INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on April 14, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site complaint investigation, Colonial House, Inc. 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 investigation.
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Plan of Correction
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709.53(a)(5) LICENSURE Progress 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:
(5) Progress notes.
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Observations
Based on a review of the client record and an interview with the counselor, the facility failed to follow standard practices of client record documentation when a clinical supervisor directed a counselor to back date a progress note.
The findings include:
One client record was reviewed and an interview with the client's counselor was conducted on April 14, 2011. This review of the client record was a result of a complaint investigation conducted on April 14, 2011. The client's counselor stated that she was not at work on the date that the client was discharged, but she learned what happened when she returned to work. After the interview this licensing specialist reviewed the clients' record and observed the progress note dated October 19, 2010, the date of the client's discharge from the program and the date that the counselor who completed the documentation was not at work. That progress note included the counselor's signature. The counselor confirmed that she back dated and signed the progress note in question at the direction of the clinical supervisor.
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Plan of Correction
The clinical supervisor responsible for directing the counselor prepare and back date the progress note in question was terminated on 4/18/11. The Director of Residential Services met with the clinical team on 4/20/11. Topic of discussion was chart documentation. She advised the team of the need for complete and correct documentation stressing that it is never acceptable to provide documentation for events that happened for which you did not participate. In addition, she reminded the team that by signing their names and credentials they are affirming that they have knowledge of the issue and were the responsible party for it. In the future, the clinical team was advised that that they are not to back date any progress notes. They need to be dated for when they are completed even if they are late. In addition, the party completing a progress should be the person with the first hand knowledge of the issue. Finally, she used this situation as an example and illustrated how this citation could have been avoided had the counselor summarized her discussions with counselor who discharged the client and written the note referencing her discussion with him and that he was the individual responsible for the discharge.
The Director of Residential Services will monitor for compliance through weekly staff supervision, chart reviews, and weekly staff meetings.
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709.53(a)(10) LICENSURE Discharge Summary
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of the client record and an interview with the counselor, the facility failed to follow standard practices of client record documentation when a clinical supervisor directed a counselor to back date a discharge summary.
The findings include:
One client record was reviewed and an interview with the client's counselor was conducted on April 14, 2011. This review of the client record was a result of a complaint investigation conducted on April 14, 2011. The client's counselor stated that she was not at work on the date that the client was discharged, but she learned what happened when she returned to work. After the interview this licensing specialist reviewed the clients' record and observed the discharge summary dated October 19, 2010, the date of the client's discharge from the program and the date that the counselor who completed the documentation was not at work. That discharge summary included the counselor's signature. The counselor confirmed that she back dated and signed the discharge summary in question at the direction of the clinical supervisor.
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Plan of Correction
The clinical supervisor responsible for directing the counselor prepare and back date the discharge summary in question was terminated on 4/18/11. The Director of Residential Services met with the clinical team on 4/20/11. Topic of discussion was chart documentation. She advised the team of the need for complete and correct documentation stressing that it is never acceptable to provide documentation for events that happened for which you did not participate. In addition, she reminded the team that by signing their names and credentials they are affirming that they have knowledge of the issue and were the responsible party for it. In the future, the clinical team was advised that that they are not to back date any discharge summary. At no time should anyone be documenting in a chart events that happened when they were not at work. They need to be dated for when they are completed even if they are late.
The Director of Residential Services will monitor for compliance through weekly staff supervision, chart reviews, and weekly staff meetings.
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709.44(b)(2) LICENSURE Medication Records
709.44. Client records.
(b) If applicable, the project shall also include the following items in the client record:
(2) Medication records.
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Observations
The facility failed to provide documentation that they followed the medication orders provided by the facility's physician.
The finding includes:
The complaint investigation took place on April 14, 2011. A client was denied use of medication that was prescribed by the facility's medical doctor. The client's medication record was reviewed on April 14, 2011 and it was revealed that the facility had not followed the physician's medication orders.
The Project Director was interviewed on April 14, 2011 and he stated "that the client's chief complaint was his allergies when he was admitted to the program. The Project Director said that they keep stock medication for clients but he said that the client did not want to take them because they did not work. They sent the client to see the medical doctor and the client wanted to be put on Vistrovil for his allergies. Vistrovil is one of the restricted drugs that can't be brought into the facility. The prescription that the client brought back read "medically necessary", even though the doctor also had a list of restrictive drugs. A call was made by the executive assistant to inform the doctor that the client couldn't take the drug prescribed and the doctor gave him a nasal spray instead. The client refused to take the nasal spray."
Staff interviewed during the complaint admitted medication determinations were made by someone other than a medical professional. Interviews with staff addressed the opinion that the patient was med seeking in his efforts to achieve medication but there was no documentation in the client record, other than a case consultation on October 18, 2010,
that addressed this concern. Further, there was no documentation in the client record to address the physician's medication order, and, specifically, there was no information in the medication record.
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Plan of Correction
As a result of this citation, the CEO and Director of Residential Services have begun meeting with the staff to discuss documentation and provide education on when an incident rises to the level that supportive documentation is needed in the client record. They stressed that any issue impeding client care, delivery of services, or coordination of care ancillary to the services provided at COlonial House needs to be thoroughly documented. Documentation should include who, what happened, how it is being adressed, any barriers to resolution, progress toward resolution and final disposition. Once completed, this note, summary, consult etc will be maintained in the cleint record once reviewed by the CEO or Director of Residential Services. The CEO and Director of Residential Services must be advised of any obstacles a client is facing which may have an impact on his/her care.
The CEO and Director of Residential Services will monitor activities and advise staff when documentation is needed through daily staff meeting reports and weekly clinical staff meetings.
No staff person at Colonial House makes medical decisions for a client. We advise our clients of our policies and work with the doctors to provide care in accordance with their drug and alcohol issues. The decision of what medication shuold be prescribed ofr a client is that of the prescribing physician. If a client is prescirbed a medication that is considered unacceptable for aclient while at Colonial House, we will contact the doctor to discuss whether or not there are suitable substitutes, advise the prescribing physician of the clients drug and alcohol history, and should the doctor feel that the medication is medically necesary and that are no other alternatives, the prescription will be filled and monitored on a controlled substance form to insure client adherence to the prescription. Documentation from the doctor outlining the necessity will be maintained in the client record. |