INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 1, 2012 through October 2, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Habit OPCO, Inc.-Allentown, 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.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the "Staffing Requirements Facility Summary Reports" (SRFSR) for three of the facilities in the Project, the Project failed to ensure that there was one full-time clinical supervisor for every eight full-time equivalent (FTE) counselors in the Project.
The findings include:
The SRFSR for the three facilities reviewed that make up part of the the project list a total of 11 full-time counselors and 3 full-time lead counselors. The total of the hours per week provided to the project by counselors equates to 14 FTE counselor positions within the project.
The SRFSR for the three facilities reviewed within the project revealed that no employees were listed as a full-time clinical supervisor. The SRFSR listed each of the three facility having a part-time clinical supervisors as facility directors; therefore they are unable to provide full-time clinical supervision. A full-time equivalency of 14 counselors would require a minimum of 1 full-time clinical supervisors and one part-time clinical supervisor within the project.
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Plan of Correction
Habit OPCO will change the title and responsibilities of two of the projects current Facility Directors to Clinical Directors (by December 17, 2012). The new responsibilities ensure that the Clinical Directors will work as Clinical Supervisors as defined in PA regulations for Drug and Alcohol Treatment Facilities. This change will ensure that Habit OPCO has an appropriate amount of Clinical Supervision for sixteen (16) clinicians in the Pennsylvania Project. Habit OPCO currently employs fifteen (15) clinicians. Additionally, to ensure that this does not recur, Habit OPCO will begin recruiting for a third (3rd) Clinical Director for the project, with an anticipated start date no later than February 2013. This will ensure that Habit has sufficient Clinical Supervision for twenty-four (24) clinicians. By December 17, 2012, Habit OPCO will appoint a Facility Director to oversee all four facilities. Notification of this change (for electronic plans of correction) will be submitted to the Pennsylvania Department of Drug and Alcohol Programs no later than December 21, 2012. |
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 a review of personnel records, the facility failed to verify that each counselor met the educational and experiential qualifications for the position.
The findings include:
Four personnel records requiring verification of educational and experiential qualifications were reviewed on October 1, 2012. The facility failed to verify the educational and experiential qualifications in one out of four records reviewed, record #7.
Employee # 7 was hired on June 4, 2012 as a counselor. At the time of the inspection, the only documentation in employee #7 ' s record was a degree from a foreign university and documentation that the employee obtained a Doctor in Medicine degree from that country. There was no documentation for current licensure in the Commonwealth as a physician, nor was there any verification that he completed a degree that met the requirements as outlined in the standard.
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Plan of Correction
The site Program Director and the Director of PA Operations reviewed findings of policy 704.7 during site visit on October 2, 2011.
The Program/ Clinical Director will work with the Director of HR ensure potential counselors meet specified qualifications upon hire. Degrees from Foreign Universities will be verified and transcripts will be included as documented proof that the degree meets the specified qualifications. All documentation will be in employee's file.
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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of agency policy and procedures, staffing requirements facility summary report, and staff personnel records the facility did not document staff training needs assessments in two of seven records reviewed.
The findings include:
Based on a review of agency policy and procedures, staffing requirements facility summary report on October 2, 2012, an interview with the facility director on October 1, 2012, and a review of personnel records, the facility failed to document staff training needs assessments. According to the policy and procedures, staff will complete a questionnaire each December and return them to the program director. According to the facility's policy the training year is based on the calendar year of January through December. Seven personnel records were reviewed on October 1, 2012. The facility failed to document needs assessments for employee's # 2 and 3.
Employee # 2 was hired August 1, 2011. The facility failed to document an assessment of the staff training needs.
Employee # 3 was hired on December 7, 2008 and was promoted to her current position on January 4, 2010. The facility failed to document an assessment of the staff training needs.
This finding was discussed with the facility director and director of Pennsylvania operations on October 2, 2012 and was not disputed.
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Plan of Correction
The Program Director reviewed regulation 704.11 with the Director of PA Opperations during the site visit on October 2, 2012.
The Program Director will ensure training needs assessments are completed with all new hires and updated annually for all existing clinicians within the stipulated time frame, as instructed by policy and procedure.
