INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 4 through 7, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kirkbride Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on October 31, 2010.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
Based on a review of the policy and procedure manual and an interview with the project director, the facility failed to document an assessment of staff training needs, as required by regulation.
The findings include:
On October 4, 2010, the policy and procedure manual was reviewed. Per the agency policy and procedure manual, the assessment forms will be distributed to each employee on June 1 or each year and then must be completed and turned in to their supervisor by June 15. The regulation requires an assessment of staff training needs to be completed as a component of a staff development program. The facility failed to document the completion of a staff training needs assessment in twelve out of sixteen records reviewed for the July 1, 2010- June 30, 2011 training year. A staff training needs assessment form was not documented in personnel records # 4, 5, 6, 7, 8, 10, 11, 12, 13, 14, 15, and 16.
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Plan of Correction
1. Each year, the Project Director formulates a series of staff surveys to evaluate the annual training plan. The surveys ask for an overview evaluation of the current year's training plan and trainings as well a projection of training needs for the coming year.
2. Survey results are aggregated and form the basis for the development of the annual training plan.
3. The surveys include:
A. A staff survey of training needs
B. A manager's evaluation of staff
training needs
C. A director's survey of
directors' needs
D. An evaluation by Licensed
Independent Practitioners'
of staff training needs.
4.In the past, the surveys have been optional for all levels of staff, and the facility had never been cited as deficient on the surveys.
5. The survey responses are contained in a separate binder together with the annual training plan. The survey responses are not included in staff personnel files, because to date the surveys have been optional.
6. During the recent on-site survey, the surveyors were provided with the training plan binder and separately, the personnel files of mostly newly hired employees.
7.Beginning with the 2011-2012 annual training plan, which will be operational from July 1, 2011, through June 30, 2012, all staff will be surveyed in the development of the annual training plan.
8. The Project Director will obtain a list of all full- and part-time employees. The Human Resources Department will check off names from the employee list as the training surveys are completed.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, a review of the facility summary report, and an interview with the facility director, the facility failed to provide documentation of HIV/AIDS and TB/STD training for five of eighteen personnel.
The findings include:
Eighteen personnel records were reviewed on October 4 through 5, 2010. The facility summary report was reviewed on October 4, 2010. The facility did not provide documentation of the required HIV/AIDS and TB/STD training for personnel record # 15. Additionally, the facility did not provide documentation of the required TB/STD training in personnel records # 17, 18, and 19. The facility failed to provide documentation of the required HIV/AIDS training for personnel record # 5.
Employee # 5 is a counselor and was hired November 15, 1999. HIV/AIDS and TB/STD training was to be completed within one year of hire, by November 15, 2000. The facility failed to provide documentation of HIV/ AIDS training.
Employee # 15 is a medical director and was hired July 1, 2007. HIV/AIDS and TB/STD training was to be completed within two years of hire, by July 1, 2009. The medical director received his degree in 1984. The facility failed to provide documentation of HIV/ AIDS and TB/STD training.
Employee #17 is a support staff and was hired October 21, 2002. HIV/AIDS and TB/STD training was to be completed within two years of hire, by October 21, 2004. The facility failed to provide documentation of TB/STD training.
Employee #18 is a support staff and was hired March 18, 2003. HIV/AIDS and TB/STD training was to be completed within two years of hire, by March 18, 2005. The facility failed to provide documentation of TB/STD training.
Employee #19 is a support staff and was hired November 7, 2007. HIV/AIDS and TB/STD training was to be completed within two years of hire, by November 7, 2009. The facility failed to provide documentation of TB/STD training.
This is a repeat citation from the licensing inspection conducted on November 17 through 20, 2009.
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Plan of Correction
1. Quarterly, the facility offers the six-hour HIV/AIDS mandatory training and the four-hour TB/STD training for employees. The trainings are conducted by a state-certified trainer through an arrangement with the AIDS Care Group of Delaware County.
