INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and complaint investigation conducted on February 2, 3 and 10, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection and investigation, Clearvision Health And Wellness 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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704.7(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 six personnel records, the facility failed to ensure one counselor had both the educational qualifications as well as the one year of clinical experience in a health or human service agency.Employee #5 was hired as a counselor on June 5, 2021 and is still current in that position. Employee #5 has a qualifying bachelor ' s degree but does not have the one year of clinical experience in a health or human service agency.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
L0037
704.9 Qualifications for the position of counselor.
Employee #5, will become a qualified counselor as of April 5, 2022.
Upon review of the qualifications, this counselor should have gone from a counselor to a counselor assistant, with a training plan on how to achieve competency to become a counselor and have documented supervision as supporting evidence.
The steps this agency will take to avoid this deficiency will be better screening of each individual hired, ensuring they have the requisite qualifications of a counselor by reviewing the educational requirements as well as the one year of clinical experience, preferably in chemical dependency.
In the future, should a person hired not meet these requirements, they will be hired as a counselor assistant, which will reduce their caseload and be required to have documented supervision as well as and have an individual training plan, addressing how they will achieve counseling competency in chemical dependency issues.
The Clinical Supervisor will ensure the corrective action(s) is implemented by reviewing the qualifications of clinicians hired and creating training plans, as well as documenting supporting supervision for each clinician. The Clinical Supervisor will ensure each employee's chart is current with such documentation monthly.
This plan of correction will take place April 15, 2022.
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705.7 (b) (3) 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:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection, the facility failed to clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.The utensils were uncovered in the eating area between meals. These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
PP075
In accordance with §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: (3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
The course of action taken will be instruct kitchen staff on the importance of cleaning all eating, drinking and cooking utensils and all food preparation areas after each usage. Kitchen staff will be given a covering to place over utensils between meals and a monthly inspection by the Assistant Executive Director will be done to ensure consistent adherence is maintained.
This correction will take place immediately.
The Assistant Executive Director will be responsible for the monitoring of the kitchen staff and the plans in place to remain compliant.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including 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.
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Observations
Based on a review of the facility ' s fire drill log from March 2021 to November 2021, the facility failed to maintain a written fire drill record including the exit route used for the months of March, April, and May 2021. These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
PP147
In accordance with §705.10. Fire Safety. (d) Fire Drills. The residential facility shall: (4) maintain a written fire drill record including the date, time, the amount of time it took for evacuation, 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 course of action taken will be to conduct, appropriately document and provide a written fire drill log upon inspection.
Also, the Assistant Executive Director will be responsible for these logs and ensuring compliance.
The Assistant Executive Director will edit the fire drill log form to directly reflect what exit routes were taken after every drill conducted.
Clear Vision will follow all regulations in accordance with §705.10 and conduct fire drills during sleeping hours at least once every 6 months.
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709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop a complete written procedure to address the confidentiality of client identity and records. The policy and procedures did not include a description of how the project plans to address security and release of electronic records and identification of the person responsible for maintenance of client records.The written procedures only included a description of how the project plans to address the security and release of paper records and the identification of the person responsible for maintenance of paper client records. The project does not utilize paper records. All client records are electronic. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LO271
In accordance with §709.28. Confidentiality. (a) A written procedure shall be developed by the project director which shall comply with 4 Pa.Code § 255.5.
To ensure compliance, the facility will amend the policy to reflect the appropriate system being used for medical records, which is an electronic medical record system. The policy will include confidentiality of client records and is done by each staff member having a username and passcode to access the electronic medical record system. Based on job title, certain functions of a client's chart are disabled and will not be accessible.
This policy will be amended within 2 weeks.
The electronic medical record also has a time-out function where someone who is logged in and has not navigated the electronic medical record for a short period of time, will need to re-submit their log-in information to re-access the system.
Chart audit's and maintenance are the responsibility of the Clinical Supervisor and will be conducted weekly. This will ensure confidential information is not being released. The security functions will also remain disabled to staff members that do no require access to a client's chart.
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709.28 (a) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(2) Identification of project staff having access to records, and the methods by which staff gain access.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop written procedures that include the identification of staff who have access to records, and the methods by which staff gain access.The written procedure did not identify staff who have access to electronic records. Additionally, the procedure addressed access to paper records, but the facility does not utilize paper records. All client records are electronic.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LO273
In accordance with §709.28. Confidentiality. (a) A written procedure shall be developed by the project director which shall comply with 4 Pa.Code § 255.5.
The amended policy will include confidentiality of client records and be changed from paper records to electronic records.
The amended policy will be completed in 2 weeks.
Each staff member has a unique username and passcode to access the electronic medical record system. The electronic medical record system also requires a 4-digit password to sign documents, thereby allowing the Clinical Supervisor to see who has put signatures of forms.
Each staff member has access to client records but certain functions on the electronic medical record system are not enabled due to job title. Only a super-admin can make these changes.
The electronic medical record also has a time-out function where someone who is logged in and has not navigated the electronic medical record for a short period of time, will need to re-submit their log-in information to re-access the system.
Chart audit's and maintenance are the responsibility of the Clinical Supervisor and will be conducted weekly.
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709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of ten client records, the facility failed to document an informed and voluntary consent from the client for the disclosure of information contained in the client record. Consent forms did not include the name of the person, agency or organization to whom information was disclosed in four records reviewed.Client #2 was admitted on January 5, 2022 and was discharged on January 28, 2022. An informed and voluntary consent from the client for the disclosure of information signed and dated on January 5, 2022, did not include the name of the person, agency or organization to whom disclosure was to be made.Client #7 was admitted on December 17, 2021 and discharged on January 19, 2022. An informed and voluntary consent from the client for the disclosure of information signed and dated on January 21, 2022, did not include the name of the person, agency or organization to whom disclosure was to be made.Client #8 was admitted on January 16, 2022 and was current at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated on January 16, 2022, did not include the name of the person, agency or organization to whom disclosure was to be made.Client #10 was admitted on January 13, 2022 and was current at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated on January 13, 2022, did not include the name of the person, agency or organization to whom disclosure was to be made.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LO277
§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 must be in writing and include, but not be limited to: (1) Name of the person, agency or organization to whom disclosure is made. The informed, voluntary consent forms for Client #2, Client #7, Client #8 and Client #10, all who have since been discharged, did not include the name of the person, agency or organization to whom disclosure was to be made.