Furthermore, the administrative Assistant will conduct quarterly reviews of employee files to ensure training needs assessments have been completed and updated annually.
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704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the policy and procedures, the facility failed to document an overall plan for addressing training needs, as required by regulation.
The findings include:
On October 1, 2012, the policy and procedures were reviewed. Per the agency policy and procedures, the facility director will collect training data and he/she will formulate a comprehensive training plan by the end of January each year. The regulation requires an overall plan for addressing training needs to be completed as a component of a staff development program. According to the facility's policy, the training year is based on the calendar year (January 2012 - December 2012). The facility failed to document the completion of an overall training plan for the 2012 training year.
The facility director was interviewed on October 1, 2012. The facility director confirmed that a plan for addressing training needs of staff was not completed.
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Plan of Correction
The Program Director reviewed the training requirements outlined by policy 704.11 with the PA Director of Operations during the site visit on October 1, 2012.
As required by policy and procedure, the Program Director will collect training data from staff training needs assessments, as well as state and company policy. The information gathered wil be formulated into a comprehensive training plan designed to promote staff development. The proceedure will be completed by the end of January each year as stipulated by company policy and procedure.
To ensure compliance, the overall completed training plan will be presented to Director of Operations for approval and sign off. Copies of the plans will be filed and available for future site visits. |
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 staffing requirements facility summary report and personnel records, the facility failed to provide documentation of individual training plans in six out of seven personnel records reviewed.
The findings include:
The facility staffing requirements summary report and personnel records were reviewed on October 1 and 2, 2012. Seven employee records were reviewed. The facility failed to document a individual training plan in employee records # 1 , 2, 3 ,4, 6, and 7.
An interview with the facility director, confirmed that the training plans for 2012 were not completed on staff.
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Plan of Correction
The Program Director reviewed the policy for individual training plans in regulation 704.11 with the Director of PA Operations during the site visit on October 2, 2012.
The Program Director and Clinical Supervisor will complete writted individual training plans with employees based on their training needs assessment summeries, as well as state and company policy. Training plans will be appropriate to each employees's skill level, and will be completed with supervisor. The individual plans will be revised annually as stipulated by policy and procedure, and will be completed at the time of employee's annual performance evaluation.
Furthermore, the administrative Assistant will conduct quarterly reviews of employee files to ensure training needs assessments have been completed and updated annually
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704.12(a)(6) LICENSURE OutPatient Caseload
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.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report form completed by the facility on October 2, 2012, the facility failed to ensure that staff caseloads remained at or under 35:1.
The findings include:
The Staffing Requirements Facility Summary Report form completed by the facility was reviewed on October 2, 2012. The form listed one lead counselor, four counselors, and a clinical supervisor/facility director as clinical staff .The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 37.5 hours per week.
Based the total number of hours per week that the facility reported the employees devoted to their clients, the total number of hours in the facility's standard work week 37.5 hours, and the total number of clients assigned to the following employees on October 2, 2012 employees # 5 and 6 exceeded the allowable maximum 35:1 caseload.
The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients 'treatment by the facility's standard workweek.
The number of hours per week devoted by Employee # 5 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 37.5 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee #5 had 39 active clients on October 2, 2012.
Employee # 5 (37.5/37.5 = 1 FTE 39 clients/1 FTE = 39:1 caseload)
The number of hours per week devoted by Employee #6 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 37.5 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 6 had 40 active clients on October 2, 2012
Employee # 6 (37.5/37.5 = .1 FTE 40 clients/1 = 40:1 caseload)
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Plan of Correction
The Program Director reviwed policy 704.12 in reference to maximum client/staff and client/ counselor ratios with the Director of PA Operations during the site visit on October 2, 2012.
The program Director will insure compliance of this regulation by running and reviewing a counselor caseload summary report prior to assignment of any new admit. This will allow viewing of actual client / counselor ratios insuring total compliance with governing regulation 704.12 (a)(b).
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709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the annual report, the facility failed to include a financial statement of income and expenses in the annual report.
The findings include:
The annual report for the 2011 year was reviewed on October 1, 2012. The annual report failed to include a financial statement of income and expenses.
This is a repeat citation from the October 11-12, 2011 licensing inspection.
