INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 24, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Colonial House Outpatient was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
704.8(c) LICENSURE Full Caseload Assignment
704.8. Qualifications for the position of counselor assistant.
(c) In addition to training, assignment of a full caseload shall be contingent upon the supervisor's positive assessment of the counselor assistant's individual skill level.
|
Observations
Based on a review of personnel records and administrative documentation, the facility failed to provide a positive assessment of the counselor assistant's individual skill level before assigning a caseload in one of one record reviewed.
The findings include:
One personnel record was reviewed for documentation of a positive assessment on April 24, 2013. The facility failed to document a positive assessment before assigning a caseload to a counselor assistant in one of one personnel record, specifically for employee # 4.
Employee # 4 was hired as a counselor assistant on 1/28/13. Employee # 4 has an Associate's Degree in Human Service and was required to receive close supervision for at least the first 9 months of employment because there was less than two years of clinical experience. The facility did not document close supervision; nor did the facility document a positive assessment before assigning a caseload to employee # 4.
At the time of inspection employee # 4 had a caseload which included 35 clients.
The Facility Director did not dispute the findings.
|
Plan of Correction
704.8704.9 (b)
All Counselor Assistants will receive a positive assessment prior to carrying a caseload.
The Director of Treatment will be re-trained on all paperwork requirements by 6/01/2013. The Director of Treatment will ensure that all Counselor Assistants have the appropriate documentation in all personnel records by 6/15/2013 to include supervision notes
100 percent of Counselor Assistant personnel records will be audited for six months to ensure completion. The CEO and Director of Treatment will be responsible for this plan of correction
Employee #4 did not return to work and abandon her position.
|
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
|
Observations
Based on a review of personnel records and administrative documentation, the facility failed to document close supervision for at least the first nine months of employment in one of one record reviewed.
The findings include:
Close supervision is defined as: "Formal documented case review and an additional hour of direct observation by a supervising counselor or clinical supervisor once a week. Supervision is to focus on the development of the counselor assistant's clinical skills. Weekly supervision notes must clearly demonstrate that close supervision is occurring, The weekly notes should also provide a reference to the charts that will demonstrate that at least one hour per week of direct observation is being conducted."
One personnel record was reviewed for documentation of close supervision on April 24, 2013. The facility failed to document close supervision in one of one personnel record, specifically for employees # 4.
Employee # 4 was hired as a counselor assistant on 1/28/13. Employee # 4 has an Associate's Degree in Human Service and was required to receive close supervision for at least the first 9 months of employment because there was less than two years of clinical experience. The facility did not document close supervision for employee # 4.
The Facility Director did not dispute the findings.
|
Plan of Correction
704.9
All Counselor Assistants will receive close supervision per policy.
The Director of Treatment will be re-trained on supervision requirements by 06/5/2013.
The Director of Treatment will maintain weekly scheduled supervision with all Counselor Assistants.
The close supervision note will be completed by end of the supervision and signed by both Supervisor and Counselor Assistant.
100 percent of Counselor Assistant files will be audited monthly for 3 months to ensure compliance.
Employee #4 is no longer employed at this facility.
This will be the responsibility of Human Resources and Director of Treatment.
|
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
|
Observations
Based on a review of administrative documentation and a review of the facility's policy and procedures manual, the facility failed to document an annual evaluation of the overall training plan.
The findings include:
The facility policy states: "The Directors will distribute questionnaires to all staff members requesting their input on areas of training needed for the agency. These questionnaires will be distributed the first week of June. In mid-June, the Directors will hold an annual meeting with staff to compile information from questionnaires, review pertinent training information, review prior years training evaluation and to brainstorm agency-wide training needs. Notes from the meeting will document this."
The facility's training year is from July to June. In accordance with facility policy an overall training plan was to be documented prior to the end of the fiscal year, or by June 30, 2012. Based on a review of administrative documentation on April 22, 2013 the facility failed to document an overall training plan.
The Project Director did not dispute the findings.
|
Plan of Correction
704.11
The CEO and Director of Treatment reviewed requirements of this regulation. All staff will receive a questionnaire by first week in June and evaluation of all training needs will be completed by 6/15/2013. This is the responsibility of the CEO and the Human Resource Department.
