INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on May 14-15, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site complaint investigation, Gaudenzia DRC Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to document that the clinical supervisor participated in monthly meetings with their supervisor as per the regulation.
The findings include:
The personnel record of employee #6, the facility's only clinical supervisor, was reviewed on May 15, 2015.
Employee # 6 was hired at the project on November 3, 2014. There was no documentation of supervision meetings for November 2014, January 2015 and March 2015.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor received 6 monthly supervisions with Program Director from November to April : Six (6) monthly supervisions were completed and placed in employees file.
These supervisions were found after date of inspection on May 14th & 15th.
Clinical Supervisions will be completed monthly and reviewed to ensure proper supervisions are taking place. Both Clinical Supervisor and Program Director will review supervisions to ensure that all staff receive supervisions monthly.
Program Director will maintain each staff members supervision in a binder and ensure prior supervision with Clinical Supervisors? goal (s) and objective (s) are being obtained.
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on the review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of six records reviewed.
Findings:
Personnel records of six counselors were reviewed on May 5, 2015. One of six counselors, employee #1 did not meet the qualifications for the position of counselor. Employee #1's Certified Alcohol and Drug Counselor (CADC) certification expired on April 12, 2015. The facility was unable to provide a current CADC.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee # 1 was transferred to a non-clinical drug and alcohol position.
Prior to hire, applicant(s) credential will be reviewed to ensure compliance with DDAP regulations. Director will proceed to interview appropriate candidates based on qualifications for inpatient treatment staffing. Final review of qualifications will be approved by Human Resources prior to hire.
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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 a review of the facility's Staffing Requirement Facility Summary Report (SRFSR) and an interview with the Clinical Director and Facility Director, the facility failed to provide documentation of individual training plans for nine employees from the SRFSR.
The findings include:
The facility's SRFSR was reviewed on May 15, 2015. The facility did not document individual training plans for the January 1 - December 31, 2015 training year in nine of nine employees documented on the SRFSR, #9, 10, 13, 14, 15, 16, 17, 18 and 19.
Employee #9 was hired on September 16, 2003. The facility failed to document on the SRFSR, employee #9's individual training plan for training year January 1 - December 31, 2015.
Employee #10 was hired on November 26, 1997. The facility failed to document on the SRFSR, employee #10's individual training plan for training year January 1 - December 31, 2015.
Employee #13 was hired on June 2, 2014. The facility failed to document on the SRFSR, employee #13's individual training plan for training year January 1 - December 31, 2015.
Employee #14 was hired on March 10, 2014. The facility failed to document on the SRFSR, employee #14's individual training plan for training year January 1 - December 31, 2015.
Employee #15 was hired on May 28, 2013. The facility failed to document on the SRFSR, employee #15's individual training plan for training year January 1 - December 31, 2015.
Employee #16 was hired on October 10, 2011. The facility failed to document on the SRFSR, employee #16's individual training plan for training year January 1 - December 31, 2015.
Employee #17 was hired on March 23, 1992. The facility failed to document on the SRFSR, employee #17's individual training plan for training year January 1 - December 31, 2015.
Employee #18 was hired on June 7, 2004. The facility failed to document on the SRFSR, employee #18's individual training plan for training year January 1 - December 31, 2015.
Employee #19 was hired on November 14, 2011. The facility failed to document on the SRFSR, employee #19's individual training plan for training year January 1 - December 31, 2015.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will meet with Human Resource to review files numbers # 9, 10, 13, 14, 16, 17, 18 and 19 to ensure Training Plans are completed. All staff will have training plans by July 31, 2015. Employee #15 is no longer employed with facility.
Individual training plans will be developed at the end of each calendar year for the upcoming new year and will be reviewed quarterly by Clinical Supervisor to ensure all proper training and hours are being met yearly.
Clinical Supervisor will review training plans quarterly to ensure they meet the needs of each counseling staff and make adjustments when needed.
Inpatient Director will review for accuracy and regulatory compliance.
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704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on a review of current client census information and clinical staff hours, the facility failed to ensure that the staff to client ratio remained at or below one full time equivalent (FTE) counselor for every eight clients, as required by regulation.
