INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on April 23, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Holcomb Associates, Inc. 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 June 30, 2010.
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Plan of Correction
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records and interviews with the clinical supervisor and facility director, the facility failed to provide a sufficient number of staff persons trained in Cardio Pulmonary Resuscitation (CPR) and First Aid (FA) during the project's hours of operation.
The findings include:
Facility Hours of operation are:
Monday through Thursday 9:00 AM- 9:00 PM
Friday 9:00 AM through 5:00 PM
Saturdays 9:00 AM through 6:00 PM by appointment
On April 23, 2010 the facility presented the Staffing Requirements Facility Summary Report along with copies of the staff persons current CPR and First Aid cards to the Licensing Specialist. The only documentation presented for CPR certification and First Aid certification were for two employees as follows:
Counselor #4 -
Hire date 11/4/09
Work hours: Tuesday 4:30 PM - 9:00 PM Wednesday 4:30 PM - 9:00 PM
CPR certification completed 6/10/2008 renewal date 6/4/2010
No documented First Aid certification
Employee #2 -
Hire date 4/9/10
Work hours: Monday through Thursday 9:00 AM - 7:00 PM Friday 9:00 AM - 5:00 PM
CPR certification completed 5/30/08 (notation on the card stipulated that the certificate is valid for one year from completion date). Thus the certification expired 5/30/2009.
First Aid certification completed 5/30/08 (notation on the card stipulated that the certificate is valid for three years from completion date).
In addition personnel records #1, 3, 5,& 6 were reviewed for CPR/FA certifications. Personnel records #3, 5 & 6 lacked documentation of current CPR/FA certification and although employee #1 had documentation for first aid, that employee is the Project Director and is not located at this site.
The clinical supervisor was asked about two additional staff, the CSS Specialist and the receptionist. It was determined that neither of these staff had documentation for current CPR or First Aid certifications.
There was no one certified in First Aid on site from October 19, 2009 through April 19, 2010 during the following hours of operation:
Monday, Tuesday, Wednesday and Thursday 9:00 AM - 9:00 PM
Friday 9:00 AM - 5:00 PM
Saturday (any scheduled appointments that may have occurred from 9:00 AM- 6:00 PM)
There was no one certified in CPR on site from October 19, 2009 through November 4, 2009 during the following hours of operation:
Monday, Tuesday, Wednesday and Thursday 9:00 AM - 9:00 PM
Friday 9:00 AM - 5:00 PM
Saturday (any scheduled appointments that may have occurred from 9:00 AM- 6:00 PM)
There was no one certified in CPR on site from November 4, 2009 through April 4, 2010 during the following hours of operation:
Monday and Thursday 9:00 AM - 9:00 PM
Tuesday and Wednesday 9:00 AM - 4:30 PM
Friday 9:00 AM - 5:00 PM
Saturday (any scheduled appointments that may have occurred from 9:00 AM- 6:00 PM)
During the licensing inspection, the facility director left the building for about a half hour so there was no employee in the building with CPR or first aid.
The facility director confirmed that there was insufficient CPR and first aid coverage during the project's hours of operation.
The clinical supervisor confirmed that prior to the facility director being hired on 4/19/2010 there were no staff trained in first aid during the project's hours of operation and that there was insufficient CPR coverage.
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Plan of Correction
5 staff completed the CPR/First Aid training at Holcomb Behavioral Health Systems in May 2010. A copy of each card has been placed in the appropriate employee files.
The Facility Director will be attending the CPR/First Aid Training on July 16, 2010 along with any remaining staff members who do not have CPR/First Aid certification.
The Clinical Supervisor is also certified in CPR/First Aid and a copy of her card is in her employee file.
Holcomb Behavioral Health Systems will offer a CPR/First Aid Training twice monthly to ensure all new employees are able to become certified in CPR/First Aid.
With the staff that is currently certified in CPR/First Aid all hours of operation are covered by at least one person who is certified in CPR/First Aid.
This will ensure Holcomb Behavioral Health Systems compliance with Licensure Standard 704.11 (c) (2).
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report Form completed by the facility on April 21, 2010, and a discussion with the facility director and clinical supervisor on April 23, 2010, the facility failed to ensure that staff to client ratios remained at or under 35:1.