We have implemented this into our performance evaluation time so that we will remain in compliance ongoing.
|
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Based on a review of personnel records and a review of the facility's policy and procedures manual, the facility failed to document a written individual training plan in two of four records reviewed.
The findings include:
The facility policy states: "The Directors will meet individually with the staff and complete all individual training assessments and individual training plans. Training plans for each staff member are conducted in June. Each employee signs the training plan."
Four personnel records were reviewed for documentation of an individual training plan on April 22, 2013 and April 24, 2013. The facility failed to document an individual training plan in two of four records reviewed; specifically personnel record # 3, and 4.
In addition, the Staffing Requirements Facility Summary Report which was completed by the facility on 4/24/13 did not document the completion of individual training plans.
According to the staffing form, the facility also did not document individual training plans for two of four support staff.
The Project Director confirmed the findings.
|
Plan of Correction
704.11
All supervisors will be re-trained on requirements of training plans by 5/20/2013. Training plans for all existing staff will be completed by 6/15/2013. Annual training plans will be completed upon hire and annually with performance evaluations. The Human Resources staff member will audit all new hires within 7 days of hire to ensure that training plans are complete. 100 percent of all personnel records will be audited to ensure that every staff member has a training plan. This is the responsibility of the Human Resources staff.
|
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of the facility's fire drill log, the facility failed to conduct unannounced fire drills at least once a month.
The findings include:
On April 24, 2013, the facility's fire drill log was reviewed. The facility failed to conduct fire drills during eleven out of eleven months.
The facility's fire drill log was requested at 8:30 AM. The Facility Director reported at 8:45 AM that there was no fire drill log. At 1:05 PM the Facility Director stated he found the facility's fire drill log book, and presented the log for inspection. A review of the fire drill log indicated that the facility's last documented fire drill was 4/3/12.
The facility failed to conduct unannounced fire drills during the months of May, June, July, August, September, October, November, December 2012, January, February and March 2013.
The Facility Director confirmed the findings.
|
Plan of Correction
705.28 (d) (1)
The policy regarding monthly fire drills was reviewed with the Facility Director. All requirements such as documentation of time, exits and methods were reviewed. The CEO will complete random audits of facility fire drill logs to ensure compliance.
Fire drills have been conducted monthly
since the inspection and will continue moving forward. This fire drill have and will continue to be unannounced and documented. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on a review of personnel records, the facility failed to ensure that all personnel are trained to perform assigned tasks during emergencies in one of one record reviewed.
The findings include:
One personnel record was reviewed on April 24, 2013 to verify that all personnel were trained to perform assigned tasks during emergencies. The facility failed to document the training upon employment in personnel record # 4.
Employee # 4 was hired 1/28/13.
The training was due upon employment; however, verification of this training was not documented at the time of review on 4/23/13.
The Facility Director did not dispute the findings.
|
Plan of Correction
705.28 (d) (3)
The policy was reviewed with all supervisors on 5/17/2013. All current staff will be trained on Emergency and Fire Safety procedures by 6/01/2013. All new hires will be trained within 7 days of start, per policy. 100 percent of new hires will be audited for 6 months to ensure compliance. Human Resources will be responsible for this action plan.
|
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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.
|
Observations
Based on a review the facility's fire drill log, the facility failed to 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.
The findings include:
On April 24, 2013, the facility's fire drill log was requested. The facility failed to maintain a written fire drill record from May 2012 - March 2013.
The Facility Director presented the facility's fire drill log book with the last fire drill being conducted on 4/3/12.
The Facility Director confirmed the findings.
|
Plan of Correction
705.28 (d) (4)
The policy regarding monthly fire drills was reviewed with the Facility Director. All requirements such as documentation of time, exits and methods were reviewed. The facility director is responsible for completing the monthly fire drill. The CEO will complete random audits of facility fire drill logs to ensure compliance.
The fire drill log consists of required components: date, time, how many people in the office, staff signature, use of different exit and use of different time, and how long the fire drill took. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a review of the facility's fire drill log, the facility failed to verify that alternate exit routes were used during fire drills.
The findings include:
On April 24, 2013, the facility's fire drill log was reviewed. The facility failed to conduct fire drills during eleven out of eleven months, and did not ensure that the facility alternated exit routes during fire drills from May 2012 - March 2013.
