INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on September 4-6 & 10, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Passages to Recovery, Inc. 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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709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on a review of client medication administration records, the facility failed to provide documentation of medication being provided as prescribed by a physician in five of five client records.
Client #2 was admitted on March 1, 2024 and was active at the time of the investigation. The medication administration record (MAR) was reviewed for August 2024.
A medication was prescribed on June 10, 2024, with physician instructions to inhale two puffs daily. The MAR did not include documentation that the client received the medication as prescribed on August 1-3, 5-9, 11-21, 23-25 and 27-30, 2024.
A second medication was prescribed on July 30, 2024, with physician instructions to take one tablet sublingually three times per day. The MAR did not include documentation that the client received the medication as prescribed on August 1-3, 11, 12, 15, 20 and 29, 2024.
A third medication was prescribed on March 29, 2024, with physician instructions to take one tablet every morning. The MAR did not include documentation that the client received the medication as prescribed on August 2, 3 & 20, 2024.
A fourth medication was prescribed on July 30, 2024, with physician instructions to take one tablet daily for seven days. The MAR did not include documentation that the client received the medication as prescribed on August 2, 3, 6 and 9, 2024.
A fifth medication was prescribed on March 14, 2024, with physician instructions to take one tablet four times daily. The MAR did not include documentation that the client received the medication as prescribed on August 3, 15, 16, 17, 18, 24, 29 and 30, 2024.
A sixth medication was prescribed on July 1, 2024, with physician instructions to take one tablet daily. The MAR did not include documentation that the client received the medication as prescribed on August 3, 15 and 28, 2024.
A seventh medication was prescribed on March 21, 2024, with physician instructions to take one capsule twice daily. The MAR did not include documentation that the client received the medication as prescribed on August 2, 3, 6, 13, 14, 15, 18, 28 and 31, 2024.
An eighth medication was prescribed on July 11, 2024, with physician instructions to take one tablet at bedtime. The MAR did not include documentation that the client received the medication as prescribed on August 3, 6, 8, 12, 13, 15, 16, 17, 18, 20, 26 and 31, 2024.
A ninth medication was prescribed on July 2, 2024, with physician instructions to take one tablet at bedtime. The MAR did not include documentation that the client received the medication as prescribed on August 3 & 6, 2024.
A tenth medication was prescribed on July 30, 2024, with physician instructions to take two puffs daily. The MAR did not include documentation that the client received the medication as prescribed on August 1-30, 2024.
An eleventh medication was prescribed on March 7, 2024 with physician instructions to take one tablet every morning. The MAR did not include documentation that the client received the medication as prescribed on August 2, 3, 7 and 14, 2024.
Client #3 was admitted on July 11, 2024 and was active at the time of the investigation. The medication administration record (MAR) was reviewed for August 2024.
A medication was prescribed on July 10, 2024, with physician instructions to take one tablet every morning. The MAR did not include documentation that the client received the medication as prescribed on August 3 & 4, 2024.
A second medication was prescribed on July 10, 2024, with physician instructions to take one tablet every evening. The MAR did not include documentation that the client received the medication as prescribed on August 2 & 3, 2024.
A third medication was prescribed on July 10, 2024, with physician instructions to take one tablet every morning. The MAR did not include documentation that the client received the medication as prescribed on August 3, 4, and 18, 2024.
A fourth medication was prescribed on July 18, 2024, with physician instructions to take one capsule twice daily. The MAR did not include documentation that the client received the medication as prescribed on August 2, 3, 4 and 18, 2024.
Client #4 was admitted on April 29, 2024 and discharged on September 5, 2024. The medication administration record (MAR) was reviewed for August 2024.
A medication was prescribed on July 30, 2024, with physician instructions to take one tablet twice daily. The MAR did not include documentation that the client received the medication as prescribed on August 1, 2, 3 and 4, 2024.
Client #9 was admitted on June 4, 2024 and was active as of the time of the investigation. The medication administration record (MAR) was reviewed for August 2024.
A medication was prescribed on July 16, 2024, with physician instructions to take one tablet twice daily. The MAR did not include documentation that the client received the medication as prescribed on August 2-4, 2024.
A second medication was prescribed on August 12, 2024, with physician instructions to take one tablet in the morning. The MAR did not include documentation that the client received the medication as prescribed on August 25 & 29, 2024.