2. The Human Resources Department will identify all associates who are not compliant with the state-mandated trainings and assign them to the next training sessions in December 2010 and March 2011.
3. Those who remain non-compliant will be taken off the schedules as of March 31, 2011, until compliance has been achieved.
4. Results will be reported to the Human Resources Executive Committee, internally called Dashboard, for oversight and monitoring. |
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
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of nine personnel records reviewed.
The findings include:
Eighteen personnel records were reviewed on October 4 through 5, 2010. Nine personnel records were counselors. One personnel record failed to document the 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record # 5.
The Project Director confirmed on October 5, 2010 that the counselor did not have the 25 clock hours of training for the 2009-20010 training year.
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Plan of Correction
1. The Human Resources Department will review all trainings completed by Primary Therapists and Social Workers by the end of the second quarter of the current training year. The facility's training year runs simulaneously with the facility's fiscal year, which is July 1 through June 30. Thus, the review will occur by December 31, 2010, to ensure that all personnel have achieved at least half of the required 25 hours of training annually.
2. The review will be conducted by the Director of Human Resources, the Facility Director and the Lead Social Worker.
3. The Facility Director and the Lead Social Worker will follow up with those employees whose training documentation falls short of the half-year benchmark of at least 12 hours of training.
4. The facility is planning two six-hour trainings for the third quarter of the training year: Ethics on January 6 and PCPC on February 17. Both will be six-hour trainings provided by an external source.
5. Results of the half-yearly review will be provided to the Human Resources Executive Committee, internally called Dashboard, in January 2011 for oversight and monitoring. |
709.123(b)(1)(iii) LICENSURE Support Service
709.123. Treatment and rehabilitation.
(b) Treatment and rehabilitation services.
(1) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(iii) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to document support services in five of eight psychiatric records reviewed.
The findings include:
Thirty two client records were reviewed on October 5 through 7, 2010. Support services were required in eight psychiatric client records. The facility did not document support services in client records # 1, 2, 3, 4 and 5
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Plan of Correction
1. The Project Director will meet with the Lead Social Worker and the Social Workers -- who develop treatment plans for chemically dependent patients on the psychiatric units -- to review the requirement that support services be included in the treatment plans.
2. Support services will include, but will not be limited to, psychiatric, psychological, case management and nutritional services support.
3. Monthly chart audits will be conducted by auditors from the Medical Records Department. Results of the audits will be presented monthly to the Executive Committee for oversight and monitoring. |
709.123(c)(4) LICENSURE Aftercare Plan
709.123. Treatment and rehabilitation.
(c) Client records. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(4) Drug and alcohol aftercare plan, if applicable.
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Observations
Based on the review of client records, the facility failed to document aftercare plans in four of four short-term psychiatric discharge client records.
The findings include:
Thirty two client records were reviewed October 5 through 7, 2010. Aftercare plans were required in four of four psychiatric discharge records, # 5, 6, 7 and 8. Per the facility's policy and procedure manual aftercare plans will be developed upon admission to the program and ending at discharge.
Client #5 was discharged on 7/10/10 and, as of the date of review, an aftercare plan was not documented.
Client #6 was discharged on 9/21/10 and, as of the date of review, an aftercare plan was not documented.
Client records #7 failed to document the contact person and reentry process and client record #8 failed to document the support services, contact person and reentry process.
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Plan of Correction
1. In each of the four psychiatric discharge charts that were referenced in the deficiency report by the surveyors, a Continuing Care/Discharge Planning form was completed and included in the closed medical record.
2. The Continuing Care Plan/Discharge Plans, which serves as the Aftercare plan, all included the plan for patient upon discharge, including housing and the next level of care.
3. Nevertheless, the Project Director, the Lead Social Worker and one of the Attending Physicians will redesign the Continuing Care/Discharge Planning form to ensure it includes support services, contact person and re-entry process.