The findings include:
The current client census information and clinical staff hours were reviewed on May 15, 2015. The documented facility had 6 full time counselors, but one counselor didn't meet the qualification for a counselor therefore their hours could not count towards the ratio. The facility now currently has 5 full time counselors at this facility and 47 clients. Based on this information, the staff client ratio was 10:1.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will maintain the 8:1 ratio for staffing/client.
Due to census increase, additional staff have been hired, effective 7/9/15.
Counselor that did not qualify was transferred to a non-clinical position.
Clinical Supervisor will review counselor/client ratio daily to ensure DDAP regulatory compliance. Director will ensure accuracy to ensure compliance per Clinical Supervisors review.
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705.1 (1) LICENSURE Gen requirements for residential facilities.
705.1. General requirements for residential facilities.
The residential facility shall:
(1) Hold a license under Chapter 709 (relating to standards for licensure of freestanding treatment facilities) or a certificate under Chapter 711 (relating to standards for certification of treatment activities which are part of a health care facility).
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Observations
Based on the review of the Residential Aide (RA) log book, the facility failed to ensure that all inpatient residential clients were housed within the licensed facility.
The findings include:
The RA log book was reviewed on May 15, 2015. During the review of the RA log book, the RA staff members documented on May 11, 2015 and May 15, 2015 that six inpatient residential clients were housed on the following floors; two housed on the 4th floor, two housed on the 5th floor and two housed on the 6th floor. The 4th, 5th and 6th floors are not licensed inpatient residential client floors.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Inpatient clients housed on other floors have been relocated and reside on the gender specific locked Inpatient floors. All residential placement (moves) were relocated and completed on Saturday, May 16, 2015 by 5pm. Operations, Security and Clinical Administration allocated the new bed assignment for The Inpatient Program.
The facility will move residents only when residents complete programming. Inpatient clients will remain on inpatient units until their designated discharge time.
The RA Log Book will be reviewed each shift (3) by Residential Aids at the start and end of each shift.
Inpatient Director to ensure that all residents are housed on Inpatient floors on a daily basis.
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a complaint investigation and interviews with the Facility Director (FD) and Clinical Director (CD), the facility failed to keep the grounds of the facility safe at all times for the safety and well-being of residents, employees and visitors.
The findings include:
During the complaint investigation conducted on May 14-15, 2015 the FD and CD were interviewed on May 14, 2015 at around 8:30 am. The FD and CD provided documentation of suspected drug use on the premises resulting in 13 overdoses on May 8, 2015. Three of the 13 overdosed were clients of the licensed inpatient facility. Additionally, another client of the licensed inpatient facility overdosed the next day, May 9, 2015.
The findings were reviewed with facility staff during the complaint investigation.
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Plan of Correction
The facility will maintain daily reviews of exterior grounds and document each review.
The facility will do daily room inspections of each Inpatient resident housing area.
The facility will do random search of Inpatient floor common areas.
The facility will conduct random pat searches of Inpatient residents.
The facility will conduct random instant urines as well as urines that have a wide scale of testing results.
The Inpatient Director will randomly review all such documentation of accuracy, monthly.
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705.4 (1) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(1) Maintain space for both individual and group counseling sessions.
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Observations
During the physical plant inspection, the facility failed to maintain space for group counseling sessions.
The findings include:
The physical plant inspection took place on May 14, 2015 around 8:30 am. During the physical plant inspection, on the women ' s wing of the facility, the women were having a group counseling session in the hallway.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will provide adequate space for all group sessions by assigning counselors to designated office space.
Group space has been made available by utilizing larger offices. Individual sessions have been allocated to non clinical personnel office space as needed for additional confidentiality.
Posting of all scheduled group locations will be made available for all residents as a notification process to group assignments.
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
During the physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
The findings include:
The physical plant inspection took place on May 14, 2015 around 8:30 am and May 18, 2015 around 8:30 am. During the physical plant inspection on May 14, 2015, on the women's wing of the facility, the women were having a group counseling session in the hallway. Additionally, on May 18, 2015 at around 10:00 am the women were having group counseling sessions in the cafeteria of the facility. The door of the cafeteria was open and one could see and hear the counseling session taking place.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will make corrections to counseling areas, ensuring that all groups counseling is behind closed doors at all times.
Clinical Supervisor and or Inpatient Director will randomly do group inspections to make sure this is being done.
Vacant office space will also be utilized to conduct individual sessions.
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705.4 (4) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(4) Locate counseling areas so that noise does not disturb or interfere with counseling sessions.
