INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection, conducted on March 11 - 12, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Coatesville Treatment Center 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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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report form, the facility failed to document complete and accurate information on the staffing form.
The findings include:
The Staffing Requirements Facility Summary Report form was completed by the facility on February 24, 2015. The facility failed to document all of the educational components and the current training plans.
Page 2 - The facility failed to document all of the required components under the education column to include institution, degree, major, and date of issue for seven out of seven clinical staff.
Page 4 & 7 - The facility failed to document current individual training plans for seven out of seven clinical staff, and for all support staff on page seven.
The facility was given until the completion of the inspection to update the information.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director will ensure that the Staffing Form is completed with accruacy during the presummition process. If any corrections are needed, Clinic Director will submit all manual corrections during the presummition process.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report form, the facility failed to ensure all staff persons receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training.
The findings include:
The Staffing Requirements Facility Summary Report form was completed by the facility on February 24, 2015. The facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
Employee # 4 is a front office assistant that was hired February 22, 2001. HIV/AIDS training and TB/STD training was to be completed within the first 2 years of employment or by February 22, 2003. The facility failed to ensure employee # 4 completed the required training's at the time of inspection on March 12, 2015.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 was actually hired on February 22, 2011 as a part-time front office assistant. She completed internal trainings offered by CRC Health Group. As there are limited trainings in the local vicinity, this employee will be registered for HIV/AIDS and TB/STD as registration on the DDAP website becomes available within a 30 miles radius. Clinic Director will ensure that they are registered by 7/31/2015. Front office staff requested registration for trainings in May, but have not received a confirmation. Clinic Director has also sent a follow-up. Clinic Director will which out to SCA authority by 4/16/2015 if no confirmation of regaistration is received.
Going forward Clinic Director will ensure that all administrative staff including Front Office Staff will receive HIV & TB/STD training within the first year of being hire. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to provide documentation of fire extinguisher training upon staff employment.
The findings include:
Three personnel records were reviewed on March 12, 2015 to verify that staff had been instructed in the use of a fire extinguisher upon employment. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel record, # 2 and 3.
Employee # 2 was hired April 7, 2014. Fire extinguisher training was due upon hire; however the facility failed to provide documentation of this training at the time of the inspection on March 12, 2015.
Employee # 3 was hired March 31, 2014. Fire extinguisher training was due upon hire; however the facility failed to provide documentation of this training at the time of the inspection on March 12, 2015.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #2 and Employee #3 received Healthy & Safety training at hire. All detail regarding Health & Safety trainings will be maintained in a the Health & Safety binder. The Certificates used for proof of completeion has been updated to include the title of the training and the date completed. The certificate will be attached to the detailed training completion report that includes the fire extinguisher training. The detail regarding the training will also be maintained in the personnel files. Clinic Director will submit detail regarding the Health & Safety trainings along with a copy of the certificates during the presummition. Health & Safety Officer will provide Health & Safety training to all new hires upon hire. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's fire drill log, the facility failed to conduct unannounced fire drills at least once a month and the fire drill logs were missing required components.
The findings include:
The facility's fire drill log was reviewed on March 12, 2015, covering the period of May 2014 through February 2015. The facility failed to conduct an unannounced fire drill during the months of July 2014, August 2014, and October 2014.
In addition, the facility is to maintain a written fire drill record that includes the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
The facility failed to include on their fire drill logs the amount of time it took for evacuation, the exit route used, and whether the fire alarm or smoke detector was operative.
The findings were reviewed with facility staff during the licensing process
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Plan of Correction
Clinical Supervisor created a yearly calendar for the Health and Safety Officer to utilize to track all monthly random drills and to ensure they are completed each month. Clinical Supervisor will review the calendar each month to ensure they are completed. The process was reviewed with the Health and Safety Officer on 3/16/2015. Additionally, the Health & Safety Officer will ensure to include on the fire drill logs the amount of time it took for evacuation, the exit route used, and whether the fire alarm or smoke detector was operative.