The findings included:
Seven counselors' caseloads were reviewed on April 23, 2010. Two of seven counselors had case loads that were greater than 35:1.
Counselor # 4 had a caseload of 140:1, which exceeds the maximum of 35:1.
Counselor #7 had a caseload of 64:1, which exceeds the maximum of 35:1.
This was confirmed by the facility director and the clinical supervisor.
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Plan of Correction
By 7/13/10 the Facility Director will seek information from the Department on how to correctly calculate caseload ratios.
Upon receipt of additional information, by July 31, 2010 the Facility Director will train the Clinical Supervisor on appropriate calculation of Full Time Equivalent (FTE) maximum client/staff and client/counselor ratios.
The Clinical Supervisor will monitor staff caseloads monthly and ensure they do not exceed the appropriate 35:1 ratio.
The Facility Director will conduct periodic reviews and implement corrective action if ratios fall out of the acceptable range.
This compliance with Licensure Standard 704.12 (a)(6).
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on the review of the fire drill log and an interview with the clinical supervisor, the facility failed to set off a fire alarm or smoke detector during each fire drill.
The findings include:
The facility's fire drill log was reviewed on April 23, 2010 for the period of October 2009 through April 2010 to coincide with the time frame that he facility has been at their new location. The facility did not document setting off the fire alarm or smoke detector during fire drills conducted during the months of December 2009, January 2010, February 2010, March 2010 and April 2010.
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The clinical supervisor confirmed that neither the fire alarm nor the smoke detector was set off during the fire drills.
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Plan of Correction
Immediately following the Licensure visit on April 23, 2010 Holcomb's Clinical Supervisor began sounding the fire alarm during each monthly fire drill. This procedure will continue and be documented in accordance with Licensure Standard 705.28 (d) (7). |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records and a review of the facility's policies and procedures, the facility failed to have the client complete a medical history during intake and admission.
The findings include:
The facility's policy states:
28.11.3.5 Medical History - a history documenting the client's personal medical history, family medical history and history of illnesses and symptoms
28.12.1 Each client will complete a Medical Self-Report upon admission and this will be reviewed with the counselor.
Three active and two closed client records were reviewed on April 23, 2010 for medical histories. The facility failed to document medical histories in accordance with the policy in two of five records reviewed, specifically client records # 4 and 5.
Client # 4 was admitted on 9/10/09 and discharged on 2/2/10.
The medical history was due at the first face to face meeting with the counselor which occurred on 9/21/2009 per progress notes.
There was no documented medical history in this client record.
Client # 5 was admitted on 10/26/09 and discharged on 1/26/10.
The medical history was due at the first face to face meeting with the client's counselor which occurred on 10/30/09 per progress note.
The medical history was completed on 11/6/09.
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Plan of Correction
As of 7/12/10 all current staff has been trained in the completion of the Medical Self-report. All clients will fill this form out upon admission.
Effective immediately the Clinical Supervisor will review all charts for the next 3 months to ensure compliance. If all charts are not in compliance, the Clinical Supervisor will conduct chart reviews until all charts are in compliance. After all charts are in compliance, the Clinical Supervisor will conduct random chart reviews to ensure continued compliance with Licensure Standard 709.91 (b)(3)(i), as well as facility policy 28.11.3.5 and 28.12.1.
There is an additional mandatory staff training scheduled for July 26, 2010 where the Facility Director and Clinical Supervisor will meet with all clinical staff to ensure all Licensure Standards and Facility Policies are understood and carefully followed.
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709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to document a consent to treatment at intake in four of five client records.
The findings include:
Three active and two closed client records were reviewed on April 23, 2010 for the consent to treatment form that was to be signed by both the client and the staff person at intake.
The facility failed to document a consent to treatment form at intake in client records # 2, 3, 4, and 5.
Client # 2 was admitted to the program on 10/26/09.
A signed consent to treatment was documented on 11/3/09.
Client # 3 was admitted to the program on 10/26/09.
A signed consent to treatment was documented on 11/18/09.
Client # 4 was admitted to the program on 9/10/09 and discharged on 2/2/10.
The facility failed to have the client complete a consent to treatment for the duration of treatment.