A third medication was prescribed on June 5, 2024, with physician instructions to take one tablet twice daily. The MAR did not include documentation that the client received the medication as prescribed on August 2 - 4, 2024.
A fourth medication was prescribed on July 30, 2024, with physician instructions to take one capsule daily after lunch for twenty-eight days. The MAR did not include documentation that the client received the medication as prescribed on August 3 & 4, 2024.
A fifth medication was prescribed on July 16, 2024, with physician instructions to take two puffs once daily. The MAR did not include documentation that the client received the medication as prescribed on August 4, 5 and 13-27, 2024.
Client #10 was admitted on March 14, 2024 was active at the time of the investigation. The medication administration record (MAR) was reviewed for August 2024.
A medication was prescribed on July 18, 2024, with physician instructions to take one tablet daily. The MAR did not include documentation that the client received the medication as prescribed on August 3, 7, 8 and 16, 2024.
A second medication was prescribed on July 18, 2024, with physician instructions to take one film daily at bedtime. The MAR did not include documentation that the client received the medication as prescribed on August 18, 2024.
A third medication was prescribed on July 18, 2024, with physician instructions to take one film daily. The MAR did not include documentation that the client received the medication as prescribed on August 3, 2024,
A fourth medication was prescribed on July 18, 2024, with physician instructions to take one film daily. The MAR did not include documentation that the client received the medication as prescribed on August 18, 19, 21 and 29, 2024.
A fifth medication was prescribed on July 18, 2024, with physician instructions to inhale one puff two times daily. The MAR did not include documentation that the client received the medication as prescribed on August 1-30, 2024.
A sixth medication was prescribed on July 18, 2024, with physician instructions to take one tablet three times daily for twenty-eight days. The MAR did not include documentation that the client received the medication as prescribed on August 1, 2, 3, 16 and 28, 2024.
A seventh medication was prescribed on May 2, 2024, with physician instructions to take one tablet every evening. The MAR did not include documentation that the client received the medication as prescribed on August 6 & 11, 2024.
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Plan of Correction
Facility Monitor(s) will be required to attend mandatory quarterly medication compliance training; this training will be outside of regular monthly monitor meeting/training facilitated by Medical staff.
Medical staff will be responsible for weekly audit with updated inventory reports to management for immediate review of inconsistencies in medication distribution and audit updates. If applicable, Medical and/or management staff will train and hold accountable any staff during their direct supervision for repeated and/or egregious errors.
Medical staff will be leading and distributing all medication passes during Mon-Friday, once PTR medical department becomes fully staffed.
Monitor staff will continue to distribute all medication calls in the interim.
Facility Manager will continue to complete monthly medication audit for oversight and will provide a report, when applicable. The report will detail staff errors and medication audit concerns. This report will also be a tool to use for medical staff to ensure ongoing updates for medication distribution and prescription reorder, when applicable.
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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 medication administration records, medication inventories and staff interviews, the facility failed to maintain accurate records of medications given and medication inventories in five of five client records.
Client #2 was admitted on March 1, 2024 and was active at the time of the onsite investigation.
On May 6, 2024, Client #2 was prescribed 10 milligrams of Baclofen to be taken every eight hours as needed. It was documented that the client took the medication one time per day on August 4, 13, 15, 19, 21, 23, 24, 25, 26 & 30, 2024. It was documented that the client took the medication two times per day on August 1, 2, 3, 6, 7, 9, 12, 14, 18, 20, 27, 28, 29 & 31, 2024. It was documented that the client took the medication three times per day on August 5, 11 and 17, 2024. None of this medication was taken on August 8, 10, 16 and 22, 2024. An inventory report for this medication was completed on August 25, 2024. According to the electronic medical record, the client should have 67 doses of the medication on hand as of that date. A physical count of the medication was recorded to be 56.
On July 30, 2024, Client #2 was prescribed 8/2 milligrams of Buprenorphine / Naloxone to be taken sublingually three times daily. The medication was taken as prescribed with the exception of August 1 (taken one time), August 3 (none taken), August 11 (taken one time), August 12 (taken twice), August 15 (taken twice), August 20 (taken twice), August 29 (taken twice). An inventory report for this medication was completed on August 25, 2024. According to the electronic medical record, the client should have 23 doses of the medication on hand as of that date. A physical count of the medication was recorded to be 18.