Health & Saftey Officer will complete all require drills each month and document the results. All documentation relating to Healthy & Safety drills will continue to be maintained in the Health & Safety Binder. Clinical Supervisor will also review the fire drill log each month to ensure all documentation has been captured. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to provide documentation that all personnel are trained to perform assigned tasks during emergencies.
The findings include:
Three personnel records were reviewed on March 12, 2015, to verify that staff had been
trained to perform assigned tasks during emergencies. The facility failed to document the completion of emergency training in personnel record, # 2 and 3.
Employee # 2 was hired April 7, 2014. Emergency training was due upon hire; however the facility failed to provide documentation of this training at the time of the inspection on March 12, 2015.
Employee # 3 was hired March 31, 2014. Emergency training was due upon hire; however the facility failed to provide documentation of this training at the time of the inspection on March 12, 2015.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #2 and Employee #3 received Healthy & Safety training at hire. All detail regarding Health & Safety trainings will be maintained in a the Health & Safety binder. The Certificates used for proof of completeion has been updated to include the title of the training and the date completed. The certificate will be attached to the detailed training completion report that includes the fire extinguisher training. The detail regarding the training will also be maintained in the personnel files. Clinic Director will submit detail regarding the Health & Safety trainings along with a copy of the certificates during the presummition. Health & Safety Officer will provide Health & Safety training to all new hires upon hire. |
709.22(e) 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:
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Observations
Based on a review of administrative documentation, the governing body failed to make an annual report available to the public.
The findings include:
The facility's administrative documentation was reviewed on March 12, 2015.
The governing body failed to provide the annual report for the 2013/2014 fiscal year during the pre-submission process which was due February 20, 2014 or during the annual inspection which was conducted March 11 - 12, 2015.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director will submitted the Annual Report that is completed internal by Clinicl Director during the pre-submission as well as the latest version of the Governing Body. Morning Star is the organization that produces the Governing Body reports typically by the end of the first Quarter. The Annual Report that is created by Clinic Director includes strategic planning goals.
The facility specific Annual Report that includes such items as strategic planning, orgainization chart, and items accomplished over the year will be completed by February 15th by Clinic Director. This report will be sent during the presummition process along with the proof of publication. The Annual Report provided and created by the Governing Body for Acadia Healthcare will be completed by the end of Quarter 1 depending on the fiscal closing. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on a physical plant inspection, the facility failed to secure client records within locked storage containers.
The findings include:
A physical plant inspection was conducted on March 12, 2015. The facility failed to secure client records within locked file cabinets in building A and B.
Building A - The facility failed to maintain client records within locked file cabinets as client records are stored on open shelves.
Building B - The facility failed to maintain client records within locked file cabinets as client records are stored on open shelves. This is a multi-purpose room which contains a fax machine and is accessible by all staff. In addition, during the physical plant inspection a stack of loose client documents, filing or a client record, was observed not in a folder or file, and was placed on a shelf by the door.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on 42 CFR regulation charts must be in a locked container which our chart room is considered a locked container. Both chart rooms were approved previously by state surveyors as both rooms were equipped with a locked key pad with a code that only staff have access to. Both rooms are locked at all times.
Photos were taken of both chart rooms and submitted to the surveyor and supervisor to review. Chart Room A was approved. Chart Room B was not approved. Locked file cabinets will be added to Chart Room B. |
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 comply with the limitations imposed by 4 Pa. Code 255.5 for an informed and voluntary consent for the disclosure of information in three of twelve client records reviewed.
The findings include:
4 Pa. Code 255.5 states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed
Twelve client records requiring documentation of informed and voluntary consents were reviewed on March 12, 2015. The facility failed to obtain an informed and voluntary consent to release in client records, # 3, 15 and 16.
Client # 3 was admitted to the program on November 21, 2014. Six consent to release forms were reviewed in client #3's record and the facility failed to document that client # 3 was offered a copy of those consent to release forms. In addition, one consent to release did not include the a dated witness signature.