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Observations
During the physical plant inspection, the facility failed to ensure that the counseling area was free from noise so not to disturb or interfere with counseling sessions.
The findings include:
The physical plant inspection took place on May 14, 2015 around 8:30 am and May 18, 2015 around 8:30 am. During the physical plant inspection on May 14, 2015, on the women's wing of the facility, the women were having a group counseling session in the hallway. Additionally, at around 10:00 am on May 18, 2015 the women were having group counseling sessions in the cafeteria of the facility. The door of the cafeteria was open and one could see and hear the counseling session taking place.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counseling session will be held in a offices behind closed doors.
All group sessions will be held in area with closed doors.
Clinical Supervisor will make random checks on groups session while they are in process.
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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on an inspection of the physical plant, the facility failed to provide documentation frozen food being stored at or below 0F.
The findings include:
The physical plant was inspected on May 18, 2915 around 8:30 am. Three refrigerators/freezers are provided for client food storage. The one freezer located in the kitchen temperature read 15 degrees.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Daily temperature checks will be made by food service manager and any change in temperature will be address immediately and documented.
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709.28(c) 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:
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Observations
Based on a review of client records, the facility failed to obtain informed and voluntary consents in two of twenty-one records reviewed.
The findings include:
Twenty-one client records were reviewed on May 15, 2015. The facility failed to document informed and voluntary consents in two client records, #4 and 5.
Client #4 - Consent to release dated March 20, 2015 for the client's parole officer failed to have what was going to be release on the consent to release form.
Client #5 - Consent to releases dated April 17, 2015 for the client's insurance company and government agencies failed to have the client's signature on the consent to release forms. The client record review confirmed that information was released to those entities in reliance of the release forms that wasn't signed by the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will audit all client records for form accuracy, signatures and dates.
Clinical Supervisor will review all open charts monthly for any missing information.
Any deficiency found will result in the corrections being made with in a 48 hour period by the counselor. In counselors absence, the clinical supervisor and then the director to ensure the corrective update has been applied. Corrections will be dated on the date corrected, and client will initial if required.
Releases that have not been appropriately completed have been voided and all new releases are being completed with specific names of persons being notified and or coordinated with. Separate forms are being used for releases outgoing and for releases incoming.
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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
Based on the review of the facilities medication administration records, the facility failed to maintain accurate records in the individual medications.
The findings include:
Six medication administration records (MARS) were reviewed on May 14 - 15, 2015. The facility failed to document the reason why clients did not receive medication as prescribed in client records, #9, 10, 11, 22, 24 and 25.
Client #9
Drug: Quetiopine 300 MG
Prescribed on 4/6/15
Frequency: One tablet @ AM
Dates not taken: May 1-16, 2015
Drug: Quetiopine 300 MG
Prescribed on 4/6/15
Frequency: two tablets @ bedtime
Dates not taken: May 1, 2015
Drug: Quetiopine 200 MG
Prescribed on 4/6/15
Frequency: One tablet @ AM
Dates not taken: May 1-16, 2015
Drug: Quetiopine 400 MG
Prescribed on 4/6/15
Frequency: one tablet @ bedtime
Dates not taken: May 1, 2015 and May 3, 2015
Client #10
Drug: Lisinpriol 10 MG
Prescribed on 3/26/15
Frequency: One pill daily.