The Facility Director confirmed the findings.
|
Plan of Correction
705.28 (d) (5)
The policy regarding monthly fire drills was reviewed with the Facility Director on 5/17/2013. All requirements such as documentation of time, exits and methods were reviewed. Specific attention was placed on use of alternate exits. The CEO will complete random audits of facility fire drill logs to ensure compliance.
Fire drills were conducted on 5/3/13 and 6/19/13. 5/3/13 2 peolpe in the building and Outside front door from 2nd floor was used. 2 minutes were used to evacute.
The 6/19/13 fire drill at 10:16 am . 16 people in the building and 3 minutes were used to evacuate the Building. Center stairs from 2nd floor to the rear exits on 1st floor and out the rear door from 1st floor.
The alternate exits are the ensuing: (1) Rear door from 1st floor (2) Ousdide door from reception area (3) Out front door from 1st floor (4) Center stairs from the 2nd floor to rear exits on 1st floor. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
|
Observations
Based on a review of the facility's fire drill log, the facility failed to set off a fire alarm or smoke detector.
The findings include:
On April 24, 2013, the facility's fire drill log was reviewed. The facility failed to conduct fire drills during eleven out of eleven months, and did not set off a fire alarm or smoke detector from May 2012 - March 2013.
The Facility Director confirmed during an interview that neither the fire alarm or smoke detector was set off.
|
Plan of Correction
705.28 (d) (7)
The policy regarding monthly fire drills was reviewed with the Facility Director on 5/17/2013. All requirements such as documentation of time, exits and methods were reviewed. Specific attention was placed on use of smoke detectors or method of drill. The CEO will complete random audits of facility fire drill logs to ensure compliance.
Fire alarm was set off by the Building manager at 5 am on 5/3/13. Two people were in the building and the alarm was reset by building manager.
Program drafted and faxed letter to apply for exception.
Copy of letter is in Fire Drill log and enclosed
Pennsylvania Department of Health
Division of Drug and Alcohol Program Licensure
June 20, 2013
To Whom It May Concern:
Colonial House Outpatient Facility is requesting a Fire Safety Exemption from code 709.92a, Fire Safety for the following reasons:
The facility is located in a building in which it does not own. There are many other non-affiliated businesses and agencies located in the building and when there is a fire anywhere on the premises a siren is sounded along with fire/ smoke alarms.
There is an annual inspection requested by the building owner of all fire alarms and smoke detectors by the fire alarm company. Written reports are provided once these inspections are completed.
The facility's Director will request the annual report from the building owner and it will be kept in a logbook. Furthermore, The facility's Director will review the logbook quarterly to ensure that all of the fire safety inspections are included.
Thank you,
|
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
|
Observations
Based on an interview with the Project Director, the governing body failed to make available to the public an annual report.
The findings include:
On April 22, 2013, the facility's annual report was requested to ensure that the governing body made the 2012 annual report available to the public.
The facility failed to document or make an annual report available to the public which included:
Activities and accomplishment of the preceding year.
A financial statement income and expenses.
A statement disclosing the names of officers, directors, and principal shareholders, where applicable.
During the inspection and exit interview the Project Director confirmed that the facility did not document an annual report for the 2012 fiscal year.
|
Plan of Correction
709.22(e)
An annual report will be completed for last fiscal year by 6/15/2013. An ad will be placed in the local newspaper for this by 6/25/2013. Ongoing, an annual report will be completed with ad placed by July 15 of each year. The CEO is responsible for this action.
|
709.23(b)(3) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(3) A performance report summarizing the progress towards meeting goals and objectives.
|
Observations
Based on a review of administrative documentation, the Project Director and governing body failed to develop an annual performance report summarizing the progress toward meeting goals and objectives.
The findings include:
A review of administrative documentation and a conversation with the Project Director on April 23, 2013 confirmed that neither the Project Director nor the governing body developed a performance report summarizing the progress toward meeting the goals and objectives for the Project's 2011 - 2012 fiscal year.
|
Plan of Correction
709.23 (b) (3)
Annual Goals will be updated per policy by end of fiscal year. Ongoing, the CEO will update goals and objectives quarterly and present to Governing Body. The CEO is responsible for this action.
|
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
|
Observations
Based on a review of the facility's policy and procedure manual and a review of personnel records, the facility failed to document work performance evaluations in accordance with facility policy.