Client # 15 was admitted to the program on January 29, 2015. The facility documented the release of information to include client # 5's medication records to a governmental agency; this information exceeds the limitations imposed at 4 Pa. Code 255.5.
On 1/29/15 the facility documented the release of 'dates of attendance' on consent to release to a governmental agency. The licensing specialist inquired about this release and was informed that the patient ' s methadone dosing log sheet or medication record was released as a means to verify dates for transportation payment. In addition, the facility failed to offer seven consents to client # 15.
Client # 16 was admitted to the program on November 5, 2014. The facility documented the release of 'All records' to a governmental agency on 11/7/14. This release constitutes a general consent and does not comply with 4 Pa. Code 255.5. In addition, the facility failed to offer two consents to client # 16.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All information requested by patients to be submitted to Rover Transportation is reviewed by the patient. The patient has the right to limit any information including medication. Rover is a transportation services that is provided through local government funding (Chester County Department of Public Welfare) as apart of the benefits.
Consents to release information to Rover Transporation are only completed as needed depending on county of residence and their financial payment status. Information was requested by Rover in order to release clients travel reimbursement checks. Proof of attenednce was needed to release the check and per the clients request, their dispensing history was released in order for them to be reibursed travel for those days.
Clinical Supervisors will conduct a training with staff on 4/6/2015 to review consent to release information to ensure all appropriate releases are utilized and all dates are entered and all check boxes are marked. All consent of releases will be completed as needed to release only the information covered on the release. Clinical Supervisors will provided monthly random chart audits to insure all consent of release are updated as needed and filled out correctly. |
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 a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in two discharge records.
The findings include:
Two administratively discharged client records were reviewed on March 9, 2015. The facility failed to notified the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in client records, #13 and 14.
Client # 13 was admitted to the program on October 7, 2014 and administratively discharged on March 2, 2015. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project as of the date of the licensing inspection.
Client # 14 was admitted to the program on February 27, 2014 and administrate discharged on January 5, 2015. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project as of the date of the licensing inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All involuntary tapers are provided with a termination letter. All tapers related to medical necessity will continue to be documented by the Medical Director and maintained in the medical section of the chart. Medical Director will continue to document interventions used prior to the medical taper including the recommendation to a higher level of care. If the patient refuses a higher level of care, Medical Director will move forward with the medical taper. Going forward, patient will receive a letter of termination that will include the Medical Directors recommendation based off of an endangerment to their health (Based on illicit use and other contraindication with Medication Assisted Treatment). Clinic Director will maintain a copy of the documentation relating to involuntary tapers in the incident report binder. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the facility failed to complete a random urinalysis at least monthly that included a test for opiates, methadone, amphetamines, barbiturates, cocaine and benzodiazepines in two of ten patient records reviewed.
The findings include:
Ten patient records were reviewed on March 9, 2015. The facility failed to show documentation of a random urinalysis that included a test for opiates, methadone, amphetamines, barbiturates, cocaine and benzodiazepines in patient records, #1 and 5.
Patient # 1 was admitted to the program on October 8, 2014. The facility failed to complete a monthly drug-screening urinalysis for the month of December 2014.
Patient # 5 was admitted to the program on January 25, 2001. The facility failed to complete a monthly drug-screening urinalysis for the months of November 2014 and February 2015.
The findings were reviewed with facility staff during the monitoring inspection.
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Plan of Correction
Director of Nursing will run a report out of the dispensing system on the 15th of each month to ensure all patients have been given a UDS including auto fails. Clinical Supervisors will conduct training on 4/13/2015 with Clinical Staff regarding the importance of timely filing and the accountability factor for not having this done. Clinical Supervisors will also ensure that 4 Peer Reviews our conducted each year to cover each quarter and to ensure all documentation is included in the patient chart. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in five of eight patient records reviewed.
The findings include:
Eight patient records were reviewed on March 9, 2015. The facility failed provided 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment in patient records, #3, 6, 7, 8 and 9.
Patient #3 was admitted to the program on November 21, 2014. The facility failed to document 2.5 hours of psychotherapy per month for the following months; December 2014, January 2015 and February 2015.