Dates not taken: May 1-2, 2015 and May 4-13, 2015
Client #10
Drug: Glipizide 10 MG
Prescribed on: (no date documented)
Frequency: 1 pill daily
Dates not taken: May 1-2, 2015, May 4-13, 2015 and May 15, 2015
Client #11
Drug: Risperidone 1MG
Prescribed on: (no date documented)
Frequency: one pill in the pm
Dates not taken: May 1-2, 2015
Drug: Risperidone 0.5 MG
Prescribed on: (no date documented)
Frequency: one pill in the pm
Dates not taken: May 1-2, 2015
Drug: Benztropine 1MG
Prescribed on: (no date documented)
Frequency: one pill in the pm
Dates not taken: May 1-2, 2015
Drug: Risperidone 1 MG
Prescribed on: (no date documented)
Frequency: one pill in the am
Dates not taken: May 1-3, 2015 and May 11-13, 2015
Drug: Risperidone 0.5 MG
Prescribed on: (no date documented)
Frequency: one pill in the am
Dates not taken: May 1-4, 2015
Drug: Benztropine 1MG
Prescribed on: (no date documented)
Frequency: one pill in the am
Dates not taken: May 1-4, 2015
Drug: HCTZ 25 MG
Prescribed on: (no date documented)
Frequency: one pill in the am
Dates not taken: May 1-3, 2015
Drug: Methimezole 10 MG
Prescribed on: (no date documented)
Frequency: one pill in the am
Dates not taken: May 1-3, 2015 and May 8-15, 2015
Drug: Methimezole 10 MG
Prescribed on: (no date documented)
Frequency: one pill in the pm
Dates not taken: May 1-2, 2015 and May 7-8, 2015
Drug: Methimezole 10 MG
Prescribed on: (no date documented)
Frequency: one pill @ bedtime
Dates not taken: May 1-2, 2015 and May 7-8, 2015
Client #22
Drug: Clinymore 150 MG
Prescribed on: (no date documented)
Frequency: 3 caps every 6hrs
Dates not taken: May 1- 7, 2015
Drug: Quetiapine 100 MG
Prescribed on: (no date documented)
Frequency: one pill in the am
Dates not taken: May 1 - 8, 2015
Drug: Escitalopram 20 MG
Prescribed on: (no date documented)
Frequency: one pill in the am
Dates not taken: May 1- 8, 2015
Drug: Quetiapine 200 MG
Prescribed on: (no date documented)
Frequency: one pill @ bedtime
Dates not taken: May 1-5, 2015
Client #24
Drug: Citalopram 40 MG
Prescribed on: 4/14/15
Frequency: one pill daily
Dates not taken: May 8, 2015
Client #25
Drug: Paroxetine 30 MG
Prescribed on: 4/26/15
Frequency: one pill @ bedtime
Dates not taken: May 2, 2015, May 6, 2015 and May 8, 2015
Drug: Mirtazapine 15 MG
Prescribed on: (no date documented)
Frequency: one pill @ bedtime
Dates not taken: May 2, 2015 and May 8-9, 2015
Drug: Amoxicillin
Prescribed on: (no date documented)
Frequency: one capsule 3 x's a day
Dates not taken: May 1-7, 2015
As a result of these findings all MARS for all 27 male clients in May were pulled and reviewed. Including the 6 clients noted above. Improper documentation existed for 18 of the 27 total of clients.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The nurse manager will implement new signature log sheets verifying medication administration by clients. On duty medical personnel will sign off in the log on each medication received.
Any medication prescribed but not administered will include a brief description for the reason it was not received. Medical personnel will document this. This has become effective May 16, 2015.
The medical department will be renovated to address new procedures including delivery of medication as well as overseeing each residents required timeline. Renovations scheduled to begin by end of August, 2015. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the facility failed to inform the client of the facility's reason for involuntarily terminating the client.
The findings include:
Four client records were reviewed for documentation of a notice of termination on May 14, 2015. The Facility failed to document, in writing, of a decision to involuntarily terminate the client's treatment at the facility in client records, #22, 23, 24 and 25.
Client #22 was admitted on May 11, 2015 and involuntarily discharged on May 11, 2015. As of the date of the complaint investigation the facility failed to document a notice of termination in client record #22.
Client #23 was admitted on April 10, 2015 and involuntarily discharged on May 11, 2015. As of the date of the complaint investigation the facility failed to document a notice of termination in client record #23.
Client #24 was admitted on April 13, 2015 and involuntarily discharged on May 11, 2015. As of the date of the complaint investigation the facility failed to document a notice of termination in client record #24.
Client #25 was admitted on April 6, 2015 and involuntarily discharged on May 11, 2015. As of the date of the complaint investigation the facility failed to document a notice of termination in client record #25.
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Plan of Correction
Clinical Supervisor shall provide individual (s) discharged/terminated from treatment with a written notice for termination.
All terminations will be documented in client?s chart and a copy of the termination notice will also be included as part of the client?s record.
Effective 7/27/15 all discharged/terminations will include documentation of either ? 1) In person notification, 2) Mail notification or 3) Phone notification of discharge/termination.
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709.51(b)(3)(i) LICENSURE Medical histories
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document a client history in eight of twenty-one client records reviewed.