4. The requirement will be added to the closed-chart audits currently conducted by the Medical Records Department. Results will be presented monthly to the Executive Committee, internally called Dashboard, for oversight and monitoring. |
709.123(c)(5) LICENSURE Follow-up information
709.123. Treatment and rehabilitation.
(c) Client records. 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) Follow-up information.
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Observations
Based on a review of the facility's policy and procedure manual and client records, the facility failed to document follow-up information within the required time frame according to regulation and facility policy in three of four psychiatric discharge records.
The findings include:
Thirty two records were reviewed on October 5 through 7, 2010. Follow-ups were required in four psychiatric discharge records, #5, 6, 7 and 8. Per the facility's policy and procedure manual follow-ups will be completed within 7 days of the clients discharge date.
Client #5 was discharged on 7/10/10 and, as of the date of review, there was no documentation of patient follow-up in the record reviewed.
Client #6 was discharged on 9/21/10 and, as of the date of review, there was no documentation of patient follow-up in the record reviewed.
Client #8 was discharged on 8/10/10 and, as of the date of review, there was no documentation of patient follow-up in record reviewed.
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Plan of Correction
1. The Project Director and the Lead Social Worker will develop a system to track psychiatric patients who have a secondary chemical dependence diagnosis and therefore are governed under the facility's dual licenses from the Department of Public Welfare and the Department of Health, Division of Drug and Alcohol Program Licensing.
2. Weekly, the Lead Social Worker will ensure that seven-day follow-ups are completed for all patients with co-occurring disorders.
3. Results will be tracked for four months and reported monthly to the Psychiatric Program Executive Committee, internally called Dashboard, for oversight and monitoring. |
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
Based on the physical plant tour, the facility failed to 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.
The findings include:
A physical plant tour was conducted on October 6, 2010 between the hours of 9:00 a.m. and 11:30 a.m. There were two broken windows observed on the tour. There was a broken window pane in bedroom # 284. Additionally, there was a broken window pane in the bathroom of room # 285. The Facility Director, Director of Nursing and the Head of Housekeeping were made aware and confirmed that the windows were broken.
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Plan of Correction
1. The two broken windows were repaired by October 28, 2010, and are now fully functional.
2. Housekeeping staff have been re-directed to report the need for such repairs to the Management Team so that repairs may be addressed expeditiously.
3. Environment of Care Rounds are conducted monthly on all units and the need for repairs is noted at least monthly.
4. Environment of Care Rounds results are reported monthly to the Safety/Infection Control/Environment of Care Committee for oversight and monitoring. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a tour of the physical plant conducted it was determined that the facility failed to maintain client bedrooms with furnishings that were in good repair.
The findings were:
A review of the physical plant conducted on on October 6, 2010 between 9:00 a.m. and 11:30 a.m. revealed that the dressers in client bedrooms were not in good repair. There were dresser drawers broken and in disrepair in bedrooms # 101 and 266.
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Plan of Correction
1. The dressers in disrepair were replaced by October 28, 2010.
2. Housekeeping staff have been re-directed to report the need for such repairs to the Management Team so that repairs may be addressed expeditiously.
3. Environment of Care Rounds are conducted monthly on all units and the need for repairs is noted at least monthly.
4. Environment of Care Rounds results are reported monthly to the Safety/Infection Control/Environment of Care Committee for oversight and monitoring. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection, the facility failed to provide slip resistant surfaces in all of the bathtubs and showers.
The findings include:
A physical plant inspection was conducted on October 6, 2010 between the hours of 9:00 a.m. and 11:30 a.m. All bathtubs/showers are required to have slip resistant flooring. The facility did not provide slip resistant flooring in the bathrooms with bathtubs/showers connected to client rooms # 110, 111, 112, 114, 116, 119 as well as the bathrooms between rooms 270-268, 310, 312, 403, 403, 414, and 502. The Director of Nursing and the Head of Housekeeping was present during the physical plant inspection and confirmed that these showers were in need of slip resistant flooring.