Client # 5 was admitted to the program on 10/26/09 and discharged on 1/26/10.
A signed consent to treatment was documented on 11/6/09.
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Plan of Correction
As of 7/12/10, all current staff has been retrained in the elements regarding proper completion and timeliness of the Consent to Treatment form. All clients will fill this form out upon admission.
Effective immediately the Clinical Supervisor will conduct regular chart reviews for the next 3 months. If all charts are not in compliance the Clinical Supervisor will continue regular chart reviews until all charts are in compliance. After all charts are in compliance, the Clinical Supervisor will conduct random chart reviews to ensure current and future compliance with Licensure Standard 709.91 (b)(4), as well as facility policy 28.11.3.5 and 28.12.1.
There is an additional mandatory staff training scheduled for July 26, 2010 where the Facility Director and Clinical Supervisor will meet with all clinical staff to ensure all Licensure Standards and Facility Policies are understood and carefully followed. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records and the facility's policies and procedures manual, the facility failed to document a psychosocial evaluation in accordance with facility policy in two of five client records.
The findings include:
The facility's policy states:
28.11.1 A complete biopsychosocial history will be collected and recorded by the counselor assigned to the client at the first face to face meeting.
28.11.3 Biopsychosocial assessment will include, at minimum:
28.11.3.1 a clear description of the client's presenting and underlying problems; client needs or problems that can or cannot be resolved through treatment or that might inhibit treatment
28.11.3.2 the client's assets, strengths or other factors that can contribute to the resolution of identified problems; the potential or available client support systems; obstacles that might effect treatment are documented as well
28.11.3.3 the client's preferred coping and defense mechanisms, conclusions regarding the client's appearance, behavior, and reaction during the evaluation will be documented and used to determine course of treatment
28.11.3.7 Client's strengths/assets, support systems and preferred coping mechanisms
28.11.3. 8 Potential treatment barriers that may impact the course of treatment
28.11.3.9 Mental status assessment
28.11.3.10 Conclusions and treatment recommendations, including preliminary treatment planning. Recommendations should include treatment modalities and frequency
28.11.4 Biopsychosocial assessments will be reviewed and co-signed by the Clinical Supervisor
Three active and two closed client records were reviewed on April 23, 2010 for documentation of a psychosocial evaluation. The facility did not document a psychosocial evaluation in accordance with facility policy in client records # 3, and 4.
Client # 3 was admitted to the program on 10/26/09.
The psychosocial evaluation was due at the first face to face meeting between the counselor and client per facility policy.
At the time of the inspection, client # 3 was an active client.
The facility failed to document a psychosocial evaluation for client # 3 as of the date of the review on 4/23/10.
Client # 4 was admitted to the program on 9/10/09 and was discharged on 2/2/10.
The psychosocial evaluation was due at the first face to face meeting between the counselor and client per facility policy.
The facility failed to document a psychosocial evaluation for client # 4.
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Plan of Correction
All current staff have been trained and retrained in the completion and timeliness of the Psychosocial Evaluation. All clinical staff will fill this form out upon admission at the first face to face contact.
Effective immediately the Clinical Supervisor will conduct regular chart reviews for the next 3 months. If all charts are not in compliance the Clinical Supervisor will continue regular chart reviews until all charts are in compliance. After all charts are in compliance the Clinical Supervisor will conduct random chart reviews to ensure current and future compliance with Licensure Standard 709.91 (b)(6), as well as facility policies 28.11.1 A, 28.11.3, 28.11.3.1, 28.11.3.2, 28.11.3.3, 28.11.3.7, 28.11.3.8, 28.11.3.9, 28.11.3.10, and 28.11.4.
There is an additional mandatory staff training scheduled for July 26, 2010 where the Facility Director and Clinical Supervisor will meet with all clinical staff to ensure all Licensure Standards and Facility Policies are understood and carefully followed.
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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records and a review of the facility's policies and procedures manual, the facility failed to complete preliminary treatment and rehabilitation plans within seven days of the initial clinical assessment, as per facility policy, in three of five client records.
The findings include:
The facility's policy states:
28.13 A preliminary treatment plan will be developed by the counselor and client within 7 days of the initial clinical assessment.