The findings include:
Twenty-one client records were reviewed fir the documentation of a history on May 14-15, 2015. The facility failed to provide documentation of a client's history in client records, 3, 5, 9, 10, 11, 14, 16 and 17.
Client # 3 was admitted on April 6, 2015. As of the date of the licensing inspection the facility failed to document client #3's medical history, personal history and drug/alcohol history.
Client # 5 was admitted on April 17, 2015. As of the date of the licensing inspection the facility failed to document client #5's personal and drug/alcohol history.
Client # 9 was admitted on April 6, 2015. As of the date of the licensing inspection the facility failed to document client #9's personal and drug/alcohol history.
Client # 10 was admitted on March 24, 2015. As of the date of the licensing inspection the facility failed to document client #10's personal and drug/alcohol history.
Client # 11 was admitted on April 27, 2015. As of the date of the licensing inspection the facility failed to document client #11's personal and drug/alcohol history.
Client # 14 was admitted on April 16, 2015. As of the date of the licensing inspection the facility failed to document client #14's personal and drug/alcohol history.
Client # 16 was admitted on March 30, 2015. As of the date of the licensing inspection the facility failed to document client #16's personal and drug/alcohol history.
Client # 17 was admitted on March 23, 2015. As of the date of the licensing inspection the facility failed to document client #17's personal and drug/alcohol history.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each intake will be reviewed by Intake Supervisor and /Clinical Supervisor within 72 hours of admissions.
All intakes will be reviewed for client history for medical care and assessment.
All current clients? drug/alcohol history section of intake and admission will be reviewed and recorded by 7/31/15.
Clients # 3, 5, 9, 10, 11, 14, 16 and 17 have been discharged. Psychosocial histories have been completed as fully as possible since inspection date.
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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document the results of the physical exam for each client in seven of twenty-one client records reviewed.
The findings include:
Twenty-one client records were reviewed on May 14-15, 2015 for physical exams. The facility failed to document the results of the physical exam for clients #5, 6, 9, 10, 11, 14 and 15.
Client #5 was admitted on April 17, 2015. As of the date of the licensing inspection there was no documented physical exam client #5.
Client #6 was admitted on May 4, 2015. As of the date of the licensing inspection there was no documented physical exam for client #6.
Client #9 was admitted on April 6, 2015. As of the date of the licensing inspection there was no documented physical exam for client #9.
Client #10 was admitted on March 24, 2015. As of the date of the licensing inspection there was no documented physical exam for client #10.
Client #11 was admitted on April 27, 2015. As of the date of the licensing inspection there was no documented physical exam for client #11.
Client #14 was admitted on April 16, 2015. As of the date of the licensing inspection there was no documented physical exam for client #14.
Client #15 was admitted on April 13, 2015. As of the date of the licensing inspection there was no documented physical exam for client #15.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The doctor will provide physical exams of each new intake within one week of admission. The nurse will schedule doctor appointments with Inpatient Director to ensure the seven day requirement is adhered to.
Since date of plan of correction all clients have either been seen and or discharged. |
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 a review of client records, the facility failed to document a psychosocial evaluation in nine of twenty-one client records.
The findings include:
Twenty-one client records were reviewed on May 14-15, 2015 for documentation of a psychosocial evaluation. The facility failed to provide documentation of a psychosocial evaluation in client records # 3, 5, 9, 10, 11, 12, 14, 16 and 17.
Client # 3 was admitted on April 6, 2015. As of the date of the licensing inspection there was no documentation of a psychosocial evaluation.
Client # 5 was admitted on April 17, 2015. As of the date of the licensing inspection there was no documentation of a psychosocial evaluation.
Client # 9 was admitted on April 6, 2015. As of the date of the licensing inspection there was no documentation of a psychosocial evaluation.
Client # 10 was admitted on March 24, 2015. As of the date of the licensing inspection there was no documentation of a psychosocial evaluation.
Client # 11 was admitted on April 27, 2015. As of the date of the licensing inspection there was no documentation of a psychosocial evaluation.
Client # 12 was admitted on April 13, 2015. As of the date of the licensing inspection there was no documentation of a psychosocial evaluation.
Client # 14 was admitted on April 16, 2015. As of the date of the licensing inspection there was no documentation of a psychosocial evaluation.
Client # 16 was admitted on March 30, 2015. As of the date of the licensing inspection there was no documentation of a psychosocial evaluation.
