INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 16, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health Systems, DD/FIR was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Twelve personnel records were reviewed on August 16, 2016. The training year reviewed was January 1, 2015 through December 31, 2015.
Employee #4, hired on November 26, 2007, had 2.5 training hours documented for the 2015 training year.
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Plan of Correction
The clinical supervisor will review the policy regarding training hours with the clinician and monitor on a monthly basis the progress toward obtaining training hours in order to avoid repeat of the failure to obtain hours. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Twelve personnel records were reviewed on August 16, 2016. The training year reviewed was January 1, 2015 through December 31, 2015.
Employee #8, hired on December 5, 2005, had no training hours documented for the 2015 training year.
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Plan of Correction
The Director of Residential services will review the policy with all clinical supervisors on or before September 23, 2016. The clinical supervisors will review current status (FY 16)of training with all clinical staff by September 3, 2016. Thee clinical supervisors will review training on a monthly basis and document status in monthly supervision notes. The clinical supervisors will be responsible for monitoring staff compliance with training requirements. The program will be fully compliant by October 15, 2016 |
705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Physical plant inspections were conducted on August 16, 2016 and August 17, 2016.
Observations included:
A washing machine located in the laundry room was broken and filled with water.
Some walls and baseboards in the hallway were buckling and there were chipped floor tiles.
The employee locker area was missing ceiling tiles.
The following rooms were missing cover plates for abandoned medical gases: 432, 433, 434, 435, 438, and 440.
Chipped paint and/or marked walls were found in the following rooms: 408, 409, 420, 424, 433, 441.
Room 403 had holes in the wall.
Room 404 had a stained ceiling tile.
Room 410 had a stained ceiling tile.
Room 419 had damaged blinds.
Room 420 was missing an outlet cover.
Room 432 had a hole in the wall and damaged ceiling tiles.
Room 451 was missing baseboard and had a hole in the wall.
Room 458 had damaged blinds.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facilities manager has been given a list of all citations and is responsible for developing a work list and assigning painters, carpenters and other maintenance personnel to complete the items listed. The washing machine was repaired on August 16, 2016; all other repairs will be completed on or before October 15, 2016 |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
The physical plant inspection was conducted on August 16, 2016 and August 17, 2016. The facility's trash compactor outside of the kitchen was filled to the point that it was unable to to be closed, thus unable to to prevent the penetration of insects and rodents.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Housekeeping is responsible for insuring that the trash compacted is empty of a timely basis, in order to prevent access by pest and rodents. The trash compacted is scheduled to be emptied on a daily basis, she will monitor the removal of trash and insure that the compactor can be closed beginning immediately. |
705.5 (a) (3) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(3) A storage area for clothing.
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Observations
Based on observation during the physical plant inspection, the facility failed to provide sufficient storage space for client room # 404.
Room 404 contained an excessive amount of client belongings that were not stored in either a closet, wardrobe or dresser.
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Plan of Correction
The Clinical Supervisor will review with staff and participants the amount of personal belongings which are allowed to be in the participants room.
The Community Recovery Specialist will be responsible to monitor on a weekly basis each participants room to ensure that all belongs are stored appropriately.
Excessive belongings will be removed from room #404 effective October 27, 2016 when the participant moves into his own apartment.
Full compliance will be achieved by October 30, 2016 |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
The physical plant inspections were conducted on August 16, 2016 and August 17, 2016.
Observations included:
Chipped paint was found in the following bathrooms: 403, 404, 408, 418, 425, 432, 435, 439, 441.
Room 404 had cracked tiles in the shower, exposed rusted metal in the shower, mold or mildew in the shower, and the toilet was running.
Room 408 had cracked tiles in the bahtroom and mold or mildew in the shower.
The baseboard was coming off the wall in the bathroom of room 417.
Room 420 had a missing ventcover in the bathroom, cracked tiles, and mold or mildew.
Room 435 had a cracked tile in the bathroom.
Room 436 had a cracked tile in the bathroom.
Room 438 - the ceiling framing in the shower appeared to be rusted.
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Room 451 had cracked tiles in the bathroom.
Room 457 had mold or mildew in the shower.
Room 458 had a cracked light fixture in the bathroom.
Room 460 had mold or mildew in the shower and rusted and chipped door frame.