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Plan of Correction
The site Program Director and the Director of PA Operations reviewed findings of policy 709.22 during site visit on October 2, 2011.
In response to this deficiency, the Program Director will include a financial statement of income and expenses in future site annual reports to ensure compliance with this policy/regulation.
This required information will be added to the outlined information to be included in the annual report so it will not be absent from future reports.
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709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
Based on the review of the agency policy and procedure manual and administrative reports on October 1, 2012, the facility failed to document collaboration between the project director and governing body in formulating annual goals and objectives for the current fiscal year.
The findings included:
The annual onsite licensing inspection was conducted October 1-2, 2012 at this facility. As part of the inspection the agency policy and procedure manual and administrative reports were reviewed. No documentation was presented to support the fact that the Project Director and the governing body collaborated on the formulation of goals and objectives for 2012. When this issue was identified by Division staff it was brought to the attention of the Facility Director who was assisting with the licensing process. The Facility Director was unable to produce the required documentation. The findings were reviewed with the Facility Director and Director of Pennsylvania Operations on October 2, 2012 and were not disputed.
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Plan of Correction
The Program Director, Director of PA Operations, and the Project Director reviewed the findings from policy 709.23 on October 15, 2012, in reference to the documented collaboration of formulated annual goals and objectives between the Project Director and governing body.
The Program Director will work with the Director of PA Operations in obtaining copies of goals and objections set in place for the fiscal year by the Project Director and the governing body , paying closer attention to the documentation that shows collaboration between the two, by providing copies of meeting minutes a minimum of 1 x annually. The Program Director will request these documents after the first meeting of the fiscal year.
These meeting minutes will become part of the required meeting minutes to be logged so they will not be missed in the future and are available during future site visits. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on the review of the facility's administrative documentation, the facility failed to document project goals and objectives which include time frames and available resources.
The findings include:
The facility's administrative documentation was reviewed on October 1, 2012. The facility director provided goals and objectives for 2012, however, they failed to include time frames and available resources. The goals and objectives also failed to indicate whether they were based on a calendar year or fiscal year.
This finding was reviewed with the facility director and was not disputed.
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Plan of Correction
The site Program Director and the Director of PA Operations reviewed findings of policy 709.23 during site visit on October 2, 2011. The Program Director and Director of PA Operations will work with the Project Director to formulate annual goals and objectives that include documented timeframes and available resources. Furthermore, the documentation will clearly state if the goals and objectives are based on a calendar or fiscal year as stipulated by the regulation.
The formulated goals and objectives will be included as a required component of the quarterly operations meeting. Copies of the documented plan which will include timeframes and resources will be filed and available for viewing during future site visits. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of patient records, the facility failed to document the lengths and patterns related to the patient's progression of drug and alcohol use in six of six records.
The findings were:
Ten patient records were reviewed on October 1-2, 2012. Six records were reviewed for required documentation of drug and alcohol history that included lengths and patterns related to the patient's progression of use. The facility failed to document the lengths and patterns related to the patient's progression of use in patient records # 1, 2, 4, 5, 9 and 10.
This finding was discussed with the facility director and lead counselor and were not disputed.
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Plan of Correction
The site Program/ Clinical Director, Lead Counselor, and the Director of PA Operations reviewed findings of policy 709.91 during site visit on October 2, 2011.
The Program/Clinical Director and the site Lead Counselor will ensure the intake and admissions procedure includes documentation of the patient's drug and/or alcohol history that includes lengths and patterns related to the patient's progression of use.
A review of this deficiency was presented to the clinical staff on October 11, 2012 during group supervision. A thorough review of policy 709.91 will occur again on November 15,2012 to ensure changes have been implemented.
Furthermore, Program/Clinical Director, Lead Counselor, and peer chart reviews will pay close attention to this policy and expectation.
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709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based on a review of patient records, the facility failed to document a physical examination that included the patient's general appearance in eight of eight records reviewed.The findings include:
Ten patient records were reviewed on October 1-2, 2012. The facility failed to document general appearances on the physical examination forms in patient records # 1, 2, 3, 4, 5, 7, 8, and 10.