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Plan of Correction
1. Slip resistant materials are installed in all bathtubs/showers.
2. Housekeeping staff have been re-directed to report the need for such repairs to the Management Team so that repairs may be addressed expeditiously.
3. Environment of Care Rounds are conducted monthly on all units and the need for repairs is noted at least monthly.
4. Environment of Care Rounds results are reported monthly to the Safety/Infection Control/Environment of Care Committee for oversight and monitoring. |
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
Based on the physical plant tour, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The findings include:
The physical plant tour was conducted on October 6, 2010 between 9:00 a.m. and 11:30 a.m. It was observed that the bathroom light in room # 405 was not working. Additionally, the call box in the bathroom of room # 119 was coming off of the wall. Also, the ceiling above the shower in the bathroom of room # 248 had paint chipping and the plaster peeling away from the ceiling.
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Plan of Correction
1. The bathroom light in room #405 was replaced on the day of the inspection.
2. The call box in room #119 was repaired.
3. Ceiling paint was applied to room #248.
4. Housekeeping staff have been re-directed to report the need for such repairs to the Management Team so that repairs may be addressed expeditiously.
5.Environment of Care Rounds are conducted monthly on all units and the need for repairs is noted at least monthly.
6.Environment of Care Rounds results are reported monthly to the Safety/Infection Control/Environment of Care Committee for oversight and monitoring. |
705.10 (b) (6) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(6) Maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
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Observations
Based on the physical plant tour and an interview with the Director of Nursing and the Facility Director, the facility failed to have a bedroom equipped with a mechanism for hearing impaired persons to be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
The finding include:
A physical plant tour was conducted on October 6, 2010 between th hours of 9:00 a.m. and 11:30 a.m. An interview with the Director of Nursing and the Facility Director confirmed that the facility failed to maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire. The facility failed to have a client bedroom equipped with a strobe light or shaker bed to alert those with hearing impairment in event of a fire in the Psychiatric D & A unit.
According to an interview with the facility director on October 6, 2010 at 11:45 a.m. there was supposed to be a strobe light installed in room 305 on this unit; however, it was recently discovered that the company that rewired the alarm system never installed the strobe light.
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Plan of Correction
1. A strobe light, which is inter-connected with the smoke detection and warning system, was installed in room #302, which is one of two psychiatric units licensed by the Pennsylvania Department of Health, Division of Drug and Alcohol Program Licensure. The work was completed on October 26, 2010.
2. The work was completed by CINTAS Fire Protection Services.
3. The Admissions Department has been informed that hearing-impaired individuals seeking psychiatric services should be assigned to room #302.
4. Strobe-ligted fire alarms also are located in room #105 for hearing-impaired detox patients and in room #505 for hearing-impaired residential patients. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records, the facility failed to document the fire extinguisher training upon staff employment.
The findings include:
Eighteen personnel records were reviewed on October 5 through 6, 2010, two of those eighteen records were hired since the last licensing inspection and were audited to verify that staff had been instructed in the use of a fire extinguisher upon employment.
The facility failed to documented the completion of fire extinguisher training upon staff employment in personnel record #11.
Employee # 11 was hired on 10/26/2009. The training was due within seven days of employment by 11/2/2009; the training was not documented until 11/20/2009.
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Plan of Correction
1. The Director of Human Resources will develop a training for new hires to complete within seven days of the first day of employment. Ideally, the training willbe provided during New Employee Orientation. The training will be on Fire Safety, Fire Extinquishers and Fire Drills.
2. The Diretor of Human Resources will develop a competency to test new employees' knowledge of Fire Safety, Fire Extinguishers and Fire Alarms. Satisfactory completion of the competency will be placed in each employees' personnel fire. A score of 90 percent or above on the competency will be considered satisfactory.
3.For employees who start work prior to completion of New Employee Orientation, which is required within the first 30 days of employment, the training and competency will be provided within seven days.
4. Fire Safety will be added to the list of training topics documented on the New Employee Orientation documentation of completion.