Room 463 appeared to have mold or mildew in the shower.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facilities manager has been given a list of all citations and is responsible for developing a work list and assigning painters, carpenters and other maintenance personnel to complete the items listed. All repairs will be completed on or before October 15, 2016 |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
The physical plant inspections were conducted on August 16, 2016 and August 17, 2016. During the inspection on August 17, 2016, the facility failed to ensure that counseling sessions could not be seen as a counseling session was being conducted with the blinds open.
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Plan of Correction
The Program Director will review the policy with all clinical staff regarding the maintenance of privacy during counseling sessions during the September monthly staff meetings. The clinical supervisors and clinical director will conduct random walk-throughs on a monthly basis to ensure the policy is followed. Full compliance will be achieved by September 23, 2016 |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Eleven personnel records were reviewed on August 16, 2016. The facility failed to document and annual performance evaluation in client records, #10 and 11.
Employees #10 and #11 did not have documentation of an annual written individual staff performance evaluation from the previous reviewing year
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Plan of Correction
The Director of Residential Services will review the policy with all staff and will monitor compliance on a monthly basis.
Clinical supervisors will develop a tickler file alerting them to performance evaluation due dates in order to avoid repeat of deficiency.
All overdue performance evaluations will be completed by November 15, 2016
Full compliance will be achieved by November 15, 2016 |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of 20 client records on August 12, 2016 and August 15, 2016, the facility failed to obtain a valid informed and voluntary consent in 19 client records, #1-7 and 9-20.
Client #1 - Two consent forms dated 6/16/16 and 6/21/16 for the client's funding source, the facility failed to have the client's signature. Consent form dated 6/21/16 to another funding source, the facility failed to have the date the client signed the consent.
Client #2 - Three consent forms dated 6/27/16 to the funding source (2) and a government agency, the facility failed to have the date the client signed the consent forms.
Client #3 - Two consent forms dated 7/11/16 to the funding source, the facility failed to have the date the client signed the consent forms.
Client #4 - Three consent forms dated 8/9/16 to the funding source (2) and a government agency, the facility failed to have the date the client signed the consent forms.
Client #5 - Two consent forms dated 8/9/16 to the funding source, the facility failed to have the date the client signed the consent forms. Consent form dated 8/9/16 to an agency, the facility failed to have the purpose for the release and what will be release marked on the consent form. Consent form dated 8/9/16 to the client's PCP, the facility failed to have documented on the consent form the purpose of the release.
Client #6 - Three consent forms dated 5/4/16 to the funding source (2) and a government agency, the facility failed to have the date the client signed the consent forms. Consent form dated 5/4/16, the facility failed to have the agency the release is for, the purpose for the release and what is being release. Additionally, the form only stated that the client can only revoke in writing.
Client #7 - Three consent forms dated 6/13/16 to the funding source (2) and a government agency, the facility failed to have the date the client signed the consent forms.
Client #9 - Three consent forms dated 3/24/16 to the funding source (2) and a government agency, the facility failed to have the date the client signed the consent forms.
Client #10 - Three consent forms dated 7/1/16 to the funding source (2) and a government agency, the facility failed to have the date the client signed the consent forms. Three consent to release forms dated 7/1/16, the facility failed to have the name of the agency the releases are for, the purpose for the release and what will be released. Lastly, consent dated 7/1/16 to probation and parole, the facility failed to have the particular name of the person or agency on the consent form, the purpose of the release and the expiration date of the consent.
Client #11 - Consent form dated 12/7/15 to the client's funding source, the facility failed to have the date the client signed the consent. Consent form dated 1/4/16 to a medical provider only gave the client the option to revoke the consent in writing. Consent form dated 1/5/16 to the client's PCP the facility failed to have the date the consent would expire. Consent form dated 5/31/16 to a medical provider, the facility failed to have the purpose of the release and the expiration date the consent would expire. Lastly, three letters dated 2/16/16, 3/15/16 and 4/12/16 to three medical providers were sent out with client identifying information and the facility failed to have consent to release forms for those medical providers.
Client #12 - Two consent forms dated 7/29/16 to two medical providers, the facility failed to have on the consent form the date the form expires. Consent form dated 1/5/16 to a treatment agency, the facility failed to have the date the client signed the consent form and the purpose for the release. Lastly, eleven letters dated 4/8/16, 4/21/16, 5/16/16, 5/20/16, 5/31/16, 6/4/16, 6/19/16, 6/28/16, 7/28/16, 8/1/16 and 8/2/16 to several medical providers and court were sent out with client identifying information and the facility failed to have consent to release forms for those agencies.