Consent forms will be completed appropriately and contain the name of the person, agency, or organization to whom the disclosure was being made. A dated signature of the consent form will be completed by the staff member filling out the consent. No blank consent forms shall be generated and left in a client's chart, not completed.
Chart Auditing will be on-going by the Clinical Supervisor.
All staff members will be shown how to appropriately fill out a consent form and this will be monitored weekly by the Clinical Supervisor.
An all-staff meeting will be scheduled monthly to ensure the staff understand how to complete these forms and ensure this deficiency does not reoccur.
This correction will take place immediately.
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709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of ten client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 for releases of information in all ten records reviewed. Client #1 was admitted on October 19, 2021 and discharged on November 16, 2021. Two informed and voluntary consents for funding sources were signed and dated on October 19, 2021, that released information beyond the limits established by 4 Pa. Code 255.5. Both consents allowed for the disclosure of treatment plans; psychosocial assessment; psychiatric history and assessment; results of physical; medical history; biopsychosocial assessment; lab results; employment information; legal status; family information; aftercare recommendations; discharge planning; and discharge summary.Client #2 was admitted on January 5, 2022 and discharged on January 28, 2022. Two informed and voluntary consents for funding sources were signed and dated on January 5, 2022, that released information beyond the limits established by 4 Pa. Code 255.5. Both consents allowed for the disclosure of treatment plans; psychosocial assessment; psychiatric history and assessment; results of physical; medical history; biopsychosocial assessment; lab results; employment information; legal status; family information; aftercare recommendations; discharge planning; and discharge summary.Client #3 was admitted on January 17, 2022 and discharged on January 28, 2022. Two informed and voluntary consents for funding sources were signed and dated on January 17, 2022, that released information beyond the limits established by 4 Pa. Code 255.5. Both consents allowed for the disclosure of treatment plans; psychosocial assessment; psychiatric history and assessment; results of physical; medical history; biopsychosocial assessment; lab results; employment information; legal status; family information; aftercare recommendations; discharge planning; and discharge summary.Client #4 was admitted on November 12, 2021 and discharged on December 13, 2021. Two informed and voluntary consents for funding sources were signed and dated on November 12, 2021, that released information beyond the limits established by 4 Pa. Code 255.5. Both consents allowed for the disclosure of treatment plans; psychosocial assessment; psychiatric history and assessment; results of physical; medical history; biopsychosocial assessment; lab results; employment information; legal status; family information; aftercare recommendations; discharge planning; and discharge summary.Client #5 was admitted on January 26, 2022 and was discharged on January 31, 2022. Two informed and voluntary consents for funding sources were signed and dated on January 26, 2022, that released information beyond the limits established by 4 Pa. Code 255.5. Both consents allowed for the disclosure of treatment plans; psychosocial assessment; psychiatric history and assessment; results of physical; medical history; biopsychosocial assessment; lab results; employment information; legal status; family information; aftercare recommendations; discharge planning; and discharge summary.Client #6 was admitted on October 19, 2021 and discharged on October 22, 2021. Two informed and voluntary consents for funding sources were signed and dated on October 19, 2021, that released information beyond the limits established by 4 Pa. Code 255.5. Both consents allowed for the disclosure of treatment plans; psychosocial assessment; psychiatric history and assessment; results of physical; medical history; biopsychosocial assessment; lab results; employment information; legal status; family information; aftercare recommendations; discharge planning; and discharge summary. Client #7 was admitted on December 17, 2021 and discharged on January 19, 2022. Two informed and voluntary consents for funding sources were signed and dated on December 17, 2021, that released information beyond the limits established by 4 Pa. Code 255.5. Both consents allowed for the disclosure of treatment plans; psychosocial assessment; psychiatric history and assessment; results of physical; medical history; biopsychosocial assessment; lab results; employment information; legal status; family information; aftercare recommendations; discharge planning; and discharge summary.Client #8 was admitted on January 16, 2022 and was current at the time of the inspection. Two informed and voluntary consents for funding sources were signed and dated on January 16, 2022, that released information beyond the limits established by 4 Pa. Code 255.5. Both consents allowed for the disclosure of treatment plans; psychosocial assessment; psychiatric history and assessment; results of physical; medical history; biopsychosocial assessment; lab results; employment information; legal status; family information; aftercare recommendations; discharge planning; and discharge summary.Client #9 was admitted on January 20, 2022 and was current at the time of the inspection Two informed and voluntary consents for funding sources were signed and dated on January 20, 2022, that released information beyond the limits established by 4 Pa. Code 255.5. Both consents allowed for the disclosure of treatment plans; psychosocial assessment; psychiatric history and assessment; results of physical; medical history; biopsychosocial assessment; lab results; employment information; legal status; family information; aftercare recommendations; discharge planning; and discharge summary. In addition, an informed and voluntary consent to disclose information singed and dated on January 20, 2022 to a government agency allowed for the disclosure of discharge planning; discharge summary, and aftercare. Client #10 was admitted on January 13, 2022 and was current at the time of the inspection. Two informed and voluntary consents for funding sources were signed and dated on January 13, 2022, that released information beyond the limits established by 4 Pa. Code 255.5. Both consents allowed for the disclosure of treatment plans; psychosocial assessment; psychiatric history and assessment; results of physical; medical history; biopsychosocial assessment; lab results; employment information; legal status; family information; aftercare recommendations; discharge planning; and discharge summary.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LO279
§ 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 must be in writing and include, but not be limited to: (2) Specific information disclosed.
Client's #1-10 who has been discharged since the inspection, all had two informed and voluntary consents for funding sources that released information beyond the limits established by 4 Pa. Code 255.5.
This facility will correct this deficiency by training staff on how to properly generate a consent form on the electronic medical record system and how to complete a consent form that keeps the disclosure of information within the limits established by 4 Pa. Code 255.5.
Staff will be trained on these limits: (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 into drug or alcohol abuse and the frequency of such relapse.