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Plan of Correction
The site Program Director, Nurse Manager, and the Medical Director reviewed policy 709.91 and its deficiency on October 10, 2012.
The Program Director and Nurse Manager have added a section to the physical examination form to include a space for documentation of the patient's general appearance which will be completed as part of the intake and admissions procedure.
The Medical Director will coach other physicians on the documentation of general appearance on physical examination forms. The Nurse Manager will review all physical examination forms upon completion to ensure compliance with this regulation.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of patient records, the facility failed to document a psychosocial evaluation in three of seven records as required.
The findings include:
Ten patient records were reviewed on October 1- 2, 2012. Seven patient records were reviewed for a psychosocial evaluation as required by the regulations. The facility's policy and procedures required the psychosocial evaluations to be documented within thirty days of admission. The facility failed to document psychosocial evaluations in patient records # 2, 3, and 4.
Patient # 2 was admitted on July 30, 2012. The psychosocial evaluation was due by August 30, 2012. The facility failed to document a psychosocial evaluation in this patient record as of the date of the inspection.
Patient # 3 was admitted on July 11, 2012. The psychosocial evaluation was due by August 11, 2012. The facility failed to document a psychosocial evaluation in this patient record as of the date of the inspection.
Patient # 4 was admitted on August 22, 2012. The psychosocial evaluation was due by September 22, 2012. The facility failed to document a psychosocial evaluation in this patient record as of the date of the inspection.
This finding was discussed with the facility director and lead counselor and was not disputed.
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Plan of Correction
The Program/Clinical Director, Lead Counselor, and Director of PA Operations reviewed the findings of policy 709.91 in reference to treatment plans on October 2, 2012. A review of the policy and its findings was discussed with the clinical staff on October 11, 2012 during a clinical staff meeting. A thorough review will occur again on November 15, 2012 to ensure the following corrective action is being implemented to ensure compliance.
The Program/ Clinical Director and Lead Counselor will ensure completion of the psychosocial assessment within 30 days of admission by reviewing and signing off on all completed psychosocial assessments.
In addition, compliance of this regulation will be monitored by running weekly services due reports to be used during individual supervision and through scheduled Program/ Clinical Director, Lead Counselor, and peer chart reviews.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 the review of patient records, the facility failed to develop individual treatment and rehabilitation plans with the patient as stated in agency policy in six of seven patient records.
The findings include:
Ten patient records were reviewed on October 1-2, 2012. Seven of the ten patient records records were required to have an individual treatment and rehabilitation plans developed with the patient within thirty days of admission, as per agency policy.
Patient records #1, 2, 3, 4, 9,and 10 did not contain individual treatment and rehabilitation plans that were developed with the client within thirty days of admission.
Patient #1 was admitted on July 20, 2012. An individual treatment and rehabilitation plan was due to be developed with the client by August 20, 2012. The individual treatment and rehabilitation plan was developed on September 12, 2012.
Patient # 2 was admitted on July 30, 2012. An individual treatment and rehabilitation plan was due to be developed with the client by August
30, 2012. The individual treatment and rehabilitation plan was developed on September 18, 2012.
Patient #3 was admitted July 11, 2012. An individual treatment and rehabilitation plan was due to be developed with the client by August 11, 2012. The facility failed to document an individual treatment and rehabilitation plan as of the date of the inspection.
Patient #4 was admitted August 22, 2012. An individual treatment and rehabilitation plan was due to be developed with the client by September 22, 2012. The facility failed to document an individual treatment and rehabilitation plan as of the date of the inspection.
Patient #9 was admitted on March 20, 2012 and discharged on September 18, 2012. An individual treatment and rehabilitation plan was due to be developed with the client by April 20, 2012. The individual treatment and rehabilitation plan was developed on May 21, 2012.
Patient #10 was admitted on May 15, 2012 and discharged on August 21, 2012. An individual treatment and rehabilitation plan was due to be developed with the client by June 15, 2012. The individual treatment and rehabilitation plan was developed on August 21, 2012.
The findings were reviewed with the facility director and the lead counselor and were not disputed.