On March 29, 2024, Client #2 was prescribed 300 milligrams of Bupropion HCL XL to be taken once daily in the morning. The medication was taken as prescribed with the exception of August 2, 3 & 20, 2024. An inventory report for this medication was completed on August 25, 2024. According to the electronic medical record, the client should have 40 doses of the medication on hand as of that date. A physical count of the medication was recorded to be 39.
On March 14, 2024, Client #2 was prescribed 600 milligrams of Gabapentin to be taken four times daily. The medication was taken as prescribed with the exception of August 3 (taken once), August 15 (taken three times), August 16 (taken 3 times), August 17 (taken three times), August 18 (taken three times), August 24 (taken three times), August 29 (taken three times) and August 30 (taken three times). An inventory report for this medication was completed on August 25, 2024. According to the electronic medical record, the client should have 134 doses of the medication on hand as of that date. A physical count of the medication was recorded to be 135.
On August 15, 2024, Client #2 was prescribed 50 milligrams of Hydroxyzine to be taken up to four times daily as needed. The medication did not arrive at the facility until August 19, 2024. The medication was taken twice daily on August 19, 20, 21, 25, 27, 28 and 29, 2024. The medication was taken three times daily on August 24, 2024. The medication was taken once daily on August 26, 30 and 31, 2024. The medication was not taken at all on August 22 & 23, 2024. An inventory report for this medication was completed on August 25, 2024. According to the electronic medical record, the client should have 109 doses of the medication on hand as of that date. A physical count of the medication was recorded to be 103.
On April 19, 2024, Client #2 was prescribed a 5% Lidocaine patch to be applied topically every 12 hours. The medication was taken by the client on August 4, 5, 10, 17, 22, 26, 29, 30 & 31, 2024. An inventory report for this medication was completed on August 12, 2024. According to the electronic medical record, the client should have 32 doses of the medication on hand as of that date. A physical count of the medication was recorded to be 25.
On March 14, 2024, Client #2 was prescribed 21 milligrams of nicotine patch to be used daily. The medication was taken by the client on August 4, 10, 17, 20, 22, 26, 29, 30 & 31, 2024. An inventory report for this medication was completed on August 12, 2024. According to the electronic medical record, the client should have 19 doses of the medication on hand as of that date. A physical count of the medication was recorded to be 18.
On March 21, 2024, Client #2 was prescribed 2 milligrams of Prazosin to be taken twice daily. The medication was taken as prescribed with the exception of August 2 (taken once), August 3 (none taken), August 6 (taken once), August 13 (taken once), August 14 (taken once), August 15 (none taken), August 18 (taken once), August 28 (taken once) and August 31 (taken once). An inventory report for this medication was completed on August 25, 2024. According to the electronic medical record, the client should have 84 doses of the medication on hand as of that date. A physical count of the medication was recorded to be 89.
On May 31, 2024, Client #2 was prescribed 25 milligrams of Quetiapine Fumarate to be taken twice daily as needed. The medication was taken once daily on August 1, 3, 5, 6, 9, 11, 12, 18, 19, 25 and 31, 2024. The medication was taken twice daily on August 11 & 12, 2024. The medication was not taken on the other days in August 2024. An inventory report for this medication was completed on August 25, 2024. According to the electronic medical record, the client should have 54 doses of the medication on hand as of that date. A physical count of the medication was recorded to be 56.
On March 22, 2024, Client #2 was prescribed Tab-a-Vite with iron to be taken twice daily. The medication was taken daily with the exception of August 3, 2024, where no medication was taken. An inventory report for this medication was completed on August 25, 2024. According to the electronic medical record, the client should have 84 doses of the medication on hand as of that date. A physical count of the medication was recorded to be 86.
On March 7, 2024, Client #2 was prescribed 225 milligrams of Venlafaxine HCL to be taken once daily. The medication was taken daily with the exception of August 2, 3, 7, & 14, 2024. An inventory report for this medication was completed on August 25, 2024. According to the electronic medical record, the client should have 21 doses of the medication on hand as of that date. A physical count of the medication was recorded to be 22.
Client #3 was admitted on July 11, 2024 and was active at the time of the onsite investigation.