The Clinical Supervisor will be responsible for reviewing the consent forms while a client is in treatment and ensuring the corrective action is implemented to prevent reoccurrence.
This deficiency will be corrected effective 4/15/2022
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709.28 (c) (3) 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 must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of ten client records, the facility failed to document an informed and voluntary consent from the client for the disclosure of information contained in the client record. Consent forms did not include the purpose of disclosure in one record reviewed.Client #10 was admitted on January 13, 2022 and was current at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to another facility was signed and dated on January 25, 2022, but it did not include the purpose of the disclosure. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LO281
In accordance with §709.28. Confidentiality. (c) The informed and voluntary consent form on Client #10, who has since been discharged, did not include the purpose of the disclosure. To remedy this, staff are expected to review the consent forms carefully and ensure no correspondence with any outside agency take place until the form is completed properly.
The Clinical Supervisor will hold in-service and re-train staff and new personnel on the importance of appropriate documentation as it relates to §709.28. Confidentiality. (c) A review of the document and how to complete the form will be included in this training. All informed and voluntary consents shall contain the name of the person, the agency/organization to whom the disclosure is made and the purpose of the disclosure, followed by a signature. This plan of correction will take place immediately.
All staff will be responsible for completing these forms properly and the Clinical Supervisor will monitor charts on a weekly basis to ensure that consent forms are filled out properly with all the required information included prior to signing the form or sending any confidential information elsewhere.
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709.28 (c) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of ten client records, the facility failed to document an informed and voluntary consent from the client for the disclosure of information contained in the client record. Consent forms did not include a dated signature of the client in one record reviewed. Client #8 was admitted on January 16, 2022 and was current at the time of the inspection. An informed and voluntary consent for the disclosure of information was in the client record for a family member, however it was not signed or dated by the client or a witness. A progress note dated January 16, 2021, in the client record documented the family member had spoken to the facility about the client being in treatment. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LO283
In accordance with §709.28. Confidentiality. (c) The informed and voluntary consent form on Client #8, who has since been discharged, did not include a dated signature of the client.
All staff members will review the consent form being completed and ensure a dated signature of the client is documented on that form.
The Clinical Supervisor will hold in-service and re-train staff and new personnel on the importance of appropriate documentation as it relates to §709.28. Confidentiality. (c) Staff will understand confidentiality and demonstrate this understanding through proper documentation. No client information shall be disclosed to anyone unless there is a dated signature consent release form. This plan of correction will take place immediately.
All staff members, both clinical and non-clinical will be responsible for completing these forms properly and the Clinical Supervisor will monitor charts on a weekly basis to ensure that consent forms are filled out properly with all the required information included and a dated signature from the client at the completion of the form.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of ten client records, the facility failed to offer the client a copy of a consent and maintain a copy in the client record in two records reviewed. Client #2 was admitted on January 5, 2022 and discharged on January 28, 2022. A consent that was signed and dated in the client record on January 5, 2022, was missing the name of the person, agency or organization to whom disclosure is made and whether copy of the client consent was offered to the client. Client #3 was admitted on January 17, 2022 and discharged on January 28, 2022. A consent that was signed and dated on January 17, 2022, for a hospital did not include whether copy of a client consent was offered to the client. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LO289
In accordance with §709.28. Confidentiality. (d) A copy of a client consent shall be offered to the client and a copy is to be maintained in the client record. The informed and voluntary consent form on Client #2, who has since been discharged, was missing the name of the person, agency, or organization to whom disclosure was being made. The consent did not state whether a copy was offered to the client.
Client #3 signed and dated a consent, but the check box was blank did not include whether a copy of a client consent was offered to the client.
Consent forms will be completed appropriately and contain the name of the person, agency, or organization to whom the disclosure was being made. A dated signature of the consent form will be completed by the staff member filling out the consent. All staff members will be shown how to appropriately fill out a consent form and this will be monitored weekly by the Clinical Supervisor.
Consent forms will be offered to each client and the appropriate box will be checked that they wanted and accepted a copy of the consent they signed. If they choose to obtain a copy, one shall be given to them at that time.
This practice shall begin immediately.
All staff members, both clinical and non-clinical will be responsible for completing these forms properly and the Clinical Supervisor will monitor charts on a weekly basis to ensure this is being done.
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of ten client records, the project failed to document written acknowledgement by clients that they have been notified of their right not to be discriminated in the provision of services on the basis of ethnicity, marital status, sexual orientation, handicap or religion in all ten records reviewed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
§ 709.30. Client rights. The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights. (2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
Client's #1-10, who have all been discharged since the inspection, did not have written acknowledgement by clients that they have been notified of their rights. Therefore, their charts are not able to be updated.
Current client charts, however, have the updated forms in the electronic medical record system and written acknowledgement by way of client's signature has been completed.
The steps taken have been an amended policy and procedure, that includes no discrimination of any client in race, ethnicity, creed, color, gender or gender identity, sex, sexual orientation, religion, marital status, national origin, age, disability, political affiliation, previous criminal record or status with regard to public assistance.
To prevent recurrence of this deficiency, the Facility Executive Director will train the staff on what the clients rights are and they will be directed to notify clients of their rights upon admission, ensure the clients understand what their rights are, offer the clients a copy of their rights, and once that has been completed, having the clients sign the form in the electronic medical record system acknowledging all of the above.
Also, the electronic medical record form on client rights, that a client signs upon admission, has been changed to reflect the amended policy. Thereby, creating written acknowledgement by clients of their protective rights.
The Clinical Supervisor will be responsible for ensuring the updated forms are in the electronic medical record and weekly chart checks by the Clinical Supervisor will be done to monitor this correction.
The Facility Executive Director will be responsible for ensuring the corrective action(s) is implemented.
This plan of correction has been completed and will be effective immediately.
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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of ten client records, the project failed to document written acknowledgement by clients, in all records reviewed, that they have been notified of their right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LO301
§ 709.30. Client rights. The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights. (3) Clients have been notified of their right to inspect their own records.
The Facility Executive Director fully acknowledges that portions of the record prior to the inspection by the client, may be removed temporarily if deemed detrimental if presented to the client.
This plan of correction has been made by amending the policy and procedure, fully explaining the clients right to inspect their own records and the steps they can take to do so.