The findings include:
The facility policy states: "Work performance evaluations will be developed on each employee. This will occur upon the end of probation period. A work performance evaluation will be conducted every 12 months thereafter. The employee's immediate supervisor will schedule a meeting with the employee and present the evaluation orally to the employee. Both will sign and a copy will be placed in the permanent employee personnel file. The clinical supervisor shall develop a written performance evaluation for counselor assistant. This evaluation is presented to the counselor assistant. Evaluation for counselor assistant will be performed at the end of a 6-month probation period and semi-annually until counselor assistant has satisfied qualification of counselor."
Four personnel records were reviewed for documentation of work performance evaluations on April 22, 2013 and April 24, 2013. The facility failed to document work performance evaluations in accordance with facility policy in three of three records reviewed, personnel record # 1, 2, and 3.
Employee # 1, the Project Director was hired 5/1/07. A work performance evaluation was due annually, or by 5/1/12. 11/16/11 was the last documented work performance evaluation.
Employee # 2, the Facility Director was hired 7/8/08. A work performance evaluation was due annually, or by 7/8/12. 1/8/12 was the last documented work performance evaluation.
Employee # 3, a counselor was hired 2/14/11. A work performance evaluation was due annually, or by 2/14/13. There was no documentation of a performance evaluation in employee # 3's personnel record.
The Project Director did not dispute the findings.
|
Plan of Correction
709.26 (d) (5) (i)
The policy for performance evaluations will be reviewed with all supervisors by 5/26/2013. All supervisors will complete evaluations upon completion of probation and annually thereafter. Human Resources will be responsible to ensure that each personnel record has the required documentation in the required timeframe. The CEO will complete random audits for 6 months to ensure compliance.
|
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
|
Observations
Based on a review of the facility's discharged client list and the client records presented to the Licensing Specialist at the time of the inspection, the facility failed to secure client records within a locked storage container.
The findings include:
On April 24, 2013, the active and discharged client lists were reviewed and a random sample of client records were selected for review. Three discharged client records were selected for review, client records # 1, 2, and 3. The facility failed to provide one out of three discharged client records requested, specifically record # 1.
The facility could not locate client record # 1 at the time of the inspection.
The Facility Director confirmed that the record could not be found.
In addition, the facility failed to maintain client records within locked storage containers.
During the physical plant inspection client records were observed on top of the file cabinets. The file cabinets were not locked and the record room also had a refrigerator for urine's and a shredding machine.
The facility failed to maintain client records within locked file cabinets and the facility used the record room for multipurpose.
The Facility Director did not dispute the findings.
|
Plan of Correction
709.28 (b)
The Facility Director was re trained on confidentiality and expectations of record storage. On 6/20/13 the staff will also be retrained on confidentiality.
Missing keys will be replaced and all cabinets will remain locked. Also, the door to file room will remain locked at all times. Any charts that are removed from the locked file room will be documented in the chart binder which will state when it was placed in the file cabinet and who placed it. It will also consist of dates and times and a place to be signed by the staff removing the chart. This will be the responsibility of the facility director to ensure that the staff are complying with this procedure.
Record #1 was found.
The refrigerator and shredder were relocated.
|
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on a review of clinical documentation, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project.
The findings include:
One record requiring documentation of notification of termination was reviewed. The facility failed to document notification of termination in one of one client records reviewed, specifically client record # 6.
Client # 6 was admitted to the program on 1/30/13, his last session was 2/1/13, and he was discharged on 2/1/13.
The facility failed to document a reason why the client was discharged, nor was their any documentation of re-engagement or an outreach letter.
The facility failed to inform the client, in writing, of a decision to involuntarily terminate treatment.
The Facility Director did not dispute the findings.
|
Plan of Correction
709.33 (a)
The procedure for notification of treatment termination and documentation requirements will be reviewed with all staff by 6/20/2013.
The Facility Director will be responsible to ensure compliance with this action by completing audits of 10 percent of discharges for 3 months
The CEO will ensure that this occurs in the time frame stated.
|
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of clinical documentation, the facility failed to document a psychosocial evaluation of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation in four of six records reviewed.
The findings include:
Six client records were reviewed for documentation of an evaluative psychosocial assessment on April 24, 2013. The facility failed to document an evaluative psychosocial assessment in four of six records reviewed, specifically client records # 4, 5, 6, and 7.