Client #13 - One consent to release dated 4/18/16 had the name of the agency listed, but the name was illegible. Consent form dated 5/31/16 for a treatment provider, the facility failed to have the date the witness signed the consent form. Consent form dated 4/13/16 for the client's funding source, the facility failed to have the date the client signed. Lastly, two letters dated 5/23/16 and 6/10/16 to two agencies were sent out with client identifying information and the facility field to have consent to release forms for those agencies.
Client #14 - Two consent forms dated 4/9/16 to the funding source, the facility failed to have the date the client signed the consent forms. Consent form dated 7/25/16 to a doctor, the facility failed to document what was being release on the consent form. Letter dated 6/27/16 to a medical doctor was sent out with client identifying information and the facility failed to have a consent to release forms for that doctor.
Client #15 - Two consent forms dated 5/18/16 to the funding source, the facility failed to have the date the client signed the consent forms.
Client #16 - Two consent forms dated 12/25/15 to the funding source, the facility failed to have the date the client signed the consent forms. Lastly, a family session took place on 2/25/16 with the client's significant other and the facility failed to have documented a consent to release for the significant other.
Client #17 - Two consent forms dated 12/23/15 to the funding source, the facility failed to have the date the client signed the consent forms. Consent to release dated 4/12/16 to a medical provider, the facility failed to have on the consent form what was being release, the date the consent expired and the date the client signed the consent form. Counselor made a call to an agency and released identifying information about the client on 4/6/16, but failed to have a consent to release for that agency. Lastly, two letters dated 12/23/15 and 3/29/16 to two agencies were sent out with client identifying information and the facility failed to have consent to release forms for those agencies.
Client #18 - Two consent forms dated 2/8/16 to the funding source, the facility failed to have the date the client signed the consent forms. Lastly, three letters dated 2/13/16, 3/31/16, 4/26/16 and 5/4/16 to four agencies were sent out with client identifying information and the facility failed to have consent to release forms for those agencies.
Client #19 - Two consent forms dated 3/12/16 to the funding source, the facility failed to have the date the client signed the consent forms. Consent form dated 3/11/16 to an unnamed agency, the facility failed to have the name of the agency, the purpose for the release and what was being release. Lastly, one letter dated 3/30/16 to the client funding source exceeded 4 PA Code 255.5 by release how often the comes in for individual and group sessions, how many meetings the client would attend and support services offered to the client.
Client #20 - Faxed mailed out to a treatment provider on 5/4/16 with client identifying information and the facility failed to have a consent to release form for that treatment provider. Two consents dated 3/24/16 to the client's funding sources exceeding 4 PA Code 255.5 by allowing the facility to send the clients medical record to the funder.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All consent forms will be reviewed and updated by the Sr. Vice President of Behavioral Health Services to ensure conformance with DDAP regulations with specific attention to Client signature and date; in service training will be provided during unit staff meetings and new forms will be issued to all staff on or before September 30, 2016.
New consent forms will be obtained on any participant who is still in treatment by October 24, 2016
Full compliance will be obtained by October 27, 2016 |
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 20 client records on August 12 and 15, the facility failed to show documentation on the client consent to release forms that the client was offered a copy of their consent in six client records, #5, 6, 10, 11, 12 and 19.
Client #5 - three consents dated 8/9/16 to the client's funding source (2) and probation & parole.
Client #6 - consent dated 5/4/16 to an agency.
Client #10 - five consents dated 7/1/16 to the client's funding source, agency (3) and probation & parole.
Client #11 - one consent dated 1/4/16 to an agency, one consent dated 1/5/16 to the client's PCP, one consent dated 2/29/16 to a doctor's office and one consent dated 5/31/16 to a doctor's office.
Client #12 - one consent dated 12/13/15 to the client's funding source, two consents dated 12/3/16 to a doctor's office and one consent dated 1/5/16 to a treatment provider.
Client #19 - one consent dated 3/11/16 (agency not doc.)