On July 18, 2024, Client #3 was prescribed 400 milligrams of Gabapentin to be taken up to three times a day as needed. The medication was taken three times daily on August 19, 2024. The medication was taken twice daily on August 1, 4, 5, 6, 11, 13, 14, 15, 17, 20, 23, 24 and 27, 2024. The medication was taken once daily on August 2, 7, 8, 9, 10, 12, 16, 18, 21, 22, 25, 26, 28, 29 30 & 31, 2024. The medication was not taken on August 3, 2024. An inventory report for this medication was completed on August 25, 2024. According to the electronic medical record, the client should have 108 doses of the medication on hand as of that date. A physical count of the medication was recorded to be 107.
On July 18, 2024, Client #3 was prescribed 100 milligrams of Hydroxyzine to be taken up to four times a day as needed. The medication was taken three times daily on August 6 & 19, 2024. The medication was taken twice daily on August 1, 4, 5, 11, 13, 14, 15, 17, 20, 23, 24 and 27, 2024. The medication was taken once daily on August 2, 7, 8, 9, 10, 12, 16, 18, 21, 22, 25, 26, 28, 29 30 & 31, 2024. The medication was not taken on August 3, 2024. An inventory report for this medication was completed on August 25, 2024. According to the electronic medical record, the client should have 46 doses of the medication on hand as of that date. A physical count of the medication was recorded to be 44.
On July 10, 2024, Client #3 was prescribed 5 milligrams of Olanzapine to be taken up once daily. The medication was taken as prescribed with the exception of August 3, 4 & 18, 2024. An inventory report for this medication was completed on August 25, 2024. According to the electronic medical record, the client should have 51 doses of the medication on hand as of that date. A physical count of the medication was recorded to be 50.
On July 18, 2024, Client #3 was prescribed 1 milligram of Prozosin to be taken up twice daily. The medication was taken as prescribed with the exception of August 2, 3, 4 & 18, 2024. An inventory report for this medication was completed on August 25, 2024. According to the electronic medical record, the client should have 54 doses of the medication on hand as of that date. A physical count of the medication was recorded to be 53.
Client #4 was admitted on April 29, 2024 and discharged on September 5, 2024.
On June 7, 2024, Client #4 was prescribed 10 milligrams of Cetirizine to be taken once daily as needed. The medication was taken twice daily on August 1 & 12, 2024. The medication was taken once daily on August 3, 5, 8, 11, 13, 17, 19, 20, 24, 26 and 28, 2024. The medication was not taken on the remaining days of August 2024. An inventory report for this medication was completed on August 26, 2024. According to the electronic medical record, the client should have 24 doses of the medication on hand as of that date. A physical count of the medication was recorded to be 22.
On June 13, 2024, Client #4 was prescribed 100 milligrams of Hydroxyzine to be taken four times daily as needed. The medication was taken four times daily on August 6, 2024. The medication was taken three times daily on August 1, 2, 4, 5, 8, 13, 17, 20, 24, 25, 26, 28 & 29, 2024. The medication was taken twice daily on August 11, 12, 14, 18 & 27, 2024. The medication was taken once daily on August 3, 5, 8, 11, 13, 17, 19, 20, 24, 26 and 28, 2024. The medication was taken once daily on August 3, 7, 16, 19, 21, 22, 23, 30 & 31, 2024. The medication was not taken on the remaining days of August 2024. An inventory report for this medication was completed on August 26, 2024. According to the electronic medical record, the client should have 98 doses of the medication on hand as of that date. A physical count of the medication was recorded to be 94.
On May 16, 2024, Client #4 was Vitamin D3 to be taken twice daily. The medication was taken daily as prescribed with the exception of August 3 (none taken), August 6 (taken once), August 12 (taken once), August 16 (taken once) and August 18 (taken once). An inventory report for this medication was completed on August 26, 2024. According to the electronic medical record, the client should have 80 doses of the medication on hand as of that date. A physical count of the medication was recorded to be 77.
Client #9 was admitted on June 4, 2024 and was active at the time of the onsite investigation.
On August 12, 2024, Client #9 was prescribed .6 milligrams of Colchicine to be taken once daily. The medication was taken as prescribed with the exception of August 25 & 29, 2024. An inventory report for this medication was completed on August 26, 2024. According to the electronic medical record, the client should have 6 doses of the medication on hand as of that date. A physical count of the medication was recorded to be 4.