The electronic medical record form on client rights, that a client signs upon admission, has been changed to reflect the amended policy. Thereby, creating written acknowledgement by clients of their protective rights.
The steps the facility will take to avoid this deficiency from reoccurring will be a training of the staff about how to ensure the form is populated in the electronic medical record system, how to fill out the client rights form, and to ensure the client's sign the form. All client records are inspected by Assistant Executive Director after an admission takes place.
During the chart inspection, the Assistant Executive Director will make sure the Clients Right form has been signed by the client and ensuring the corrective action(s) is implemented.
This plan of correction has been completed and will be effective immediately.
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709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of ten client records, the project failed to document written acknowledgement by clients, in all records reviewed, that they have been notified of their right to inspect their own records, and they have the right to appeal a decision limiting access to their records to the director.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LO0303
§ 709.30. Client rights. The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights. (4) Clients have the right to appeal a decision limiting access to their records to the Facility Executive Director.
This plan of correction has been made by amending the policy and procedure on Client rights, fully explaining the clients right to appeal a decision limiting access to their records to the Facility Executive Director.
The electronic medical record form on client rights, that a client signs upon admission, has been changed to reflect the amended policy. Thereby, creating written acknowledgement by clients that they have the right to appeal a decision limiting access to their records to the Facility Executive Director.
The steps the facility will take to avoid this deficiency from reoccurring will be a training of the staff about how to ensure the form is populated in the electronic medical record system, how to fill out the client rights form, and to ensure the client's sign the form.
To prevent recurrence of this deficiency, the Facility Executive Director will train the staff on what the clients rights are and they will be directed to notify clients of their rights upon admission, ensure the clients understand what their rights are, offer the clients a copy of their rights, and once that has been completed, having the clients sign the form in the electronic medical record system acknowledging all of the above.
Written acknowledgement will be monitored by the Clinical Supervisor by ensuring the updated form is on the electronic medical record during weekly chart audits.
This written acknowledgement by clients is a form that is signed upon admission stating their rights have been explained to them and they understand what their rights are.
The Clinical Supervisor will make sure the Clients Right form has been signed by the client and ensuring the corrective action(s) is implemented.
This plan of correction has been completed and will be effective immediately.
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709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of ten client records, the project failed to document written acknowledgement by clients, in all records reviewed, that they have been notified of their right to inspect their own records, and that they have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LO305
§ 709.30. Client rights. The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights. (5) Clients have been notified of their right to inspect their own records, and that they have the right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records.
Client's #1-10, who have all been discharged since the inspection, did not have written acknowledgement by clients that they have been notified of their right to inspect their own records. Therefore, their charts are not able to be updated.
Current client charts, however, have the updated forms in the electronic medical record system and written acknowledgement by way of client's signature has been completed.
This plan of correction has been made by amending the policy and procedure on Client rights, fully explaining the clients right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records.
The electronic medical record form on client rights, that a client signs upon admission, has also been changed to reflect the amended policy. Thereby, creating written acknowledgement by clients that they have the right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records.
To prevent recurrence of this deficiency the following steps will be taken: The Facility Executive Director will train the staff on what the clients rights are and they will be directed to notify clients of their rights upon admission, ensure the clients understand what their rights are including their right to inspect their own records, offer the clients a copy of their rights, and once that has been completed, having the clients sign the form in the electronic medical record system acknowledging all of the above.
Also, the electronic medical record form on client rights, that a client signs upon admission, has been changed to reflect the amended policy. Thereby, creating written acknowledgement by clients of their protective rights.
The Clinical Supervisor will be responsible for ensuring the updated forms are in the electronic medical record and weekly chart checks by the Clinical Supervisor will be done to monitor this correction.
The Clinical Supervisor will be responsible for ensuring the corrective action(s) is implemented.
This plan of correction has been completed and will be effective immediately.
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709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of ten client records, the project failed to document written acknowledgement by clients, in all records reviewed, that they have been notified of their right to inspect their own records, and that they have the right to submit rebuttal data or memoranda to their own records.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LO307
§ 709.30. Client rights. The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights. (6) Clients have been notified of their right to inspect their own records and that they have the right to submit rebuttal data or memoranda to their own records.
This plan of correction has been made by amending the policy and procedure on Client rights, fully explaining the clients right to inspect their own records and that they have the right to submit rebuttal data or memoranda to their own records.
The electronic medical record form on client rights, that a client signs upon admission, has also been changed to reflect the amended policy. Thereby, creating written acknowledgement by clients that they have the right to inspect their own records and that they have the right to submit rebuttal data or memoranda to their own records.
The steps the facility will take to avoid this deficiency from recurring will be a training of the staff about how to ensure the form is populated in the electronic medical record system, how to fill out the client rights form, and to ensure the client's sign the form. The Facility Executive Director will train the staff on what the clients rights are and they will be directed to notify clients of their rights upon admission, ensure the clients understand what their rights are, offer the clients a copy of their rights, and once that has been completed, having the clients sign the form in the electronic medical record system acknowledging all of the above.
Written acknowledgement will be monitored by the Clinical Supervisor by ensuring the updated form is on the electronic medical record during weekly chart audits.
This written acknowledgement by clients is a form that is signed upon admission stating their rights have been explained to them and they understand what their rights are.
The Clinical Supervisor will make sure the Clients Right form has been signed by the client and ensuring the corrective action(s) is implemented.
This plan of correction has been completed and will be effective immediately.
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709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on an inspection of the medication room on February 10, 2022, the facility failed to follow their policy for removing outdated and unused medication. The policy states outdated and unused drugs will be removed monthly, and disposal of drugs will be recorded on an inventory sheet. During the inspection, both outdated and unused medication for active and discharged clients was being stored in the medication cart and cabinet. Dates of the medication ranged from May 2021 to present. Seventy-one different outdated and unused medications were found during the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LO0323
§709.32 Medication control. (3) Inspection of storage areas that ensure compliance in ensuring (iv) Outdated drugs are removed.
The steps this facility has taken to ensure recurrence does not happen are as follows:
For current residents and residents who have been discharged, outdated and unused medications will be scheduled with a pharmacy to be picked up.