28.13.1 Preliminary treatment plans will document critical problems areas and strategies for addressing these issues.
28.13.2 Barriers to treatment will be listed on plan and considered in the development of goals and objectives.
Three active and two closed client records were reviewed on April 23, 2010 for the completion of a preliminary treatment and rehabilitation plan. The facility failed to complete a preliminary treatment plan within seven days of the initial clinical assessment per policy in client records # 1, 3, and 4.
Client # 1 was admitted to the program on 10/27/09.
The preliminary treatment plan was due on 11/16/09 within 7 days of the initial clinical assessment.
The facility failed to document a preliminary treatment plan at the time of review on 4/23/10.
Client # 3 was admitted to the program on 10/26/09.
The preliminary treatment plan was due within 7 days of the initial clinical assessment.
The facility failed to document a preliminary treatment plan at the time of review on 4/23/10.
Client # 4 was admitted to the program on 9/10/09.
The preliminary treatment plan was due on 9/28/09 within 7 days of the initial clinical assessment.
The preliminary treatment plan was completed on 10/8/09.
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Plan of Correction
All current staff have been trained and retrained in the completion and timeliness of the Preliminary Treatment and Rehabilitation Plans. All clinical staff will fill this form out upon admission at the first face to face contact.
Effective immediately the Clinical Supervisor will conduct regular chart reviews for the next 3 months. If all charts are not in compliance the Clinical Supervisor will continue regular chart reviews until all charts are in compliance. After all charts are in compliance, the Clinical Supervisor will conduct random chart reviews to ensure current and future compliance with Licensure Standard 709.91 (b)(7), as well as facility policies 28.13, 28.13.1, and 28.11.2
There is an additional mandatory staff training scheduled for July 26, 2010 where the Facility Director and Clinical Supervisor will meet with all clinical staff to ensure all Licensure Standards and Facility Policies are understood and carefully followed.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on the review of client records and a review of the policies and procedures, the facility failed to document a comprehensive treatment and rehabilitation plan in accordance with facility policy.
The findings include:
The facility's policy states:
A comprehensive treatment plan will be developed within 30 days of the date of admission.
Three active and two closed client records were reviewed on April 23, 2010 to ensure that a comprehensive treatment plan was completed within 30 days of admission. The facility did not document a comprehensive treatment plan per policy in two of five records reviewed, specifically client records # 2 and 5.
Client # 2 -
admitted to the program on 10/26/09
comprehensive treatment plan due on 11/26/2009
comprehensive treatment plan completed on 12/29/09.
Client #5 -
admitted to the program on 10/26/09.
comprehensive treatment plan due on 11/26/09
comprehensive treatment plan completed on 12/10/09.
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Plan of Correction
All current staff have been trained and retrained in the completion and timeliness of the Comprehensive Treatment Plans. All clinical staff will fill this form out within the first 30 days of client's admission to the program.
Effective immediately the Clinical Supervisor will conduct regular chart reviews for the next 3 months. If all charts are not in compliance the Clinical Supervisor will continue regular chart reviews until all charts are in compliance. After all charts are in compliance, the Clinical Supervisor will conduct random chart reviews to ensure current and future compliance with Licensure Standard 709.92 (a).
There is an additional mandatory staff training scheduled for July 26, 2010 where the Facility Director and Clinical Supervisor will meet with all clinical staff to ensure all Licensure Standards and Facility Policies are understood and carefully followed.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the review of client records and a review of the policies and procedures, the facility failed to document treatment and rehabilitation plan updates at least every 60 days in two of four client records reviewed.
The findings include:
The facility's policy states:
28.15 Treatment plans will be updated at minimum every 60 days.
28.15.1 Treatment plan updates will include a review of the client's progress in relationship to the stated goals within the comprehensive treatment plan.
28.15.2 The progress review will direct the counselor and client in the development of the current treatment plan.
28.15.3 Treatment plan updates will be signed and dated by the primary counselor.
28.15.3.1 Treatment plan updates will be co-signed by the clinical supervisor.
Three active and two closed client records were reviewed on April 23, 2010 for treatment plan updates..
Four client records required treatment and rehabilitation plan updates at least every 60 days per facility policy. The facility did not document a treatment and rehabilitation update in client records # 3 and 4.