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All consent forms will be reviewed and updated by the Sr. Vice President of Behavioral Health Services to ensure conformance with DDAP regulations with specific attention to Client signature and date; in service training will be provided during unit staff meetings and new forms will be issued to all staff on or before September 30, 2016.
New consent forms will be obtained on any participant still active in the program by October 24, 2016.
Full compliance will be obtained by October 27, 2016. The Clinical supervisor is responsible for monitoring ongoing compliance. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of 20 client records on August 16, 2016, the facility failed to have documented that that client was notified of their client rights in client records, #1-7 and 8-20.
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Plan of Correction
The Sr. Vice President will review all Participant handbooks for content related to client rights. The Sr. Vice President will also review the client rights provided in the Behavioral Access Center to ensure that the forms contain appropriate Participant signatures. The clinical supervisor on the program and the BAC will monitor the process to ensure that Participants are signing that they have been notified of their rights. Full compliance will be achieved by October 15, 2016 |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of 20 client records on August 12, 2016 and August 15, 2016, the facility failed to document a notice of termination in one client record. Client #19 was admitted on March 12, 2016 and administratively discharged on July 13, 2016.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The clinical supervisor will review the policy regarding notification of intent with all counselors in individual supervision and document the same.
The clinical supervisor will monitor discharges on a monthly basis to ensure that notification is provided and documented on all administrative discharges.
Full compliance will be achieved by October 31, 2016 |
709.51(b)(3)(i) LICENSURE Medical histories
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of 10 inpatient non-hospital rehabilitation client records on August 12, 2016 and August 15, 2016, the facility failed to document a medical history during the intake process in three client records, 12, 15 and 18.
Client #12 was admitted December 14, 2015. There was no documentation of a medical history as of the date of the licensing inspection.
Client #15 was admitted May 19, 2016. There was no documentation of a medical history as of the date of the licensing inspection.
Client #18 was admitted February 8, 2016 and discharged on May 23, 2016. There was no documentation of a medical history as of the date of the licensing inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Staff physicians and CRNP's are responsible for the completion of admission physicals.
In- service review will be provided during the medical staff meeting on 9-21-16 and the nurse manager and program clinical supervisors will be responsible for monitoring the completion of physicals within program guidelines.
All active clients will be reviewed and medical histories will be completed by October 24, 2016
Full compliance will be reached by 9/30/16 |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the review of 10 inpatient non-hospital rehabilitation client records on August 12, 2016 and August 15, 2016, the facility failed to document a drug and alcohol history during the intake process in three client records, 12, 14 and 15.
Client #12 was admitted December 14, 2015. There was no documentation of a drug and alcohol history as of the date of the licensing inspection.
Client #14 was admitted April 8, 2016. There was no documentation of a drug and alcohol history as of the date of the licensing inspection.
Client #15 was admitted May 19, 2016. There was no documentation of a drug and alcohol history as of the date of the licensing inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All active cases will be reviewed by the nurse and clinical supervisor and drug and alcohol histories will be completed on or before 10/31/16.
The clinical supervisor will monitor all new admissions after 72 hours to insure that drug and alcohol histories are completed in accordance with program policy.
Full compliance will be achieved by 10/31/16 |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of 10 client inpatient non-hospital rehabilitation records on August 12, 2016 and August 15, 2016, the facility failed to document a personal history during the intake process in three client records, 12, 14 and 15.
Client #12 was admitted December 14, 2015. The personal history wasn't documented until August 10, 2016.
Client #14 was admitted April 8, 2016. There was no documentation of a personal history as of the date of the licensing inspection.
Client #15 was admitted May 19, 2016. There was no documentation of a personal history as of the date of the licensing inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The clinical supervisor will review the citations with all staff during the September staff meeting and provide in-service training regarding the content and time frame for completing personal histories.
All active cases will be reviewed by the clinical supervisor and documentation of personal histories updated on or before October 31,2016.
The clinical supervisor will conduct weekly reviews of new admissions to determine that histories are being completed in a timely fashion.
Full compliance will be reached by October 31, 2016 |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of 10 inpatient non-hospital rehabilitation client records on August 12, 2016 and August 15, 2016, the facility failed to document a psychosocial evaluation during the intake process in seven client records, 11, 12, 13, 14, 15, 17 and 18.
Client #11 was admitted December 17, 2015. There was no documentation of a psychosocial evaluation as of the date of the licensing inspection.
