staff have been trained by the clinical supervisor regarding providing counseling according to program policy.
|
709.52(e)(1) LICENSURE Medical/dental support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(1) Medical/dental.
|
Observations
Based on a review of facility forms and staff interviews, the facility failed to assist the client in obtaining medical support services in one of one record reviewed, #1. Interviews with staff revealed that although the Board of Directors and Executive Director state that funding will be provided to clients who are experiencing problems in obtaining prescribed medications, this practice does not occur. Documentation in client record #1 supported this claim. On July 2, 2007, the client signed the "Resident Acknowledgement of Financial Liability for Medications" form that stated "...I am responsible for the reimbursement of any and all medications purchased by Harwood House for me during my treatment ...Failure to not pay for medications will not result in my discharge...". Client #1 was unable to get his prescription filled and missed several days of anti-depressant and anti-psychotic medication. There was no documentation that the facility provided money for this client to obtain medical services.
|
Plan of Correction
709.52(e)(1)
It is the program directors responsibility to ensure that the policy and procedure manual is updated.
The policy titled "Taking Medication" and "Dispensing Medication has been revised.
The new policies read, Harwood House will provide purchase medication if a client has no other way of obtaining medication.
It is the clinical supervisors responsibility to ensure through bi weekly inspections that all clients have medication. The program director will have responsibility for overall compliance.
Time frame for compliance: This plan of correction has already been implemented.
|
709.52(e)(2) LICENSURE Psychiatric supt serv
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(2) Psychiatric.
|
Observations
Based on staff interviews, client #1 informed the Executive Director on August 2, 2007 that he "was having trouble getting his medications", specifically Depakote, Lexapro, Seroquel and Hydrochlorothiazide. The Executive Director stated that he spoke with the psychiatrist on August 7, 2007 and said that "the psychiatrist wished he (Executive Director) would have contacted him since he had Depakote samples".
|
Plan of Correction
709.52(e)(2) Psychiatric Supportive Services
It is the primary counselors responsibility to identify any and all needed support services of the client. It is the clinical supervisor along with the counselors responsibility to ensure that referrals are made to the needed services. It is the program directors responsibility to ensure that overall compliance and assist in the necessary referrals when needed.
Full compliance achieved 09/07/2007.
All old policies were removed from policy manual.
The policy titled "Taking Medication" and "Dispensing Medication has been revised on 09/07.
The new policies read, Harwood House will purchase medication or obtain samples form staff psychiatrist, if a client has no other way of obtaining medication.
|
709.53(a) LICENSURE Complete Client Record
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:
|
Observations
Based on a review of the facility policy and procedure and one client record, the facility failed to maintain a complete client record and document a complete medication administration record for client #1.
The facility's policy dated 7/96 entitled "Storage of Medication" stated "If an individual does not take, or refuses to take, a prescribed medication, the fact that the medication was not taken shall be documented on the medication card and in the clinical record. The individual not taking the medication shall be seen by the primary counselor or the Clinical Supervisor within 24 hours". There was no documentation that a session occurred between the primary counselor or clinical supervisor regarding the fact that the client did not take his medication.
The facility's policy entitled "Record of Service", dated 5/97, stated that "It shall be the policy of Harwood House that all services a client is provided, receives, or is referred to shall be documented on the CLIENT SERVICE LOG...The primary counselor, or staff person providing the service of referral, is responsible for documenting the service in the service log. The Clinical Supervisor is responsible for ensuring compliance to this policy through ongoing chart reviews. The Executive Director is responsible for overall compliance to this policy." Client #1 was referred to a psychiatrist on July 26, 2007 and this service was not documented on the client service log.
A policy dated 10/96 entitled "Program Implementation" stated "Case conferences are held on a weekly basis with staff and client present ..." A second policy dated 12/96 entitled "Case consultations/case conferences" stated "All clients shall be the subject of a case conference every 30 days when the treatment plan is updated ..." A review of the client record revealed that a case consultation/case conference was not documented for client #1 from July 2 through August 4, 2007.
A policy dated 10/96 entitled "Discharge Summary" stated "It shall be the policy of Harwood House that a discharge summary shall be completed for all residents when their treatment experience at Harwood ends. It shall be the policy of Harwood House that the discharge summary shall be completed within five (5) days. The primary counselor is responsible for completing the discharge summary within five (5) days and placing it in the client record. The clinical supervisor is responsible for ensuring overall compliance to this policy and procedure." Client #1 died at the facility on August 4, 2007. A review of the client record, for client #1, revealed that a discharge summary was not completed.
A policy and procedure dated 6/99 entitled "Thirty day (30) day (sic) resident evaluation" stated that "all individuals admitted to the halfway house shall be placed upon thirty (30) days probation to determine their commitment to recovery and seriousness about treatment...The primary counselor is responsible for documenting the staff decision in the clinical record." A form entitled "Client acknowledgement of resident information" signed by the client stated "I understand that after my first 30 days here that I will be re-evaluated by staff to make sure that Harwood House is the proper level of care for me at this time". A review of the client record for client #1 revealed that the facility failed to document a thirty day evaluation.
|
Plan of Correction
1791
Full compliance achieved 9/25/2007
The new medication log is now in place and bi-weekly med checks will by done by staff. The information gather form med checks will be passed on to the primary counselor and the client. The policy entitled "Taking Medications" has been revised to include medication checks to ensure all medications are being taken properly. The primary counselor is responsible for addressing missed medication doses with the client.
The clinical supervisor will ensure compliance in weekly staff meetings when all clients are reviewed.
Full compliance achieved 9/25/2007
The service log policy has changed to document individual and group sessions only. When client is seen by psychiatrist the form will be placed under the medication tab in the client record, this will serve as documentation that client was seen by psychiatrist.
