INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on November 22, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site complaint investigation, White Deer Run, 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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709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of client records, the facility failed to consider client #1's rights when the client was denied a request to make a phone call home and/or secure safe transportation home after leaving against medical advice (AMA).The findings includeOne client record was reviewed on November 22, 2011 as a result of a complaint submitted to the Division. The client was admitted on September 26, 2011 and discharged AMA on October 10, 2011. The client was denied access to a phone call home in an effort to obtain transportation to her home. The client was discharged on October 10, 2011 and was transported off the grounds of the facility and dropped off along Route 15 with no means of transportation back to her Pittsburgh home.
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Plan of Correction
Effective December 19, 2011 an addition was made to the patient handbook through which clients are provided documentation on admission stating they will be able to make a phone call to arrange personal transportation if he or she elects to leave against medical advice. If personal transportation is not available and the patient has available funds, he or she will be provided transportation by safety staff to the bus station during first shift. If personal transportation is not available and the patient has no available funds, the patient can be transported by safety staff to Route 15 where a motel, restaurant and a gas station/convenience store are located, which offers the availability of shelter, telephone and food until personal transportation can be secured. The patient may elect to stay in treatment until a continuing care plan can be developed and scheduled for transportation by White Deer Run staff.
This will be the responsibility of the Unit Supervisors in conjunction with the Director of Safety and Risk Management
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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 the review of client records, the facility failed to have a complete client record in one of one client record reviewed.The findings include:One client record was reviewed on November 22, 2011. Client record #1 was missing the medical nursing notes from the client's admission date of September 26, 2011 through discharge October 10, 2011. An interview with facility staff on November 22, 2011 confirmed the findings.
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Plan of Correction
The following is White Deer Run of Allenwood's policy and procedure for ensuring that all medical records are complete prior to the closing and storing the medical record:
When a patient is discharged, the Nursing Department utilizes a check list to ensure that all forms in the medical chart are accounted for and complete. This check sheet is forwarded to Medical Records with the medical chart.
When the clinical chart is received in Medical Records, the department combines the medical and clinical charts into one complete chart. The chart is then checked by a member of the Medical Records department to ensure that all documentation is accounted for and complete. A check sheet is utilized and is kept in the front of the chart along with the check sheet received from the Nursing Department.
If any deficiencies exist, a report is submitted to the appropriate person(s) for completion. When the deficiency/deficiencies are resolved, the chart is closed and sent to the appropriate storage location. A review of staff activities revealed, in this case, that the procedures outlined above were followed. Given that a progress note by the Clinical Director describes having reviewed the Nursing notes in a discussion with the patient prior to her discharge, our best explanation for the lack of the nursing charts being in the record is that after the chart was closed and the record again utilized by clinical staff to address charting deficiencies, the Nursing notes were accidently removed and mis-placed as a result of human error.
Additionally, when a chart is identified as deficient and the appropriate clinical staff member corrects/completes the patient record, a second audit by Medical Records staff will be done to ensure that the patient chart is complete. This will be documented via on the chart audit checklist.
The Medical Records Supervisor will conduct a chart audit of 10% of completed charts, which had deficiencies corrected, beginning February 16, 2012 and ongoing, to ensure compliance with these updated policies and procedures.
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