A log has been created and when the pharmacy arrives, the pharmacy personnel picking up the medications, sign that the medications were returned to them and the staff member at this facility signs acknowledging the medication was given to the pharmacy personnel and is no longer in the facility.
Until the pharmacy personnel picks up the medications, these medications will be removed from the medications that are not outdated and placed in a separate, locked drawer designated only for medication pick-up by pharmacy personnel.
The outdated and unused medications will be stored away from the medications being used by current clients.
The inspecting staff on-duty will complete the Drug Control Inventory Sheet and the Medication Log and provide their initials confirming the inspection has been completed.
The Facility Executive Director will ensure the corrective action is implemented by a monthly inspection of the drug control inventory sheet and medication log ensuring the policy and procedure is being adhered to.
This plan of correction will be effective April 15, 2022.
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709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of ten client records, six medication error reports, and the facility ' s policy and procedure manual, the facility failed to follow their system for recording drugs, which includes the name of the drug, the dosage, the staff person, and the time and the date. On seven occasions, client medication was not administered as prescribed, and/or the client received the wrong medication. Client #4 was admitted on November 12, 2021 and discharged on December 13, 2021. On November 17, 2021, client #4 was to receive suboxone 2-0.5 mg film, but instead was administered Subutex 2mg.Client #6 was admitted on October 19, 2021 and discharged on October 22, 2021. On October 20, 2021, client #6 was administered Suboxone 8-2mg, however there was not a doctor ' s order for the client to receive this medication. A medication error report stated, on January 6, 2022, a client was administered suboxone 8mg/2mg film, instead of the prescribed Buprenorphine/Naloxone 4mg/1mg.A medication error report stated, on January 6, 2022, a client was administered two suboxone 8mg/2mg film, instead of the prescribed one suboxone 8mg/2mg film.A medication error report stated, on December 2, 2021, a client was administered buprenorphine/naloxone 8mg/2mg film, instead of the prescribed buprenorphine/naloxone tablets.A medication error report stated, on December 2, 2021, a client was administered Buprenorphine 8mg (Subutex), instead of the prescribed Buprenorphine/naloxone 8-2 tablet.A medication error report stated, on November 25, 2021, a client was administered suboxone 8-2mg instead of the prescribed 2-.05mg suboxone.These findings were reviewed with the facility during the licensing process.
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Plan of Correction
LO0325
§ 709.32. Medication control. (4) Methods for control and accountability of drugs, including, but not limited to: (i) Who is authorized to remove drug. (ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
Client's #4 and #6, both who have been discharged since the inspection, were not administered medication as prescribed or received the wrong medication.
This facility has taken the following steps to avoid to recurrence in this deficiency:
A log form has been created containing the clients name, the name of the drug, the amount of the medication (number of pills, etc.), the dosage, the time and frequency the medication should be taken, a space for the date and time the medication was taken, and a space for the staff member who supervised the self-administered medication to initial, as well as a space for the client to initial that they received that specific medication, has been implemented.
A the staff member supervising the self-administered medication time is required to document the appropriate count of medication after each medication is observed being taken. The staff member initials on the medication log, created for each client for each medication they are prescribed, that this has been done.
A second staff member that is on-duty, will count the medication before the end of the shift to ensure the count is accurate and are expected to initial this form as well. They have also been instructed to immediately notify the Facility Executive Director of any medication errors.
A video tutorial has been created by the Assistant Facility Director for all staff members to have access to watch if they are unsure how to properly complete the procedure.
The staff have been shown how to appropriately log medications and have watched the video. They signed a form stating they have watched the video and understand how to properly supervise and log medications.
The staff also has a sheet on the wall to remind them to double check prior to supervising self-administering medications and while the client is present, that the medication they are supervising belongs to the client, they are taking the appropriate amount and taken at the time prescribed.
The Facility Executive Director will ensure the corrective action is implemented by monthly checks of the medication and inventory logs.
This corrected action will take place April 15, 2022. |
709.32 (c) (5) LICENSURE Medication control
§ 709.32. Medication control.
(5) Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
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Observations
Based on an inspection of the medication room on February 10, 2022, the facility failed to follow their policy for the security of drugs, including, but not limited to, the loss, theft or misuse of drugs. The facility was found to be misusing medication of discharged clients by crossing off their names and writing house stock or Clearvision on the medication card where the client ' s name had been. Some of these medications were controlled substances. These findings were reviewed with the facility during the licensing process.
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Plan of Correction
LO327
§709.32 Medication control. (5) Security of drugs, including the loss, theft or misuse of drugs.
The facility was found to be misusing medication of discharged clients.
The steps the facility has taken to avoid recurrence in this deficiency has been to contact the pharmacy once a client is discharged from the facility and schedule a time to pick up the medications. The medications, including controlled substances to be picked up are to be removed from the rest of the current clients medications and stored in a different drawer in the medication cart, designated only for medication pick-up by the pharmacy personnel.
The entire medication cart shall be locked and the medication room will be secured.
A log has been created and when pharmacy personnel arrives, they signs for the medications that were returned to them and a staff member signs acknowledging the medication was given to the pharmacy personnel and is no longer in the facility.
The staff members on duty will have access to the medication cart and medication room. The staff members on-duty will have access to the clients medication.
The medication will be monitored by the staff member supervising the self-administered medications. There is a log created of a clients medication that requires a staff members signature and a second staff member to review the medication counts prior to the end of the shift.
The medication room is equipped with a camera and a second staff member on-duty will recount the medications prior to the end of the shift ensuring no medication was misused.
At no time will the facility or any staff member cross off a clients name and write house stock in place of that.
This policy and procedure will be given to each staff member who will sign a form stating they have received the policy, understand the procedure, and will follow the steps accordingly.
Employee's will also be informed should they not follow the policy and procedure, a write up will be issued and placed in their personnel file. Should it not be adhered to again, it is grounds for immediate termination.
The Facility Executive Director will be responsible for ensuring the corrective action(s) is implemented by ensuring the pharmacy has been contacted to pick up the medication checking the medication log upon a client's discharge.