Client # 3 (active) was admitted to the program on 10/26/09. The comprehensive treatment plan was completed on 11/18/09. Treatment plan updates were due on 1/17/10 and 3/18/10. There were no treatment plan updates documented as of the time of review on 4/23/10.
Client # 4 (discharged) was admitted to the program on 9/10/09 and discharged on 2/2/10. The comprehensive treatment plan was completed on 10/8/09. A treatment plan update was due on 12/7/10. There was no treatment plan update documented as of the the time of review on 4/23/10.
This is a repeat deficiency from the 4/3/2009 inspection.
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Plan of Correction
All current staff have been trained and retrained in the completion and timeliness of the updating of Comprehensive Treatment Plans every 60 days. All clinical staff will update treatment plans at least every 60 days.
Effective immediatley the Clinical Supervisor will conduct regular chart reviews for the next 3 months. If all charts are not in compliance the Clinical Supervisor will continue regular chart reviews until all charts are in compliance. After all charts are in compliance the Clinical Supervisor will conduct random chart reviews to ensure current and future compliance with Licensure Standard 709.92 (b), as well as facility policies 28.15, 28.15.1, 28.15.2, 28.15.3, 28.15.3.1
There is an additional mandatory staff training scheduled for July 26, 2010 where the Facility Director and Clinical Supervisor will meet with all clinical staff to ensure all Licensure Standards and Facility Policies are understood and carefully followed.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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 client records, the facility failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in three of six client records reviewed.
The findings include:
Three active and two closed client records were reviewed on April 23, 2010 to ensure that counseling services were provided according to the individual treatment plan.
The facility failed to document, either in the record of service or progress notes, that counseling services were provided according to the individual treatment and rehabilitation plan in client records # 1, and 4.
Client # 1 was prescribed individual and group session once a week in treatment plan 3/1/10. The facility documented individual and group sessions on 11/9/09, 11/30/09, 12/14/09, 12/21/09, 1/4/10, 1/11/10, 3/1/10, 3/15/10, 3/22/10, 4/5/10, 4/12/10, and 4/19/10.
Client # 4 was prescribed sessions once a week in treatment plan 10/8/09.
The facility documented sessions on 9/21/09, 9/28/09, 10/8/09, 10/19/09, 11/9/09, 11/16/09, 11/30/09, 12/7/09, 12/28/09, 1/11/10, 1/19/10 and 2/2/10.
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Plan of Correction
All current staff have been trained and retrained in the necessary steps to take in order to assure clinical services are provided as prescribed in the treatment and rehabilitation plan.
Effective immediately the Clinical Supervisor will conduct regular chart reviews for the next 3 months. If all charts are not in compliance the Clinical Supervisor will continue regular chart reviews until all charts are in compliance. After all charts are in compliance the Clinical Supervisor will conduct random chart reviews to ensure current and future compliance with Licensure Standard 709.92 (c).
There is an additional mandatory staff training scheduled for July 26, 2010 where the Facility Director and Clinical Supervisor will meet with all clinical staff to ensure all Licensure Standards and Facility Policies are understood and carefully followed.
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709.93(a)(8) LICENSURE Client records
709.93. 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) Case consultation notes.
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Observations
Based on the review of client records and a review of the policies and procedures, the facility failed to document case consults for each client at least bi-monthly in four of four client records reviewed.
The findings include:
The facility's policy states:
28.17 Case Consultations will be conducted on a regular basis to ensure effective treatment interventions.
28.17.1 Supervision with the counselor and the clinical supervisor will be held at least once a month.
28.17.2 A case consultation note will be documented by the clinical supervisor for each client at least bi-monthly. It will include the date of consultation, names and discipline of those attending, names of clients reviewed, summary of discussion and disposition of cases reviewed.
Three active and two closed client records were reviewed on April 23, 2010 to ensure that case consults were provided in accordance with policy.
Four records required case consults at least bi-monthly.
The facility failed to document a case consult in four of five client records reviewed, specifically, client records # 2, 3, 4, and 5.
Client # 2 was admitted to the program on 10/26/09. Case consultations were due in December and February but the first one documented was on 3/3/10.