The facility documented psychosocial evaluations for client records # 4, 5, 6, and 7; however, the psychosocial assessments failed to evaluate the individuals in relationship to their collected historical information in order to identify possible relationships, conditions and causes leading to their current situation.
During a conversation with the Facility Director he confirmed the findings.
|
Plan of Correction
709.91 (b) (6)
Clinical staff and evaluators will receive training and supervision on documentation of psychosocial evaluations. A new psychosocial assessment has been created and will be implemented by 7/4/13. This will be approved by the Board. The facility director/CEO will ensure that the training and supervision is ongoing throughout the year, to refresh and retrain. The Facility Director will be responsible to ensure compliance with this action plan by completing audits on 100 percent of all admissions for three months.
. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Based on a review of clinical documentation, the facility failed to document an individual treatment and rehabilitation plan in one of five records reviewed.
The findings include:
Five client records were reviewed for documentation of an individual treatment plan on April 24, 2013. The facility failed to document an individual treatment plan in one of five records reviewed, specifically client record # 5.
Client # 5 was admitted to the program on 1/8/13 and was still an active client at the time of review on 4/24/13. The treatment plan was due in 30 days or by 2/8/13. The facility failed to document a treatment plan for client # 5.
The Facility Director confirmed the findings.
|
Plan of Correction
709.92 (a)
The procedure for completion of treatment plans will be reviewed with all staff by 6/1/2013. All staff will sign acknowledgement of this procedure. The facility Director will be responsible to ensure compliance with this action plan by completing random chart audits on 25 percent of client records for three months.
Client # 5 is no longer active in the program. Client dropped out of treatment before completing. |
709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
|
Observations
Based on a review of clinical documentation and a review of the facility's policy and procedure manual, the facility failed to document a complete client record which included a discharge summary in one of three records reviewed.
The findings include:
The facility's policy states: "Discharge summaries will be completed within one week after discharge."
Three client records requiring documentation of a discharge summary were reviewed on April 24, 2013. The facility failed to document a discharge summary in one of three records reviewed; specifically client record # 6.
Client # 6 was admitted to the program on 1/30/13 and discharged 2/1/13. Client # 6's last day of counseling was documented as 2/1/13, the facility indicated that the client failed to return to treatment and was discharged on 2/1/13 after leaving the facility against staff advice. The facility was required to document a complete client record which included a discharge summary within one week or by 2/8/13. The facility failed to document a discharge summary as of 4/24/13.
The Facility Director did not dispute the findings.
|
Plan of Correction
709.93 (a) (10)
The policy for completion of discharge summaries will be reviewed with all staff by 7/11/2013. All staff will sign acknowledgement of this procedure.
The Facility Director, during supervision will review the counselor's chart prior to that time.
Discharges will be reviewed in supervision. The Facility Director will have all discharge summaries completed by the counselor by the end of that day and placed in the discharge drawer. Facility Director will complete audits on 100 percent of all discharged clients to ensure on going compliance.
|
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
|
Observations
Based on a review of clinical documentation and a review of the facility's policy and procedure manual, the facility failed to document a complete client record which included follow-up information in one of three records reviewed.
The findings include:
The facility's policy states: "Consumers who have completed the program successfully shall be contacted within 30 days of their discharge. An attempt will be made to reach clients that are unsuccessful also. A record of the contact made shall be kept in the consumer chart."
Three client records requiring documentation of follow-up information were reviewed on April 24, 2013. The facility failed to document follow-up information in one of three records reviewed; specifically client record # 6.
Client # 6 was admitted to the program on 1/30/13 and discharged 2/1/13. The facility was required to document a complete client record which included follow-up information within 30 days or by 3/1/13. The facility failed to document follow-up information as of 4/24/13.
The Facility Director did not dispute the findings.
|
Plan of Correction
709.93 (a) (11)
The policy and procedure will be reviewed with all staff by 6/01/2013. Staff will sign acknowledgement of this procedure. The Facility Director, during supervision will review all follow up forms with the employee that is assigned to this task. All charts requiring follow ups will be placed in a drawer specified follow ups. Facility Director will randomly complete audits of 100 percent of these charts to remain in compliance.
Follow up for chart #6 has been completed. |