This deficiency will be effective April 15, 2022. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Based on a review of the project ' s policy and procedure manual, the project failed to develop and implement procedures to respond to physical assault or sexual assault by staff or a client. The manual only listed their policy of reporting the unusual incident.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LO337
§709.34. Reporting of unusual incidents. (a) The project shall develop and implement policies and procedures to respond to unusual events regarding an event at the facility regarding (1)Physical assault or sexual assault by staff or a client.
This facility will develop a policy and procedure to identify the specific steps that will be taken to ensure safety in response to physical assault or sexual assault by staff or a client.
This policy will reflect all staff members to report any incident of physical assault or sexual assault by staff or a client to the Facility Executive Director immediately.
An incident report will be written by staff members that were on-duty during the incident, describing what took place, and will be forwarded to the Facility Executive Director.
The procedure will identify who will be responsible for handling the clients involved, who will be responsible for handling the clients that are not involved, notifying emergency personnel, where clients who are involved will be transported to, if necessary, and keeping the safety of all parties as priority.
A post incident debrief meeting will be required for all staff members to ensure the policy and procedure was followed and avoid a reoccurrence in this deficiency.
The policy and procedure will be given to all staff members who will sign a form acknowledging the receipt and understanding of the policy and procedure.
The Facility Executive Director will be responsible in forwarding incident reports to the appropriate reporting agencies and monitoring the corrective plan of action.
This plan of correction will be effective April 15, 2022.
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709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on a review of the project ' s policy and procedure manual, the project failed to develop and implement procedures to respond to selling or use of illicit drugs on the premises. The manual only listed their policy of reporting the unusual incident.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LO339
§ 709.34. Reporting of unusual incidents. (a) The project shall develop and implement policies and procedures to respond to the following unusual incidents: (2) Selling or use of illicit drugs on the premises.
This facility will develop a policy and procedure to identify the specific steps that will be taken if an unusual event of selling or use of illicit drugs on the premises occurs.
This policy will reflect all staff members to immediately report any incident of selling or use of illicit drugs on the premises. An incident report will be written by staff who were on-duty the day the incident occurred, describing what took place, and will be forwarded to the Facility Executive Director.
The procedure will identify who will be responsible for handling the clients involved, who will be responsible for handling the clients that are not involved, notifying police and/or ambulance personnel, obtaining statements of any person(s) who witnessed the selling or use of illicit drugs on the premises and keeping the safety of all parties as top priority.
A post incident debrief meeting will be held by the Facility Executive Director and will be required for all staff members to attend to ensure the policy and procedure was followed and avoid a recurrence in this deficiency.
The policy and procedure will be given to all staff members who will sign a form acknowledging the receipt and understanding of the policy and procedure.
The Facility Executive Director will be responsible for maintaining a record of the incident reports and forwarding incident reports to the appropriate reporting agencies and monitoring the corrective plan of action.
This plan of correction will be effective April 15, 2022.
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709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
Based on a review of the project ' s policy and procedure manual, the project failed to develop and implement procedures to respond to a death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services. The manual only listed their policy of reporting the unusual incident.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LO0341
§ 709.34. Reporting of unusual incidents. (a) The project shall develop and implement policies and procedures to respond to the following unusual incidents: (3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
This facility will develop a policy and procedure to identify the specific steps that will be taken to respond to a death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
This policy will reflect all staff members to immediately report to the Facility Executive Director of any death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
An incident report will be written by staff on-duty during the incident, describing what took place, and will be forwarded to the Facility Executive Director.
The procedure will identify who will be responsible for handling the clients involved, who will be responsible for handling the clients that are not involved, notifying police and ambulance personnel, notifying the medical director, notifying a coroner in the event of a death, obtaining statements of any person(s) who witnessed the death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services, keeping the safety of all parties as top priority.
A post incident debrief meeting will be held by the Facility Executive Director and will be required for all staff members to attend to ensure the policy and procedure was followed and avoid a recurrence in this deficiency.
The policy and procedure will be given to all staff members who will sign a form acknowledging the receipt and understanding of the policy and procedure.
The Facility Executive Director will be responsible for maintaining a record of the incident reports and forwarding incident reports to the appropriate reporting agencies within the allotted time frame and monitoring the corrective plan of action.
This plan of correction will be effective April 15, 2022.
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709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
Based on a review of the project ' s policy and procedure manual, the project failed to develop and implement procedures to respond to a significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day. The manual only listed their policy of reporting the unusual incident.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LO0343
§ 709.34. Reporting of unusual incidents. (a) The project shall develop and implement policies and procedures to respond to the following unusual incidents: (4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
This facility will develop a policy and procedure to identify the specific steps that will be taken in the event of significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
This policy will reflect all staff members to immediately report any significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day to the Facility Executive Director.
An incident report will be written by staff on-duty during the incident, describing what took place, and will be forwarded to the Facility Executive Director.
The procedure will identify who will be responsible for handling the clients, what agencies will be contacted, where to and how the clients will be transported, notifying police personnel, notifying clients emergency contacts and appropriately documenting that call was made. Also, keeping the safety of all parties as top priority.
A post incident debrief meeting will be held by the Facility Executive Director and will be required for all staff members to attend to ensure the policy and procedure was followed and avoid a recurrence in this deficiency.
The policy and procedure will be given to all staff members who will sign a form acknowledging the receipt and understanding of the policy and procedure.
The Facility Executive Director will be responsible for maintaining a record of the incident reports and forwarding incident reports to the appropriate reporting agencies and monitoring the corrective plan of action.
This plan of correction will be effective April 15, 2022.
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709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on a review of the project ' s policy and procedure manual, the project failed to develop and implement procedures to respond to a theft, burglary, break-in or similar incident at the facility. The manual only listed their policy of reporting the unusual incident.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LO345
§ 709.34. Reporting of unusual incidents. (a) The project shall develop and implement policies and procedures to respond to the following unusual incidents: (5) Theft, burglary, break-in or similar incident at the facility.
This facility will develop a policy and procedure to identify the specific steps that will be taken to ensure safety in response to theft, burglary, break-in or similar incident at the facility.
This policy will reflect all staff members to immediately report any incident of theft, burglary, break-in or similar incident at the facility. An incident report will be written by staff on-duty during the incident, describing what took place, and will be forwarded to the Facility Executive Director.