Client # 3 was admitted to the program on 10/26/09. Case consultations were due in December and February but no case consultations were documented as of the date of the inspection on 4/23/10.
Client # 4 was admitted to the program on 9/10/09. Case consultations were due in November and January. The client was discharged on 2/2/10. A case consultation was not documented for the client during the course of treatment.
Client # 5 was admitted to the program on 10/26/09 and discharged on 1/26/10. Case consultations were due in December but there were no case consultations documented for the client during the course of treatment.
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Plan of Correction
All current staff as well as the Clinical Supervisor have been trained and retrained in the completion, frequency, and timeliness of completing Case Consultation notes.
Effective immediately the Facility Director will conduct regular chart reviews for the next 3 months to ensure the Clinical Supervisor has completed all case consultation notes timely. If all charts are not in compliance the Facility Director will continue regular chart reviews until all charts are in compliance. After all charts are in compliance the Facility Director will conduct random chart reviews to ensure current and future compliance with Licensure Standard 709.93 (a) (8), as well as facility policies 28.17, 28.17.1, 28.17.2.
There is an additional mandatory staff training scheduled for July 26, 2010 where the Facility Director and Clinical Supervisor will meet with all clinical staff to ensure all Licensure Standards and Facility Policies are understood and carefully followed.
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709.93(a)(9) LICENSURE Client records
709.93. 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 a complete client record which included an aftercare plan in one of four client records where required.
The findings include:
Four closed client records were reviewed on April 23, 2010 to ensure that aftercare plans were documented per facility policy.
An aftercare plan was only required in three client records due to client #7 leaving treatment without notice shortly after being admitted to treatment.
The facility failed to document an aftercare plan in one of three records where required, specifically, client record # 6.
Client #6 was admitted to the program on 11/13/09 and discharged on 2/18/10. An aftercare plan was not documented at the time of review on 4/23/10.
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Plan of Correction
All current staff have been trained and retrained in the completion and timeliness of Aftercare Plans. This will ensure current and future compliance with Licensure Standard 709.93 (a) (9).
There is an additional mandatory staff training scheduled for July 26, 2010 where the Facility Director and Clinical Supervisor will meet with all clinical staff to ensure all Licensure Standards and Facility Policies are understood and carefully followed.
All issues addressed in the survey's deficiencies will be monitored by the Clinical Supervisor and Facility Director through weekly supervision of staff and charts. |
709.93(a)(10) LICENSURE Client records
709.93. 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 the review of client records and the facility's policies and procedures manual, the facility failed to document a complete client record which included a discharge summary in two of three client records reviewed.
The findings include:
The facility's policy states:
28.23 Discharge summaries will be completed within 7 days of the client's discharge.
28.23.1 Discharge summaries will document, at minimum:
28.23.1.1 the reason for referral/services
28.23.1.2 a summary of services provided
28.23.1.3 a summary of the client's response to services
28.23.1.4 the client's clinical status/condition at discharge
28.23.1.5 the discharge diagnosis
28.23.1.6 aftercare recommendations
Three closed client records were reviewed on April 23, 2010 for discharge summaries.
The facility failed to document a discharge summary per policy in two of three client records, specifically # 5 and 6.
Client # 5 was admitted to the program on 10/26/09 and discharged on 1/26/10. The discharge summary was completed on 2/11/10.
Client # 6 was admitted to the program on 11/13/09 and discharged on 2/18/10. A discharge summary was not documented at the time of review on 4/23/10.
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Plan of Correction
All current staff have been trained and retrained in the completion and timeliness of the Discharge Summary. This will ensure current and future compliance with Licensure Standard 709.93 (a) (10), as well as facility policies 28.23, 28.23.1, 28.23.1.1, 28.23.1.2, 28.23.1.3, 28.23.1.4, 28.23.1.5, 28.23.1.6.
There is an additional mandatory staff training scheduled for July 26, 2010 where the Facility Director and Clinical Supervisor will meet with all clinical staff to ensure all Licensure Standards and Facility Policies are understood and carefully followed.
All issues addressed in the survey's deficiencies will be monitored by the Clinical Supervisor and Facility Director through weekly supervision of staff and charts.
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