Client # 17 was admitted on March 23, 2015. As of the date of the licensing inspection there was no documentation of a psychosocial evaluation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will review each chart within seven days to ensure that all active psychosocial evaluations have been started and or completed.
All active Psychosocial will be reviewed by Clinical Supervisor on or before day Five (5). Program Director will review Psychosocial by day seven (7) to ensure regulatory compliance
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709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
Based on review of client records, the facility failed to document an individual treatment and rehabilitation plan in eight of twenty-one client records reviewed.
The findings include:
Twenty-one client records were reviewed on May 14-15, 2015 for documentation of an individual treatment and rehabilitation plan. The facility failed to document individual treatment and rehabilitation plans in records, #3, 9, 10, 11, 14, 16 and 17. Additionally, the facility failed to include on the individual treatment and plan the type & frequency and support services in eight of twenty-one client records, #1, 2, 4, 13, 14, 18, 19, and 20.
Client #1 was admitted on March 23, 2015. Client #1's individual treatment and rehabilitation plan developed on March 29, 2015 did not include type and frequency of sessions for client #1.
Client #2 was admitted on March 25, 2015. Client #2's individual treatment and rehabilitation plan developed on March 30, 2015 did not include type and frequency of sessions for client #2.
Client #3 was admitted on April 6, 2015. Client #3's individual treatment and rehabilitation plan developed on April 6, 2015 did not include type and frequency of sessions for client #3.
Client #4 was admitted on April 20, 2015. Client #4's individual treatment and rehabilitation plan developed on May 8, 2015 did not include type and frequency of sessions for client #4.
Client #9 was admitted on April 6, 2015. Client #9's individual treatment and rehabilitation plan was not documented as of the date of the licensing inspection.
Client #10 was admitted on March 24, 2015. Client #10's individual treatment and rehabilitation plan was not documented as of the date of the licensing inspection.
Client #11 was admitted on April 27, 2015. Client #11's individual treatment and rehabilitation plan was not documented as of the date of the licensing inspection.
Client #12 was admitted on April 13, 2015. Client #12's individual treatment and rehabilitation plan was not documented as of the date of the licensing inspection.
Client #13 was admitted on March 23, 2015. Client #13's individual treatment and rehabilitation plan developed on March 30, 2015 did not include type and frequency of sessions and support services for client #13.
Client #14 was admitted on April 16, 2015. Client #14's individual treatment and rehabilitation plan was not documented as of the date of the licensing inspection.
Client #15 was admitted on April 13, 2015. Client #15's individual treatment and rehabilitation plan developed on April 17, 2015 did not include type and frequency of sessions and support services for client #15.
Client #16 was admitted on March 30, 2015. Client #16's individual treatment and rehabilitation plan was not documented as of the date of the licensing inspection.
Client #17 was admitted on March 23, 2015. Client #17's individual treatment and rehabilitation plan was not documented as of the date of the licensing inspection.
Client #18 was admitted on December 1, 2014 and discharged on February 2, 2015. Client #18's individual treatment and rehabilitation plan developed on January 8, 2015 did not include support services for client #18.
Client #19 was admitted on January 20, 2015 and discharged on March 23, 2015. Client #19's individual treatment and rehabilitation plan developed on January 27, 2015 did not include type and frequency of sessions and support services for client #19.
Client #20 was admitted on January 20, 2015 and discharged on March 23, 2015. Client #20's individual treatment and rehabilitation plan developed on January 27, 2015 did not include type and frequency of sessions and support services for client #20.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will review each chart within seven days for Initial Treatment Plan and follow up on Treatment Plans weekly thereafter.
Clinical Supervisor will conduct training for all clinical staff on clinical documentation on Treatment Plans monthly
to ensure measurable data (type and frequency) as well as support services on treatment plans are being documented. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document a treatment plan update per regulations in four of eight client records reviewed.
The findings include:
Eight client records requiring treatment plant updates were reviewed on May 14 - 15, 2015. The facility failed to document a treatment plan update in client records #1, 19 and 20. Additionally, the facility failed to document the client's treatment plan update within 30 days of the client comprehensive treatment plan in one client record, #21.
Client #1 was admitted on March 23, 2015. The comprehensive treatment plan was completed on March 29, 2015. A treatment plan update was due by April 29, 2015 and was not completed as of the date of the licensing inspection.