The procedure will identify the following steps: who will be responsible for handling the clients involved, who will be responsible for handling the clients that are not involved, notifying police personnel, obtaining statements of any person(s) who witnessed the theft, burglary, break-in or similar incident including identifying what was stolen as a result of theft, burglary and identifying where the break-in took place. Keeping the safety of all parties as top priority.
A post incident debrief meeting will be held by the Facility Executive Director and will be required for all staff members to attend to ensure the policy and procedure was followed and avoid a recurrence in this deficiency.
The policy and procedure will be given to all staff members who will sign a form acknowledging the receipt and understanding of the policy and procedure.
The Facility Executive Director will be responsible for maintaining a record of the incident reports and forwarding incident reports to the appropriate reporting agencies and monitoring the corrective plan of action.
This plan of correction will be effective April 15, 2022.
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709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the project ' s policy and procedure manual, the project failed to develop and implement procedures to respond to an event at the facility requiring the presence of police, fire or ambulance personnel. The manual only listed their policy of reporting the unusual incident. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LO347
§709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to unusual events regarding an event at the facility requiring the presence of police, fire or ambulance personnel.
This facility will develop a policy and procedure to identify the specific steps that will be taken to ensure safety in response to an event at the facility requiring the presence of police, fire or ambulance personnel.
The procedure will specify if the police, fire and ambulance personnel showed up due to the facility contacting them, or if they showed up without being called. The procedure will identify who will be responsible for handling the clients involved, and who will be responsible for handling the clients that are not involved, keeping safety of all parties as priority.
The policy and procedure will be given to all staff members who will sign a form acknowledging the receipt and understanding of the policy and procedure.
The Facility Executive Director will be responsible ensuring the corrective action(s) is implemented as well as maintaining a record of the incident reports and forwarding incident reports to the appropriate reporting agencies, as well as monitoring the corrective plan of action.
This plan of correction will take place April 15, 2022. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
Based on a review of the project ' s policy and procedure manual, the project failed to develop and implement procedures to respond to a fire or structural damage to the facility. The manual only listed their policy of reporting the unusual incident. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LO349
§709.34. Reporting of unusual incidents. (a) The project shall develop and implement policies and procedures to respond to unusual events regarding an event at the facility regarding(7)fire or structural damage.
This facility will develop a policy and procedure to identify the specific steps that will be taken to respond to a fire or structural damage to the facility.
To avoid this deficiency from reoccurring, The Facility Executive Director will provide the policy and procedure to all staff members and have staff sign a form acknowledging that they have received the policy and procedure and fully understand how to respond in such event.
The procedure will identify who will be responsible for handling the clients specify the safest way to evacuate the facility keeping safety of all parties as priority.
This policy will reflect all staff members to report any incident involving fire or structural damage to the facility to their immediate supervisor and appropriate documentation shall be forwarded, if necessary, to DDAP in the required time frame.
The Assistant Executive Director will be responsible in forwarding incident reports and monitoring the corrective plan of action.
This plan of correction will take place on April 15, 2022.
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709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
Based on a review of the project ' s policy and procedure manual, the project failed to develop and implement procedures to respond to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification. The manual only listed their policy of reporting the unusual incident. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LO350
§ 709.34. Reporting of unusual incidents. (a) The project shall develop and implement policies and procedures to respond to the following unusual incidents: (8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
This facility will develop a policy and procedure to identify the specific steps that will be taken to ensure safety in response to an Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
This policy will reflect all staff members to report any incident of an outbreak of a contagious disease requiring Centers for Disease Control notification to their immediate supervisor. Appropriate documentation shall be forwarded to the CDC and, if necessary, to DDAP in the required time frame.
The procedure will identify who will be responsible for handling the clients involved, who will be responsible for handling the clients that are not involved, what hygienic methods will be used to minimize the spread of the contagious disease, where infected clients will be quarantined or transported to, if necessary, and keeping the safety of all parties as priority.
A post incident debrief meeting will be required for all staff members to ensure the policy and procedure was followed and avoid a reoccurrence in this deficiency.
The policy and procedure will be given to all staff members who will sign a form acknowledging the receipt and understanding of the policy and procedure.
The Assistant Executive Director will be responsible in forwarding incident reports to the appropriate reporting agencies and monitoring the corrective plan of action.
This plan of correction will be effective April 15, 2022.
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709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
Based on a review of the project's policy and procedure manual, the project failed to develop policies and procedures that include the ongoing monitoring of the corrective action plan.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LO357
§ 709.34. Reporting of unusual incidents. (4) Ongoing monitoring of the corrective action plan.
This facility will develop a policy and procedure that will include ongoing monitoring of a corrective action plan.
The following are the actions the facility will take regarding this plan of correction:
If/when an incident report is created, the Facility Executive Director will review the report and compare it to the policies and procedures that are currently in place for the facility. As a component of the policy and procedure for ongoing monitoring, the Facility Executive Director will ensure the policies and procedures were followed as written.
If deemed the policy and procedures were not followed, a meeting will be scheduled with staff members to ensure proper actions are to be taken based on the policy and procedure.
An annual review of the policies and procedures will be the responsibility of the Facility Executive Director. Upon review, the Facility Executive Director will issue a document to all staff members notifying them of any changes to current policies and procedures.
The amended policies and procedures will be attached to the policy and procedure manual and the updated policy will reflect the date of revision and forwarded to DDAP.
A post incident debrief meeting will be required for all staff members to ensure the policy and procedure was followed and avoid a reoccurrence in this deficiency.
The Facility Executive Director will be responsible for monitoring the corrective plan of action.
This plan of correction will be effective April 15, 2022.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of ten client records and unusual incident reports submitted to the Department of Drug and Alcohol Programs, the facility failed to file an unusual incident report with the Department within 3 business days following an unusual incident involving an event at the facility requiring police personnel. Client record #9 included information that police personnel were at the facility on January 29, 2022, to calm the client down. An unusual incident report was not submitted to the Department. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LO362
§ 709.34. Reporting of unusual incidents. (c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving: (4) Event at the facility requiring the presence of police, fire or ambulance personnel.
Client #9, who has been discharged since the inspection, required police personnel to be called. An unusual incident report was not submitted to DDAP.