5. Following New Employee Orientation, the Human Resrouces Department will audit new employee personnel files to ensure the fire safety and fire extinguisher trainings have been completed and documented.
6. Results will be presented monthly to the Executive Committee, internally called Dashboard, for oversight and monitoring. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
The findings include:
Eighteen personnel records were reviewed on October 5 through 6, 2010, two of those eighteen records were hired since the last inspection and were audited to verify that all personnel on all shifts were trained to perform assigned tasks during emergencies. The facility did not document that emergency training was provided upon employment in personnel record # 11.
Employee # 11 was hired on 10/26/2009. The training was due within seven days of employment by 11/2/2009, the training was not documented until 11/20/2009.
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Plan of Correction
1. The Director of Human Resources will develop a training for new hires to complete within seven days of the first day of employment. Ideally, the training willbe provided during New Employee Orientation. The training will be on Fire Safety, Fire Extinquishers and Fire Drills. 2. The Diretor of Human Resources will develop a competency to test new employees' knowledge of Fire Safety, Fire Extinguishers and Fire Alarms. Satisfactory completion of the competency will be placed in each employees' personnel fire. A score of 90 percent or above on the competency will be considered satisfactory. 3.For employees who start work prior to completion of New Employee Orientation, which is required within the first 30 days of employment, the training and competency will be provided within seven days. 4. Fire Safety will be added to the list of training topics documented on the New Employee Orientation documentatin of completion.
5. Following New Employee Orientation, the Human Resources Department will monitor the personnel files of newly hired employees to ensure that the training has been completed and documented. Results of the audits will be provided monthly to the Executive Committee, internally called Dashboard, for oversight and monitoring. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the fire drill log and staff interview it was determined that the facility failed to conduct a fire drill during sleeping hours at least once over a six months period.
The findings were:
A review of the fire drill log was conducted on October 4, 2010. The only documented fire drill during sleeping hours occurred on September 23, 2010 in the past 12 months. A conversation with the project director and facility director on October 4, 2010 confirmed that only one fire drill was conducted during sleeping hours since the last licensing inspection in November of 2009.
This is a repeat citation from the licensing inspection conducted on November 17 though November 20, 2009.
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Plan of Correction
1. The facility conducts unannounced fire drills on a monthly basis. The facility rotates shifts when the fire drills occur on a monthly basis. Thus, the following outlines the schedule of unannounced fire drills each quarter:
A. First Month of the Quarter
First shift.
B. Second Month of the Quarter:
Second shift.
C. Third Month of the Quarter:
Third shift.
The schedule of rotations continues during each of the four quarters of the year; a total of 12 unannounced fire drills is conducted each year, with four of the drills occurring during first shift; four of the drills occurring during second shift; and four of the drills occurring during third shift.
2. The Chief Engineer and the Supervisor of Security have been directed to ensure that the third-shift drills occur during sleeping hours. In the past, the drills that were scheduled during third shift -- which ends at 7:30 a.m. each day -- were scheduled to coincide with wake-up times. However, the facility was cited for this practice and appeal the citation, but failed in the appeal.
3. The Chief Engineer and the Supervisor of Security have been directed to ensure at least one fire drill each quarter occurs about 5:30 a.m., which is one-half hour before wake-up calls on all the units.
4. The Supervisor of Security presents information about the fire drills monthly to the Safety/Infection Control/Environment of Care Committee, which is charged with monitoring and oversight. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to have documented complete consent to release forms in thirty of thirty two client records reviewed.
The findings include:
Thirty two client records were reviewed on October 5 through 7, 2010. Consent to release forms are required in thirty two client records.
Client records #3, 4, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26,27, 28, 29, 30, 31 and 32 had a consent to release form from a funding source that requested the facility release information to them. The facility failed to have a consent to release form that provided approval from the client to give this funding source the requested information.