On June 5, 2024, Client #9 was prescribed 5 milligrams of Eliquis to be taken twice daily. The medication was taken as prescribed with the exception of August 3 & 4, 2024. An inventory report for this medication was completed on August 26, 2024. According to the electronic medical record, the client should have 76 doses of the medication on hand as of that date. A physical count of the medication was recorded to be 74.
On July 30, 2024, Client #9 was prescribed 300 milligrams of Gabapentin to be taken once daily. The medication was taken as prescribed with the exception of August 3 & 4, 2024. An inventory report for this medication was completed on August 26, 2024. According to the electronic medical record, the client should have 37 doses of the medication on hand as of that date. A physical count of the medication was recorded to be 38.
On July 30, 2024, Client #9 was prescribed 300 milligrams of Gabapentin to be taken once daily. The medication was taken as prescribed with the exception of August 3 & 4, 2024. An inventory report for this medication was completed on August 26, 2024. According to the electronic medical record, the client should have 37 doses of the medication on hand as of that date. A physical count of the medication was recorded to be 38.
On August 12, 2024, Client #9 was prescribed 25 milligrams of Metoprolol Tartrate to be taken twice daily. The medication was taken as prescribed. An inventory report for this medication was completed on August 26, 2024. According to the electronic medical record, the client should have 30 doses of the medication on hand as of that date. A physical count of the medication was recorded to be 28.
Client #10 was admitted on March 14, 2024 and was active at the time of the onsite investigation.
On April 4, 2024, Client #10 was prescribed 20 milligrams of Duloxetine to be taken once daily. The medication was taken as prescribed with the exception of August 3, 9, 13 & 16, 2024. An inventory report for this medication was completed on August 26, 2024. According to the electronic medical record, the client should have 40 doses of the medication on hand as of that date. A physical count of the medication was recorded to be 38.
On July 18, 2024, Client #10 was prescribed 800 milligrams of Gabapentin to be taken three times daily. The medication was taken twice daily on August 1, 2 & 3, 2024. The medication was taken three times daily on August 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30 & 31, 2024. An inventory report for this medication was completed on August 26, 2024. According to the electronic medical record, the client should have 2 doses of the medication on hand as of that date. A physical count of the medication was recorded to be 3.
On April 4, 2024, Client #10 was prescribed 50 milligrams of Hydroxyzine to be taken four times daily as needed. The medication was taken three times daily on August 11, 12 & 18, 2024. The medication was taken twice daily on August 3, 5, 13, 19, 20, 21, 27 & 31, 2024. The medication was taken once daily on August 1, 2, 4, 6, 9, 16, 17, 22, 23, 24, 26, 27, 28 & 29, 2024. The medication was not taken on August 7, 8, 10, 14, 15 & 25, 2024. An inventory report for this medication was completed on August 26, 2024. According to the electronic medical record, the client should have 79 doses of the medication on hand as of that date. A physical count of the medication was recorded to be 74.
On April 2, 2024, Client #10 was prescribed 30 milligrams of Isosorbide Monon ER to be taken once daily. The medication was taken as prescribed with the exception of August 2, 3, 4, 9 & 16, 2024. An inventory report for this medication was completed on August 26, 2024. According to the electronic medical record, the client should have 8 doses of the medication on hand as of that date. A physical count of the medication was recorded to be 12.
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Plan of Correction
Facility Monitor(s) will be required to attend mandatory quarterly medication compliance training; this training will be outside of regular monthly monitor meeting/training facilitated by Medical staff.
Medical staff will be responsible for weekly audit with updated inventory reports to management for immediate review of inconsistencies in medication distribution and audit updates. If applicable, Medical and/or management staff will train and hold accountable any staff during their direct supervision for repeated and/or egregious errors.
Medical staff will be leading and distributing all medication passes during Mon-Friday, once PTR medical department becomes fully staffed.
Monitor staff will continue to distribute all medication calls in the interim.
Facility Manager will continue to complete monthly medication audit for oversight and will provide a report, when applicable. The report will detail staff errors and medication audit concerns. This report will also be a tool to use for medical staff to ensure ongoing updates for medication distribution and prescription reorder, when applicable.
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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 a review of policy and procedure and a physical plant inspection, the facility failed to provide for the security of drugs by securing the medication cart.
The facility policy states that keys will be stored on hooks in the key box with the label on the key. On September 4, 2024, the auditor walked into the office, where the door was found to be unlocked and the medication cart was observed to have the cart keys laying on top of the cart, unattended.