The actions this facility will take to correct this deficiency will be as follows:
An unusual incident report will be written by the Facility Executive Director before the end of the shift in which the incident occurred. If the Facility Executive Director is not available, the Assistant Executive Director will complete the report. This report will then be forwarded to the Department of Drug and Alcohol Programs within 72 hours.
A debrief with staff members present on the day the incident occurred will take place with the Facility Executive Director and Assistant Executive Director to ensure proper procedures were followed and the report was submitted in a timely fashion.
The Facility Executive Director will be responsible for ensuring the corrective action(s) is implemented.
This deficiency will be effective April 15, 2022.
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709.63(a)(4) LICENSURE Medication records
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(4) Medication records.
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Observations
Based on the review of ten client records, the facility failed to have a complete client record that included information relative to the client's involvement with the project that included medication records in one record reviewed. Client #6 was admitted on October 19, 2021 and discharged on October 22, 2021. A nurse's note in the client record on October 20, 2021, indicated Suboxone 8-2mg was given. There was no documentation in the medication record that there was a doctor's order for the client to be given the medication. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LO1677
709.63. Client records. (a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following: (4) Medication records
Client #6, who has been discharged since the inspection, had no documentation record that there was a doctor's order for the client to be given medication the client received.
This facility will take the following steps to ensure this deficiency does not recur:
Upon admission, the staff will ensure each client has medication records in their chart, if they are on medication and that each medication on that client's chart is accurate and a prescribed medication.
The staff will be trained on how to properly fill out the medication log created for each client that specifies the medication they are on and will enter that medication information in the electronic medical record system.
This will be monitored by the Clinical Supervisor during weekly chart audits. If any errors are found, the Clinical Supervisor will enter the medication record in a client's chart and will immediately notify the Facility Executive Director.
The Clinical Supervisor will be responsible for ensuring the corrective action(s) is implemented.
This plan of correction will take place effective April 15, 2022.
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709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of ten client records, the facility failed to develop individual treatment and rehabilitation plans with the client that include the type of treatment and rehabilitation service in seven records reviewed.Client #1 was admitted on October 19, 2021 and discharged on November 16, 2021. A treatment and rehabilitation plan dated October 26, 2021 was missing the type of treatment and rehabilitation service.Client #2 was admitted on January 5, 2022 and was discharged on January 28, 2022. A treatment and rehabilitation plan dated January 10, 2022 was missing the type of treatment and rehabilitation service.Client #4 was admitted on November12, 2021 and discharged on December 13, 2021. A treatment and rehabilitation plan dated November 17, 2021 was missing the type of treatment and rehabilitation service.Client #7 was admitted on December 17, 2021 and discharged on January 19, 2022. A treatment and rehabilitation plan dated December 21, 2021 was missing the type of treatment and rehabilitation service.Client #8 was admitted on January 16, 2022 and was current at the time of the inspection. A treatment and rehabilitation plan dated January 18, 2022 was missing the type of treatment and rehabilitation service.Client #9 was admitted on January 20, 2022 and was current at the time of the inspection. A treatment and rehabilitation plan dated January 25, 2022 was missing the type of treatment and rehabilitation service.Client #10 was admitted on January 13, 2022 and was current at the time of the inspection. A treatment and rehabilitation plan dated January 19, 2022 was missing the type of treatment and rehabilitation service. These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
§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: (2) Type and frequency of treatment and rehabilitation services.
Client's #1,2,4,7,8,9,10, who have all been discharged since the date of inspection, were missing the type of treatment and rehabilitative service.
This facility will ensure this deficiency does not recur by the following:
When the client and counselor meet to develop the treatment plan goals together, each counselor will specify the type of service (group, individual session) and the frequency (1x a week, 2x's, etc.) at the conclusion of the narrative in their plan, until the EMR form can be changed.
The Clinical Supervisor will be responsible for ensuring the corrective action(s) are implemented.
A meeting will be set up with the electronic medical record system administrator. The new form will have 2 sections created near each treatment plan goal that will specify type of service (group, individual session) and frequency (1x a week, 2x's, etc.) A meeting will be scheduled to have this electronic form amended to reflect these changes.
The Clinical Supervisor will monitor the electronic medical record weekly and ensure the type of treatment and rehabilitation service as well and the frequency of the service provided is included in the treatment plan form that is created by the client and clinician.
The Clinical Supervisor will find any missing information regarding this deficiency when doing the chart audits weekly and address the clinicians so it is corrected immediately.
This plan of correction will be effective April 15, 2022.
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709.53(a)(8) LICENSURE Case Consultation Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on the review of the facility policy and procedure manual and seven applicable client records, the facility failed to have a complete client record that included information relative to the client ' s involvement with the project that included case consultations in all seven records reviewed.The facility ' s policy and procedure manual states case consultations would be completed weekly. There was no documentation of weekly case consultations in the seven applicable client records. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LO1807
§709.53. Client records. (a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following: (8) Case consultation notes.
Client's #1-7, who have all been discharged since the inspection, failed to have a complete client records that included information relative to the clients involvement with the project that included case consultations.
This plan of correction has been made by the following: The electronic medical record system has been updated and reflects a Case Consultation tab.
The Facility Executive Director has met with Clinical staff and the policy was provided to the staff. The Clinician's understand the policy and procedure which states the Case Consultations must be done weekly and must include written documentation of the clients involvement in their treatment.
The policy and procedure will be given to all Clinical staff members who will sign a form acknowledging the receipt and understanding of the policy and procedure.
Upon weekly chart audits, the Clinical Supervisor will be responsible for ensuring the Case Consultations are generated on the electronic medical record and are completed on a weekly basis.
The Case Consultation will be a meeting between the clinician's and the Clinical Supervisor to discuss clients and their progress in treatment, how their treatment plan goals are being achieved, if they are not making progress and what steps will be taken to provide the client with the necessary tools to be successful in their treatment goals.
The Clinical Supervisor will collect the information from the meeting and ensure the information that is entered into the electronic medical record by the clinicians involved in the meeting is completed weekly, and accurately describes what was discussed in the meeting, including solutions to clients that are not making little to no progress.
The Clinical Supervisor will be responsible for implementing and monitoring the corrective plan of action.
This plan of correction will take place immediately.
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