Full compliance achieved 9/25/07
Program Implementation Policy from 10/96 has been updated to match the updated case consult/case conference policy. Case conferences will be done at a minimum or 30 days.
The new discharge summary policy has extended time to 7 days for typing of the complete discharge summary. The program director shall be responsible for overall compliance.
The policy dated 6/99 entitled "Thirty day resident evaluation was revised.
Compliance achieved 9/25/07.
the old Policy was removed from manual and all clients are accessed for level of care, as well as progress in treatment, during our weekly staff meeting and during case conference process. The thirty day evaluation paragraph was removed from client acknowledgment of resident information. All clinical staff will be responsible for client assessments during the weekly staff meeting. |
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 facility's policy and procedure and a review of client records, the facility failed to document all services provided as stated in policy in one of one client record reviewed, #1.
The facility's policy entitled "Record of Service", dated 5/97, stated that "It shall be the policy of Harwood House that all services a client is provided, receives, or is referred to shall be documented on the CLIENT SERVICE LOG ...The primary counselor, or staff person providing the service of referral, is responsible for documenting the service in the service log. The Clinical Supervisor is responsible for ensuring compliance to this policy through ongoing chart reviews. The Executive Director is responsible for overall compliance to this policy." Client #1 was referred to a psychiatrist on July 26, 2007 and this service was not documented on the client service log.
|
Plan of Correction
709.53(a)(3) Records of Service
The service log policy has changed to document individual and group sessions only. When client is seen by psychiatrist the form will be placed under medication tab in the client record, this will serve as documentation that client was seen by psychiatrist. The clinical staff is responsible for documenting clinical activities in the record of service. The clinical supervisor is responsible for ensuring that the record of service logs are up to date during monthly chart reveiws.
Full compliance achieved 9/25/2007
|
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.
|
Observations
Based on a review of facility policy and procedure and staff and client interviews conducted on August 10, 2007 and August 14, 2007, the facility failed to refer client #1 for care. According to the interviews, client #1 was exhibiting manic behaviors on August 3, 2007, the day before he committed suicide. The facility policy dated 6/93 entitled "Crisis Management - Psychiatric Emergencies" stated "Staff shall, in the course of their clinical duties, maintain awareness of an individuals mood, affect, and behavior, documenting any observed differences. Staff shall, at all times, investigate any reports of unusual or bizarre behavior on the part of residents made by other residents. Such reports shall be investigated immediately." Observations by the staff regarding the client's behaviors, a report regarding the unusual behavior or investigation were not documented by the facility.
|
Plan of Correction
709.53(a)(4)Referral Contact.
It is the responsibility of all staff to be aware of,respond to ,and document any psychiatric crisis. It is the responsibility of the clinical supervisor and the program director to follow through with referring to emergency care as needed. All staff will be trained in recognizing signs of distress in clients, documentation of client behavior and making referrals.
Time frame for compliance. The program director has already updated policy. All staff will be trained by 11/30/07
|
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.
|
Observations
Based on the facility's policy and procedure and a review of client records, the facility failed to document case consultations as stated in policy in one of one client record reviewed, #1.
A policy dated 10/96 entitled "Program Implementation" stated "Case conferences are held on a weekly basis with staff and client present ..." A second policy dated 12/96 entitled "Case consultations/case conferences" stated "All clients shall be the subject of a case conference every 30 days when the treatment plan is updated ..." A case consultation/case conference was not documented for client #1 from July 2 through August 4, 2007.
|
Plan of Correction
709.53(a)(8)
The policy has been changed to state that case consultations shall be done every 45 days.
It is the counselors responsibility to complete a case consultation every 45 days. It is the responsibility of the clinical supervisor to ensure compliance by completing monthly chart reviews. It is the program directors responsibility for overall compliance.
Time frame for compliance: All clinical staff will be trained in proper documentation and time frames by 10/31/2007
|
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 facility's policy and procedure and a review of client records, the facility failed to document a discharge summary as stated in policy in one of one client record reviewed, #1.
A policy dated 10/96 entitled "Discharge Summary" stated "It shall be the policy of Harwood House that a discharge summary shall be completed for all residents when their treatment experience at Harwood ends. It shall be the policy of Harwood House that the discharge summary shall be completed within five (5) days. The primary counselor is responsible for completing the discharge summary within five (5) days and placing it in the client record. The clinical supervisor is responsible for ensuring overall compliance to this policy and procedure." Client #1 died at the facility on August 4, 2007. A review of the client record, for client #1, revealed that a discharge summary was not completed.
|
Plan of Correction
709.53 Discharge Summary
It is the resonsibility of the counselor to complete the discharge summary in 7 days. It is the responsibility of the clinical supervisor to ensure that the discharge summaries are being completed by reveiwing all discharges. It is the program directors responsibility to ensure overall compliance.
Time frame for compliance: All clinical staff will be trained in new policy and proper documentation of discharges by 10/31/2007
|
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
|
Observations
Based on staff interviews, a review of client records and the staff log book, the facility failed to document that work done by the client at the project is an integral part of the treatment plan. The staff log book acknowledged clients performing work at the treatment facility such as cleaning the bathrooms, the sidewalks and the kitchen and replacing ceiling tiles. Staff interviews confirmed that client #1 recently completed replacing the ceiling tiles in the bathroom where he later hung himself. Work therapy was not documented in client record, #1.
|
Plan of Correction
709.53 (a)(12)Work Therapy
It is the counselors responsibility to document work therapy on all treatment plans.It is the clinical supervisors responsibility to ensure that this is documented on all treatment plans by reveiwing treatment plans during supervision with clinical staff. No client will every be allowed to do building maintenance. The program director is responsible for ensuring overall compliance.
Time frame for compliance:All clinical staff will be trained on policy and proper documentation by 10/31/2007
|