Client #19 was admitted on January 20, 2015 and discharged on March 23, 2015. The comprehensive treatment plan was completed on January 27, 2015. A treatment plan update was due by February 27, 2015 and was not completed as of the date of the licensing inspection.
Client #20 was admitted on January 20, 2015 and discharged on March 23, 2015. The comprehensive treatment plan was completed on January 27, 2015. A treatment plan update was due by February 27, 2015 and was not completed as of the date of the licensing inspection.
Client #21 was admitted on November 24, 2014 and discharged on January 26, 2015. The comprehensive treatment plan was completed on November 27, 2014. A treatment plan update was due by December 27, 2015 and was not completed until January 15, 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All active clients will have updated treatment plans completed by program counselor and reviewed by Program Director by July 31, 2015.
Clinical Supervisor will review all Treatment Plans for updates every thirty days for each resident.
Clinical Supervisor will sign off on each Treatment Plan reviewed.
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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.
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Observations
Based on twenty-five client records reviewed thirteen contained a treatment plan, five of the thirteen failed to proivde counseling services as stated on the treatment plan.
The findings include:
Twenty-five client records were reviewed on May 14-15, 2015. Counseling services are required to be provided according to the treatment plan in thirteen client records. The facility did not document counseling services provided according to the treatment plan in client records, # 4, 5, 6, 7 and 8.
Client #4 was admitted on April 20, 2015 and still an active client. Client #4's treatment plan dated May 8, 2015 states that individual sessions will occur once per week. The facility failed to conduct an individual session as of the date of the treatment plan and as of the date of the licensing inspection.
Client #5 was admitted on April 17, 2015 and still an active client. Client #5's treatment plan dated April 24, 2015 states that individual sessions will occur once per week and group sessions 5 times a week. It is documented that the client had no individual session documented and 7 group sessions documented, April 26, 2015, April 28, 2015, April 30, 2015, May 4, 2015, May 7, 2015, May 12, 2015 and May 13, 2015.
Client #6 was admitted on May 4, 2015 and still an active client. Client #6's treatment plan dated May 4, 2015 states that individual sessions will occur once per week and group sessions once per week. It is documented that the client had once group session, May 13, 2015 and two individual sessions, May 12, 2015 and May 17, 2015.
Client #7 was admitted on December 1, 2014 and discharged on February 2, 2015. Client #7's treatment plan dated December 8, 2014 states that individual sessions will occur once per week and group sessions 5 times a week. It is documented that the client had 3 individual sessions documented, January 7, 2015, January 13, 2015 and January 22, 2015 and 4 group sessions documented, January 5, 2015, January 13, 2015, January 14, 2015 and January 26, 2015.
Client #8 was admitted on October 14, 2014 and discharged on December 15, 2014. Client #8's treatment plan dated November 7, 2014 states that individual sessions will occur once per week and group sessions 5 times a week. It is documented that the client had 2 individual session documented, December 5, 2014 and December 12, 2014 and 6 group session documented, December 3, 2014, December 4, 2014, December 8, 2014, December 9, 2014, December 10, 2014 and December 11, 2014.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will audit charts for accuracy. Any deficiency will be corrected with 48 ? 72 hours by counselor and documents that correction was made.
All individual sessions will be held weekly. Upon arrival, each new resident will be seen by program counselor for individual session within the first seven days of arrival. Each individual session will continue to be held weekly for all new and active residents.
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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:
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Observations
Based on a review of client records, the facility failed to maintain a complete record in seventeen of twenty-five records reviewed.
The findings include:
Twenty-five client records were reviewed on March 14-15, 2015. The facility failed to maintain a complete record for client's, #1, 3, 4, 5, 6, 7, 8, 9, 11, 13, 14, 15, 16, 17, 18, 19, and 21.
Client #1 was admitted on March 23, 2015 and was still an active client. The facility failed to document client #1's record of service as of the date of the licensing inspection.
Client #3 was admitted on April 6, 2015 and was still an active client. The facility failed to document client #3's record of service as of the date of the licensing inspection.
Client #4 was admitted on April 20, 2015 and was still an active client. The facility failed to document client #4's record of service as of the date of the licensing inspection.
Client #5 was admitted on April 17, 2015 and was still an active client. The facility failed to document client #5's record of service as of the date of the licensing inspection.