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Plan of Correction
The Program/Clinical Director, Lead Counselor, and Director of PA Operations reviewed the findings of policy 709.92 in reference to treatment plans on October 2, 2012. A review of the policy and its findings was discussed with the clinical staff on October 11, 2012 during a clinical staff meeting. A thorough review will occur again on November 15, 2012 to ensure the following corrective action is being implemented to ensure compliance.
The Program/ Clinical Director and Lead Counselor will ensure that all treatment and rehabilitation plans are completed with the client within the stipulated 30 day period. All completed treatment plans will be reviewed and signed off on by a clinical supervisor.
In addition, compliance of this regulation will be monitored by running weekly services due reports to be used during individual supervision to identify when this service is due, and through scheduled Program/ Clinical Director, Lead Counselor, and peer chart reviews.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of patient records, the facility failed to document treatment plan updates as per agency policy in two of three patient records.
The findings include:
Ten patient records were reviewed on October 1-2, 2012. According to facility policy, treatment and rehabilitation plans shall be reviewed and updated at least every 60 days. Treatment and rehabilitation plans were not updated at least every 60 days in patient records # 7 and 8.
Patient #7 was admitted on May 18, 2009 and discharged on September 10, 2012. The record contained a treatment plan update on June 13, 2012. The next treatment and rehabilitation plan was due to be reviewed and updated by August 13, 2012. The facility documented the treatment and rehabilitation plan on September 26, 2012, after the patient was discharged.
Patient #8 was admitted on July 15, 2011 and discharged on September 21, 2012. The record contained a treatment plan update on June 1, 2012. The next treatment and rehabilitation plan was due to be reviewed and updated by August 1, 2012. The facility documented the treatment and rehabilitation plan on August 28, 2012.
An interview with the facility director and lead counselor confirmed these findings and were not disputed.
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Plan of Correction
The Program/Clinical Director, Lead Counselor, and Director of PA Operations reviewed the findings of policy 709.92 in reference to treatment plans reviews on October 2, 2012. A review of the policy and its findings was discussed with the clinical staff on October 11, 2012 during a clinical staff meeting. A thorough review will occur again on November 15, 2012 to ensure the following corrective action is being implemented to ensure compliance.
The Program/ Clinical Director and Lead Counselor will ensure that all treatment and rehabilitation plans are updated at least every 60 days. All completed treatment plan updates will be reviewed and signed off on by a clinical supervisor.
In addition, compliance of this regulation will be monitored by running weekly services due reports to be used during individual supervision to identify when this service is due, and through scheduled Program/ Clinical Director, Lead Counselor, and peer chart reviews.
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709.93(a)(10) LICENSURE Client records
709.93. 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.
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Observations
Based on a review of patient records, the facility failed to document a discharge summary that included the patient's reason for treatment, services offered, response to treatment and client's status upon discharge in two of four patient records.
The findings include:
Ten patient records were reviewed on October 1-2, 2012. Four records were reviewed for discharge summaries. According to the facility policy, discharge summaries are to be completed within one week from patient's discharge date. The facility failed to document a discharge summary in records # 7 and 10.
Patient # 7 was admitted on 5/18/2009 and discharged on 9/10/2012. The discharge summary was due 9/17/2012. The facility failed to document a discharge summary in this patient record as of the date of the inspection.
Patient # 10 was admitted on 5/15/2012 and discharged on 8/21/2012. The discharge summary was due 8/28/2012. The facility failed to document a discharge summary in this patient record as of the date of the inspection.
This finding was discussed with the lead counselor and was not disputed.
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Plan of Correction
The Program/Clinical Director, Lead Counselor, and Director of PA Operations reviewed the findings of policy 709.93 in reference to discharge plans on October 2, 2012. A review of the policy and its findings was discussed with the clinical staff on October 11, 2012 during a clinical staff meeting. A thorough review will occur again on November 15, 2012 to ensure the following corrective action is being implemented to ensure compliance.
The Program/ Clinical Director and Lead Counselor will ensure that all discharge summaries are completed within the 7 day specified time frame. All completed discharge plans will be reviewed and signed off on by a clinical supervisor.
In addition, compliance of this regulation will be monitored by running weekly services due reports to be used during weekly individual supervision sessions to identify when service is due, and through scheduled Program/ Clinical Director, Lead Counselor, and peer chart reviews.
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