December 2014 - no psychotherapy provided.
January 2015 - 1 hour of psychotherapy provided.
February 2015 - 2 hours of psychotherapy provided
Patient # 6 was admitted to the program on December 1, 2014. The facility failed to document 2.5 hours of psychotherapy per month for the following months; January 2015 and February 2015.
January 2015 - 1 hour of psychotherapy provided.
February 2015 - no psychotherapy provided.
Patient # 7 was admitted to the program on November 10, 2014. The facility failed to document 2.5 hours of psychotherapy per month for the following months; December 2014, February 2015.
Patient # 8 was admitted to the program on November 20, 2014. The facility failed to document 2.5 hours of psychotherapy per month for the following months; January 2015 and February 2015.
Patient # 9 was admitted to the program on December 17, 2013. The facility failed to document 2.5 hours of psychotherapy per month for the following months; December 2014, January 2015 and February 2015.
December 2014 - no psychotherapy provided.
January 2015 - 1 hour of psychotherapy provided.
February 2015 - 1 hour of psychotherapy provided
The findings were reviewed with facility staff during the monitoring inspection.
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Plan of Correction
Clinical Supervisors added counseling hours to the peer review tracking sheet to highlight the number of counseling hours completed. Clinical Supervisors will address all lack of counseling hours with Counselor and patient. Clinical Supervisors will run on the 15th and 25th of every month a counseling hours status report to ensure the hours are met. |
715.22(a) LICENSURE Patient grievance procedures
(a) A narcotic treatment program shall develop and utilize a patient grievance procedure.
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Observations
Based on a review of patient records, the facility failed to utilize a patient grievance procedure in two of two patient records.
The findings include:
Two administratively discharged patient records were reviewed on March 9, 2015. The facility failed to permit patient # 13 and 14 a full and fair opportunity to grieve an involuntarily termination.
Patient # 13 was admitted to the program on October 7, 2014 and administratively discharged on March 2, 2015. The facility failed to permit patient # 13 a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of a grievance by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposed of grievance adjudication.
Patient # 14 was admitted to the program on February 27, 2014 and administrate discharged on January 5, 2015. The facility failed to permit patient # 14 a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of a grievance by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposed of grievance adjudication.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All involuntary tapers are provided with a termination letter. All tapers related to medical necessity will continue to be documented by the Medical Director and maintained in the medical section of the chart. Medical Director will continue to document interventions used prior to the medical taper including the recommendation to a higher level of care. If the patient refuses a higher level of care, Medical Director will move forward with the medical taper. Going forward, patient will receive a letter of termination that will include the Medical Directors recommendation based off of an endangerment to their health (Based on illicit use and other contraindication with Medication Assisted Treatment). The letter will include the patient's right to grieve the termination. Clinic Director will maintain a copy of the documentation relating to involuntary tapers in the incident report binder. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to document an annual evaluation in one of two patient records reviewed.
The findings include:
Two patient records were reviewed on March 9, 2015, for documentation of an annual evaluation. The facility failed to document an annual evaluation in patient record, # 5.
Patient # 5 was admitted to the program on January 25, 2001. The facility failed to document an annual evaluation in patient record # 5 which was to start on the date of the patient's admission to the narcotic treatment program or by January 25, 2015.
The findings were reviewed with facility staff during the monitoring inspection.
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Plan of Correction
Clinical Supervisor will perform monthly chart audits to ensure all clinical and medical documentation including annual evaluations are displayed in the patient chart. Peer Reviews will also be conducted once a quarter to review all documentation in the charts. Ntifications of Corrections will be given for any missing data.
All patients upon admission will continue to be given a Physical that will be maintained in the chart. Director of nursing and Physician Assistant will continue to track all annual evaluations to ensure they are completed within the approapraite time frame, which would be prior to their anniversary/admission date.
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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 a review of client records, the facility failed to document a psychosocial evaluation in two of two drug-free client records reviewed.