Client #6 was admitted on May 4, 2015 and was still an active client. The facility failed to document client #6's record of service as of the date of the licensing inspection.
Client #7 was admitted on December 1, 2014 and discharged on February 2, 2015. The facility failed to document a follow-up as of the date of the licensing inspection.
Client #8 was admitted on October 14, 2014 and discharged on December 15, 2014. The facility failed to document a follow-up as of the date of the licensing inspection.
Client #9 was admitted on April 6, 2015 and was still an active client. The facility failed to document client #9's record of service as of the date of the licensing inspection. Additionally, client #9's case consultation was signed by the counselor on April 8, 2015 and the clinical supervisor signed on April 13, 2015. The case consultation only documented the counselor as being a part of the case consultation.
Client #10 was admitted on March 24, 2015 and was still an active client. The facility failed to document client #10's record of service as of the date of the licensing inspection. Additionally, client #10's case consultation was signed by the counselor on March 25, 2015 and the clinical supervisor signed on April 13, 2015. The case consultation only documented the counselor as being a part of the case consultation.
Client #11 was admitted on April 27, 2015 and was still an active client. The facility failed to document client #11's record of service as of the date of the licensing inspection.
Client #13 was admitted on March 23, 2015 and was still an active client. Client #13's aftercare was signed by the counselor on May 18, 2015, but the date of the licensing inspection was May 15, 2015. Additionally, client #13's discharge summary was signed by the counselor on May 18, 2015 and the clinical supervisor signed but didn't date. Both the aftercare plan and discharge was signed and dated prior to the date they documented on those forms.
Client #14 was admitted on April 16, 2015 and was still an active client. The facility failed to document client #14's record of service as of the date of the licensing inspection.
Client #15 was admitted on April 13, 2015 and was still an active client. The facility failed to document client #15's record of service as of the date of the licensing inspection.
Client #16 was admitted on March 30, 2015 and was still an active client. The facility failed to document client #16's record of service as of the date of the licensing inspection.
Client #17 was admitted on March 23, 2015 and was still an active client. The facility failed to document client #17's record of service as of the date of the licensing inspection.
Client #18 was admitted on December 1, 2015 and discharged on February 2, 2015. Client #18's case consultation was signed by the counselor on January 28, 2015 and the clinical supervisor signed on January 30, 2015. The case consultation only documented the counselor as being a part of the case consultation. Additionally, the facility failed to document client #18's discharge summary and follow-up as of the date of the licensing inspection.
Client #19 was admitted on January 20, 2015 and discharged on March 23, 2015. The facility failed to document client #19's discharge summary and follow-up as of the date of the licensing inspection.
Client #21 was admitted on November 24, 2014 and discharged on January 26, 2015. The facility failed to document client #21's discharge summary and follow-up as of the date of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeated citation for licensing inspections October 13, 2014 and October 22, 2013.
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Plan of Correction
Clinical Supervisor will review each chart for accurate records of service, weekly as well as monthly.
Clinical Supervisor will have check record of service documented on audit sheet for frequency of submission.
Clinical Supervisor and Inpatient Director will review each chart for accuracy monthly.
Program counselors will complete follow- ups within seven days of discharge and documents each follow up in clinical chart. Those clients that were discharged in the past thirty days will receive follow -ups from Clinical Supervisor and or Program Director.
Case consults will be conducted along with treatment plans/treatment plan updates, monthly, then reviewed by Clinical Supervisor and or Program Director.
Discharge and aftercare plans will be reviewed prior to any clients discharge date, up to and or including day of discharge.
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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.
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Observations
Based on the review of client records, the facility failed to document that work done by the client at the project is an integral part of the treatment and rehabilitation plan in eleven of twenty-five client records.
The findings include:
Twenty-five client records were reviewed on May 14 - 15, 2015. Verification of work as an integral part of the treatment and rehabilitation plan was required in twenty-one client records. The facility did not document work as an integral part of the treatment and rehabilitation plan in client records #1, 2, 3, 4, 5, 13, 15, 18, 19, 20 and 21.
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Plan of Correction
Clinical Supervisor will review each chart for record of work done and maintained for accuracy and completion.
Each program counselor will review all Record of Service weekly for verification of treatment attendance.
Clinical Supervisor will review all Record of Service during weekly supervision.
Program Director will conduct random audits of all clinical charts bi-weekly for proper documentation.
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