INITIAL COMMENTS
|
This report is a result of an onsite follow-up inspection regarding the plans of correction for the May 20, 2009 licensure renewal inspection. The follow-up inspection was conducted on December 1, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Gaudenzia Kindred House 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 December 21, 2009.
|
Plan of Correction
|
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
|
Observations
Based on a review of client medical records and an interview with the facility director and clinical supervisor the agency failed to document complete physical examinations within seven day of admission.
Findings:
Intake and admission procedures reviewed on May 5, 2009 and May 6, 2009 require client physical examinations be completed or documented in the client medical record within seven day of admission Based on a review of eight client records, seven were reviewed on December 1, 2009 for physical exams. An interview with the facility director and clinical supervisor on December 1, 2009 at 12:50 PM confirmed the agency failed to document complete physical examinations in three out of seven records within seven days of admission. These were in records #1, 2, and 4. Additionally, the facility failed to document physician's impressions in four out of seven records. These were in records #2, 3, 4, and 8. Lastly, the facility failed to document a complete physical in client record #6.
Client record #1 was admitted on September 29, 2009. No documentation of a physical examination in the medical file was found during the December 1, 2009 record review.
Client record #2 was admitted July 14, 2009. The physical was completed on July 29, 2009. This was documented 8 days late. Additionally, the physician failed to document the physician's impressions.
Client record #3 failed to have the physician document the physician's impressions on the physical form.
Client record #4 was admitted on October 28, 2009. No documentation of a physical examination in the medical file was found during the December 1, 2009 record review.
Client record #5 failed to have the physician document the physician's impressions on the physical form.
Client record #6 failed to include the vital signs, review of organ systems, and general appearance on the physical exam form.
Client record #8 .failed to have the physician document the physician's impressions on the physical form.
The staff interviews confirmed that the above identified information was missing from the client records.
|
Plan of Correction
Chess-Pen will give clients without insurance an inital physical exam with in 72 hrs. Clients with insurance will be taken to their community Health Clinic. The medical staff (i.e.nursing) will be responsible for ensuring all medical exams are done according to the contract.
The plan of correctioin is effective 1-11-2010. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
|
Observations
Based on a review of client records, organizational treatment management procedures, treatment models and a description of the therapeutic community which identifies work therapy assignments, the agency failed to include documentation of work therapy as an integral component of the treatment and rehabilitation plan.
Findings:
Eight client records reviewed on December 1, 2009. Six required documentation of work therapy in the treatment plan. Five out of six records failed to document work therapy in the preliminary, comprehensive or treatment plan updates. An interview with the clinical supervisor and facility director on December 1, 2009 between the hours of 12:30 and 12:50 provided additional verification of the lack of work therapy assignments in treatment and rehabilitation plans. The facility failed to document work therapy in client records #1, 2, 4 ,5, and 6.
|
Plan of Correction
The Counselor will intergrate the work therapy goal into the initial comprehensive treatment plan upon admission, and be updated monthly.
Each client will be given a unique job description.
Through weekly chart audits and supervision the Clinical Supervisor will ensure that all work therapy goals are appropriate and updated.
During Clinical Meeting on December 2, 2009 the Clincal Supervisor, trained and informed the staff on how to implement work therapy goals in our therapeutic community.
This is effective immediately. |