The findings include:
Two drug-free client records were reviewed on March 9, 2015, for documentation of a psychosocial evaluation. The facility failed to document a psychosocial evaluation in client records, # 15 and 16.
Client # 15 was admitted to the program on January 29, 2015. The facility failed to document a psychosocial evaluation in client record # 15 as of the date of the licensing inspection.
Client # 16 was admitted to the program on November 5, 2014. The facility failed to sign, date and complete an evaluative psychosocial evaluation in client record # 16 as of the date of the licensing inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisors will implement a tracking system after patients are assigned a counselor within 2 weeks after admission to ensure that psychosocials are completed within 30 days of admission. The tracking system will be reviewed with Counselors on 4/13/2015. The Clinical SUpervisor will review the tracking sheet weekly. If psychosocials are not completed within the appropriate timeframe, Clinical Supervisor will ensure the patient is scheduled for the psychosocial review to be completed within a week of the initial finding. |
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 a review of client records, the facility failed to document an individual treatment and rehabilitation plan which was developed with a client and included support services in four of ten records reviewed.
The findings include:
Ten client records requiring documentation of an individual treatment and rehabilitation plan were reviewed on March 12, 2015. The facility failed to document an individual treatment and rehabilitation plan which was developed with a client and included support services in client records, # 2, 3, 6 and 7.
Client # 2 was admitted to the program on February 4, 2015. The facility documented an individual treatment plan on March 2, 2015; however, the plan was not developed with or signed by client # 2.
Client # 3 was admitted to the program on November 21, 2014. The facility documented the individual treatment plan on February 19, 2015; however, the plan did not contain documentation of proposed support services being offered.
Client # 6 was admitted to the program on December 1, 2014. The facility failed to document an individual treatment plan with client # 6 at the time of the licensing inspection on March 12, 2015.
Client # 7 was admitted to the program on November 10, 2014. The facility documented the individual treatment plan on November 19, 2014; however, the plan did not contain documentation of proposed support services being offered.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisors will review all preliminary treatment plans to ensure all support services are highlighted. Clinical Supervisors have reviewed the treatment plans of client #6 and provide the counselor with the correction to make.
Clinical Supervisor will conduct random chart reviews each month on all direct reports to review clinical documentation starting 04/6/2015. Peer Reviews will be conducted quarterly. The last Peer Review will be completed by 4/3/2015. All plans of correction from the Peer Review Results are due by 4/10/2015.
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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 client records, the facility failed to document treatment and rehabilitation plan updates at least every 60 days in four of ten records reviewed.
The findings include:
Ten client records requiring documentation of treatment plan updates at least every 60 days were reviewed on March 12, 2015. The facility failed to document treatment plan updates every 60 days in client records, # 7, 9, 12 and 16.
Client # 7 was admitted to the program November 10, 2014. The facility documented the individual treatment plan on November 19, 2014. The facility failed to document a treatment plan update at least every 60 days. There was no documentation of an update as of the date of the licensing inspection.
Client # 9 was admitted to the program on December 17, 2013. The last two treatment plan updates were documented, October 29, 2014 and January 7, 2015. The facility failed to document treatment plan update for March 7, 2015.
Client # 12 was admitted to the program on March 29, 2007 and discharged on January 12, 2015. The last treatment plan update documented in client #12's record was dated July 23, 2014. The facility failed to document treatment plan updates for the following months; September 2014 and November 2014.
Client # 16 was admitted to the program on November 5, 2014. The last two treatment plan updates were documented, November 5, 2014 and February 23, 2015. The facility failed to document treatment plan updates at least every 60 days.
The findings were reviewed with facility staff during the inspection process.
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Plan of Correction
Clinical Supervisors will conduct random chart reviews each month on all direct reports to review clinical documentation starting 04/6/2015. Peer Reviews will be conducted quarterly. The last Peer Review will be completed by 4/3/2015. All plans of correction from the Peer Review Results are due by 4/10/2015. The carts of client records #7,9,12, and 16 have been reviewed and correction have been made. |