Client #12 was admitted December 14, 2015. There was no documentation of a psychosocial evaluation as of the date of the licensing inspection.
Client #13 was admitted April 3, 2016. There was no documentation of a psychosocial evaluation as of the date of the licensing inspection.
Client #14 was admitted April 8, 2016. The psychosocial evaluation wasn't documented until August 3, 2016.
Client #15 was admitted May 19, 2016. The psychosocial evaluation wasn't documented until July 25, 2016.
Client #17 was admitted December 23, 2015 and discharged on April 29, 2016. There was no documentation of a psychosocial evaluation as of the date of the licensing inspection.
Client #18 was admitted February 8, 2016 and discharged on May 23, 2016. There was no documentation of a psychosocial evaluation as of the date of the licensing inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The clinical supervisor will review the citations with all staff during the September staff meeting and provide in-service training regarding the content and time frame for completing psychosocial evaluations.
All active cases will be reviewed and psychosocial evaluations completed by 10/31/16
The clinical supervisor will conduct weekly reviews of new admissions to determine that evaluations are being completed in a timely fashion.
Full compliance will be reached by October 31, 2016 |
709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
Based on the review of 10 inpatient non-hospital rehabilitation client records on August 12, 2016 and August 15, 2016, the facility failed to either document a comprehensive treatment plan, the type /or frequency, support service or obtain the signature/date of the client or counselor in client records, #11 and 13 through 19.
Client #11 was admitted on December 17, 2015. The facility failed to document client #11's comprehensive treatment plan as of the date of the licensing inspection.
Client #13 was admitted on April 3, 2016. The comprehensive treatment plan was developed on April 12, 2016. The facility failed to document the type and frequency of services.
Client #14 was admitted on April 8, 2016. The facility documented a comprehensive treatment plan, but failed to date the day the treatment plan was developed with the client and the client's signature.
Client #15 was admitted on May 19, 2016. The comprehensive treatment plan was developed on May 23, 2016. The facility failed to document the type and frequency of services.
Client #16 was admitted on December 27, 2015 and discharged on April 1, 2016. The facility documented a comprehensive treatment plan, but failed to date the day the treatment plan was developed with the client. Additionally, the facility failed to document the type and frequency of services.
Client #17 was admitted on December 23, 2015 and discharged on April 29, 2016. The facility failed to document client #11's comprehensive treatment plan as of the date of the licensing inspection.
Client #18 was admitted on February 8, 2016 and discharged on May 23, 2016. The facility documented a comprehensive treatment plan, but failed to date the day the treatment plan was developed with the client.
Client #19 was admitted on March 12, 2016 and discharged on July 13, 2016. The facility failed to show documentation of a comprehensive treatment plan for client #19.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The clinical supervisor will review the citations with all staff during the September staff meeting and provide in-service training regarding the content and time frame for completing comprehensive treatment plans.
By 9-30-16, Clinical Supervisor will train staff on how to include in the treatment plans, the frequency of treatment and rehabilitation services.
Beginning 09-26-16, the Clinical supervisor will inspect participants' electronic chart to ensure:
1. that treatment plans are completed on time and are located in the right electronic file.
2. that treatment plans include propose support services list
3. that treatment plans include frequency of treatment and rehabilitation services.
All active cases will be reviewed and treatment plans will be updated to include type and frequency of services as well as support services by 10/31/16
Full compliance will be reached by October 31, 2016 |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of 10 inpatient non-hospital rehabilitation client records on August 12, 2016 and August 15, 2016, the failed to document a complete client record in records, #17 and 19.
Client #17 was admitted on December 23, 2015 and discharged on April 29, 2016. The facility failed to document a case consultation and discharge summary as of the date of the licensing inspection.
Client #19 was admitted on March 12, 2016 and discharged on July 13, 2016. The facility failed to document a case consultation as of the date of the licensing inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The clinical supervisor will review the citations with all staff during the September staff meeting and provide in-service training regarding the content and time frame for completing consultations and discharge summaries.
Case Consultations/Treatment Team Notes will be completed on a least once per month for all individuals admitted to the program in accordance with program policy.
The clinical supervisor will conduct monthly reviews of new admissions and all discharges to determine that consultations and discharge summaries are being completed in a timely fashion.
Full compliance will be reached by October 31, 2016 |