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Plan of Correction
1. The Facility Director met with representatives from the Behavioral Health Services Initiative of Philadelphia to re-design the consent forms that are provided to chemically dependent patients entering detox, residential or psychiatric programs.
2. The new form is a facility form and requests permission from patients to contact BHSI if necessary.
3. The revised consent forms have replaced BHSI consent forms for detox, residential and psychiatric patients.
4. The old consent forms have been destroyed and no longer are in circulation. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document psychosocial evaluations in eight of eight short-term detoxification client records.
The finding includes:
Thirty two client records were reviewed on October 5 through 7, 2010. Psychosocial evaluations were required to be documented in eight short-term detoxification client records, #9, 10, 11, 12, 13, 14, 15 and 16.
Client record #9, 10, 11, and 14 failed to document the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, attitude towards treatment and the counselor conclusions/impressions.
Client records #12 and 13 failed to document the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions/impressions.
Client record #15 and 16 failed to document a composite picture of the client, the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, attitude towards treatment and the counselor conclusions/impressions.
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Plan of Correction
1. The Management Team -- the Project Director, the Facility Director, the Clinical Director, the Clinical Operations Supervisor and the Lead Social Worker -- will initiate a project to revise the biopsychosocial template.
2. The template will ensure compliance with the requirement that it includes assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor's conclusions/impressions.
3. The Clinical Director will conduct a monthly audit for four months to ensure completion of the biopsychosocial evaluation of detox patients. The audit will be of 10 percent of patients admitted to the detox program each month.
4. Results will be presented to the Executive Committee, internally called Dashboard, for oversight and monitoring. |
709.63(a)(6) LICENSURE Aftercare plan
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(6) Aftercare plans, if applicable.
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Observations
Based on the review of client records, the facility failed to document aftercare plans in four of four short-term detoxification discharge client records.
The findings include:
Thirty two client records were reviewed October 5 through 7, 2010. Aftercare plans were required in four of four short-term detoxification discharge records, # 13, 14, 15 and 16. Per the facility's policy and procedure manual aftercare plans will be developed upon admission to the program and ending at discharge.
Client records #13 and 14 failed to document the goals with time frames.
Client #15 was discharged on 6/14/10 and, as of the date of the review, an aftercare plan was not documented.
Client #16 was discharged on 5/25/10 and, as of the date of the review, an aftercare plan was not documented.
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Plan of Correction
1. The Discharge Summary and Continuing Care Plan, which includes aftercare recommendations, was in place in Client Records #13 and #14.
2. The Discharge Summary and Continuing Care Plan for Client #15 clearly indicates that the patient refused aftercare. The patient's refusal was clearly documented on both the Discharge Summary and Continuing Care Plan as well as on the Follow-up form.
3. A Discharge Summary and Continuing Care Plan, which includes aftercare recommendations, was in place for Client #16.
4. The Clinical Team -- Project Director, Facility Director, Clinical Director and Clinical Operations Supervisor -- will review the aftercare plan template and ensure that it includes goals and timeframes.
5. The revisions will be presented to the Executive Committee, internally called Dashboard, for oversight and monitoring. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(8) Follow-up information.
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Observations
Based on a review of the facility's policy and procedure manual and client records, the facility failed to document follow-up information within the required time frame according to regulation and facility policy in three of four short-term detoxification records.
The findings include:
Thirty two records were reviewed on October 5 through 7, 2010. Follow-ups were required in four short-term detoxification discharge records, #13, 14, 15, and 16. Per the facility's policy and procedure manual follow-ups will be completed within 7 days of the clients discharge date.
Client #14 was discharged on 7/6/10; the follow-up documentation was completed it could not be determined when the follow-up was conducted as the date was not documented.
Client #15 was discharged on 6/14/10; as of the date of review there was no follow-up documentation in client record # 15.
Client #16 was discharged on 5/25/10; the follow-up documentation was completed but could not determine when the follow-up was conducted as the date of the follow-up was not documented.