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Plan of Correction
Facility keys will be locked in the medical office in a locked storage box at all times outside of medication administration. Medical staff will be responsible to ensure that the keys are in the box outside of administration times.
Monitors and Facility Manager are responsible for random facility walkthroughs at least 3x a day. Locked medication carts and key storage boxes will be reviewed during facility walkthroughs. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of policy & procedure and client records, the facility failed to provide individual counseling, as per the treatment and rehabilitation plan, in five of six client records.
Client #1 was admitted on January 26, 2024 and discharged on July 16, 2024. The client ' s treatment plan, documented on January 29, 2024, states that individual sessions are to be provided weekly. The progress notes for the months of May through July 2024 were reviewed. The client did not have individual sessions documented for the weeks of May 5, May 12, May 19, June 9, June 23, June 30 and July 7, 2024.
Client #2 was admitted on March 1, 2024 and was active at the time of the investigation. The client ' s treatment plan, documented on March 7, 2024, states that individual sessions are to be provided weekly. The progress notes for the months of March through August 2024 were reviewed. The client did not have individual sessions documented for the weeks of March 10, 17, 24, 31, April 7, 14, 21, 28, May 5, 12, 19, 26, June 9, 16, 23, 30, July 7, 14, 21, 28 and August 4, 18, 25, 2024.
Client #3 was admitted on July 11, 2024 and was active in treatment at the time of the investigation. The client ' s treatment plan, documented on July 12, 2024, states that individual sessions are to be provided weekly. The client did not have individual sessions documented for the weeks of July 14 and August 11 & 23, 2024.
Client #5 was admitted on April 10, 2024 and discharged on July 3, 2024. The client ' s treatment plan, documented on April 12, 2024, states that individual sessions are to be provided weekly. The client did not have individual sessions documented for the weeks of April 28, May 5, 12, June 16 & 23, 2024.
Client #7 was admitted on May 15, 2024 and was active in treatment at the time of the investigation. The client ' s treatment plan, documented on May 16, 2024, states that individual sessions are to be provided weekly. The progress notes for the months of June through August 2024 were reviewed. The client did not have individual sessions documented for the weeks of June 2, 16 and August 4, 2024.
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Plan of Correction
On 12/12/24, all therapists were trained on appropriate treatment
planning and documentation of individual and group therapy sessions
by the Clincal Supervisor and Director of Clinical Services.
This training will occur quarterly by the Clinical Supervisor and/or Director of Clinical Services.
Clinical Supervisor will increase individual note audits to 1x week at random for all
therapists as of 12/17/24. Director of Clinical Services will maintain bi-monthly individual note audits since 06/09/24. |
709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of policy & procedure and client records, the facility failed to provide individual counseling on a regular and scheduled basis in five of six client records.
Client #1 was admitted on January 26, 2024 and discharged on July 16, 2024. The facility policy and client ' s treatment plan document that individual sessions are to be provided weekly. The progress notes for the months of May through July 2024 were reviewed. The client did not have individual sessions documented for the weeks of May 5, May 12, May 19, June 9, June 23, June 30 and July 7, 2024.
Client #2 was admitted on March 1, 2024 and was active at the time of the investigation. The facility policy and client ' s treatment plan document that individual sessions are to be provided weekly. The progress notes for the months of March through August 2024 were reviewed. The client did not have individual sessions documented for the weeks of March 10, 17, 24, 31, April 7, 14, 21, 28, May 5, 12, 19, 26, June 9, 16, 23, 30, July 7, 14, 21, 28 and August 4, 18, 25, 2024.
Client #3 was admitted on July 11, 2024 and was active in treatment at the time of the investigation. The facility policy and client ' s treatment plan document that individual sessions are to be provided weekly. The client did not have individual sessions documented for the weeks of July 14 and August 11 & 23, 2024.
Client #5 was admitted on April 10, 2024 and discharged on July 3, 2024. The facility policy and client ' s treatment plan document that individual sessions are to be provided weekly. The client did not have individual sessions documented for the weeks of April 28, May 5, 12, June 16 & 23, 2024.