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Plan of Correction
1. The Clinical Operations Supervisor will redesign the Follow-Up form to ensure that it includes a line to notate the date that the follow-up was conducted.
2. The Clinical Team -- the Project Director, the Facility Director, the Clinical Director and the Clinical Operations Supervisor -- will revise the policy governing follow-up to ensure that follow-up is conducted in three types of discharges:
1. Treatment Complete
2. AWOL
3. AMA
The policy will indicate that within seven days following an AWOL or AMA discharge that one call will be placed or one letter will be sent to the home of the patient as part of outreach. The policy also will state that in some cases of two other categories of discharges -- special circumstances and administrative -- that follow-up will not be conducted.
Special circumstances are cases in which external factors prevented the patient from completing treatment. This would include patients who are incarcerated following a meeting with criminal justice during treatment or cases in which agents come to the facility with a court order or bench warrant to take a patient away; or the death of a patient.
The new policy will be monitored through monthly audits by the Clinical Team. Results of the audits will be presented monthly to the Executive Committee, internally called Dashboard, for oversight and monitoring.
Previously, the policy did not require -- but recommended -- follow-up for patients who were non-routine discharges such as AMAs. |
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 a review of client records, the facility failed to document psychosocial evaluations in eleven of sixteen rehabilitation client records.
The finding includes:
Thirty two client records were reviewed on October 5 through 7, 2010. Psychosocial evaluations were to be documented in sixteen rehabilitation client records, #17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32.
Client records #19, 22, 23 and 30 failed to document the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, attitude towards treatment and the counselor conclusions/impressions.
Client records #17, 18, 21, 24, 25, 26 and 27 failed to document a composite picture of the client, the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, attitude towards treatment and the counselor conclusions/impressions.
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Plan of Correction
1. The Management Team -- the Project Director, the Facility Director, the Clinical Director and the Clinical Operations Supervisor -- will review the template for the psychosocial evaluation to ensure that it includes information on the following:
A. Patient's assets/strengths
B. Support Systems
C. Coping Mechanisms
D. Negative factors that might
inhibit treatment
E. Attitude toward treatment
F. The counselor's conclusions and
impressions.
2. Once completed, the psychosocial assessment will be the basis for a training of Primary Therapists.
3. Monthly for four months, the Clinical Director will audit 10 percent of open charts at the time of the audit to determine compliance with the revised psychosocial evaluation.
4. Results of the audits will be shared monthly for four months with the Executive Committee, internally called Dashboard, for oversight and monitoring.
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709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records, the facility failed to document aftercare plans in five of eight discharge rehabilitation client records.
The findings include:
Thirty two client records were reviewed October 5 through 7, 2010. Aftercare plans were required in eight rehabilitation discharge records, #25, 26, 27, 28, 29, 30, 31, 32. Per the facility's policy and procedure manual aftercare plans will be "developed upon admission to the program and end at discharge".
Client #27 was discharged on 7/4/10; there was no aftercare plan in the client record.
Client #28 was discharged on 7/8/10; there was no aftercare plan in the client record.
Client records #26, 29, 31 failed to document the contact person and reentry process.
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Plan of Correction
1. Note of Clarification: Both Client #27 and Client #28 were non-routine discharges, leaving the facility Against Medical Advice.
2. In the past, aftercare plans have not been developed for patients who leave the facillity AMA and who refuse aftercare.
3. The Management Team -- Project Director, Facility Director, Clinical Director and Clinical Operations Supervisor -- will revise the present policy and procedure governing aftercare, following recommendations from a licensing specialist who was contacted today. The revisions will require aftercare plans for all patients who complete treatment. Aftercare plans will be recommended for patients who leave the facility AMA. No aftercare can be provided to patients who leave the facility AWOL.
4. The Clinical Director will conduct an audit of 10 percent of closed charts each month for four months to ensure compliance. The results of the audits will be provided monthly to the Executive Committee, internally called Dashboard, for oversight and monitoring. |