Client #7 was admitted on May 15, 2024 and was active in treatment at the time of the investigation. The facility policy and client ' s treatment plan document that individual sessions are to be provided weekly. The progress notes for the months of June through August 2024 were reviewed. The client did not have individual sessions documented for the weeks of June 2, 16 and August 4, 2024.
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Plan of Correction
The compliance component of Electronic Health Record (EHR)
will be updated to show therapists and direct supervisors
alerts to notify of need for completion of individual session and note by 01/31/2025.
Clinical Supervisor will increase individual note audits to 1x week at random for all
therapists as of 12/17/24. Director of Clinical Services will maintain bi-monthly individual note audits since 06/09/24. |
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 client records, the facility failed to document progress notes for individual sessions in four of seven client records.
Client #2 was admitted on March 1, 2024, and was active in treatment at the time of the investigation. It was documented that individual sessions took place on March 9, June 5 and August 14, 2024; however, the progress notes for these sessions were incomplete, as they were started, but not finished.
Client #3 was admitted on July 11, 2024, and was active in treatment at the time of the investigation. It was documented that individual session took place on July 12, 24 & 31, 2024; however, the progress notes for these sessions were incomplete, as they were started, but not finished.
Client #5 was admitted on April 10, 2024, and discharged on July 3, 2024. It was documented that an individual sessions took place on June 11, 2024; however, the progress notes for this session was incomplete, as it was started, but not finished.
Client #7 was admitted on May 15, 2024, and was active in treatment at the time of the investigation. It was documented that individual sessions took place on June 24, July 4, 8, 26 and August 1 & 19, 2024; however, the progress notes for these sessions were incomplete, as they were started, but not finished.
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Plan of Correction
The compliance component of Electronic Health Record (EHR)
will be updated to alert therapists and direct supervisors
for need for completion of individual sessions within
7 days of last individual session by 01/31/2025.
On 12/12/24, all therapists were trained on appropriate treatment
planning and documentation of individual and group therapy sessions
by the Clincal Supervisor and Director of Clinical Services.
This training will occur quarterly by the Clinical Supervisor and/or Director of Clinical Services.
Clinical Supervisor will increase individual note audits to 1x week at random for all
therapists as of 12/17/24. Director of Clinical Services will maintain bi-monthly individual note audits since 06/09/24.
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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 client records, the facility failed to document discharge summaries in two of six client records.
Client #5 was admitted on April 10, 2024 and discharged on July 3, 2024. There was no discharge summary documented in client record #5.
Client #11 was admitted on January 23, 2024 and discharged on July 27, 2024. There was no discharge summary documented in client record #11.
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Plan of Correction
The compliance component of Electronic Health Record (EHR) w
ill be updated to show therapists and direct supervisors alerts for
completion of discharge summaries, based on discharge date as of 01/31/2025.
Client #5's discharge summaries were completed on 12/17/24.
Client #11's discharge summaries were completed on 12/17/24.
On 12/12/24, all therapists were trained on appropriate treatment
planning and documentation of individual and group therapy sessions
by the Clincal Supervisor and Director of Clinical Services.
This training will occur quarterly by the Clinical Supervisor and/or Director of Clinical Services.
Clinical Supervisor will increase individual chart audits to 1x week at random for all
therapists as of 12/17/24. Director of Clinical Services will maintain bi-monthly individual chart audits since 06/09/24. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of policy, procedure and client records, the facility failed to document follow up contact, within 7 days, as per agency policy, in two of six client records.
Client #5 was admitted on April 10, 2024 and discharged on July 3, 2024. There was no follow up contact documented in client record #5.
Client #11 was admitted on January 23, 2024 and discharged on July 27, 2024. There was no follow up contact documented in client record #11.
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Plan of Correction
The compliance component of Electronic Health Record (EHR) w
ill be updated to show therapists and direct supervisors alerts for
7 and 30 day follow up, based on discharge date as of 01/31/2025.
Client #5's discharge follow ups were completed on 12/17/24.
Client #11's discharge follow ups were completed on 12/17/24.
On 12/12/24, all therapists were trained on appropriate treatment
planning and documentation of individual and group therapy sessions
by the Clincal Supervisor and Director of Clinical Services.
This training will occur quarterly by the Clinical Supervisor and/or Director of Clinical Services.
Clinical Supervisor will increase individual note audits to 1x week at random for all
therapists as of 12/17/24. Director of Clinical Services will maintain bi-monthly individual note audits since 06/09/24. |