INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 13, 14 and 15, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc. - Concept 90 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 18, 2009.
|
Plan of Correction
|
704.8(a) LICENSURE Qualifications-Counselor Assistant
704.8. Qualifications for the position of counselor assistant.
(a) A person who does not meet the educational and experiential qualifications for the position of counselor may be employed as a counselor assistant if the requirements of at least one of the following paragraphs are met. However, a project may not hire more than one counselor assistant for each employee who meets the requirements of clinical supervisor or counselor.
|
Observations
Based on a review of the staffing form, the facility hired more than one counselor assistant for each employee who meets the requirements of clinical supervisor or counselor.
Findings:
The staffing form was reviewed on May 13, 2009. The facility is required to have one employee who meets the requirements of clinical supervisor or counselor for each counselor assistant. The facility has three counselor assistants but only one counselor and a facility director who meets the requirements for clinical supervisor or counselor.
|
Plan of Correction
Program Director and Program Supervisor will insure that Gaudenzia Concept 90 ratio will be adjusted to meet Counselor Assistant to Counselor ratio. Program Director, Program Supervisor and Counsolor I will each directly supervise one COunselor assistant. This will be achieved by 7-20-09. No counselor assistants will be hired at this time to place COncept 90 out of ratio. This will be monitored by the Program Director. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
|
Observations
Based on a review of supervision notes, the facility failed to document close supervision in two personnel records.
Findings:
Seven personnel records and supervision documentation for two employees was reviewed on May 5 and 13, 2009. Close supervision of one hour direct observation and formal documentation of one hour of supervision per week was required for one personnel record, #4. The facility documented only weekly supervision notes with no documentation of one hour of direct observation for employee #4. Employee #4 is a counselor assistant with a high school diploma who was hired on 4/14/08. Employee #5, who was hired on 4/29/09, is a counselor assistant with a high school diploma, who is required to have documentation of direct observation for the first three months. The facility failed to document direct observation for employee #5.
|
Plan of Correction
Program Director and Program Supervisor will provide direct supervision to Counselor Assistant# 5. Program Supervisor will provide formal documentation of one hour of direct observation for all counselor assistants that require such supervision for a three month period. At this time Program Director will provide close supervision to all counselor assistants and document this supervision. Program Director will monitor the supervision of all counselor assistants to ensure that the documentation meets standards. |
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.
|
Observations
Based on a review of personnel and training records, the facility failed to document 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 for two of seven employees.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.
Findings:
Seven personnel and training records were reviewed on May 5 and 13, 2009. A minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training was required for five personnel. The facility failed to document a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training for employee #4. Employee #4, a counselor assistant, was hired on 4/14/08 and had not received the training as of the ending date of this inspection. The facility failed to document a minimum of 6 hours of HIV/AIDS training for employee #7. Employee #7 was hired on 7/1/06 and was required to have the training within 2 years of employment and had not yet received the training as of the ending date of this inspection,
|
Plan of Correction
Program Director has scheduled all personel for the next scheduled HIV/AIDS and TB/STD trainings provided by the Gaudenzia Training Institute. Program Supervisor will monitor and schedule all staff for needed trainings to maintain compliance. Program Director will monitor overall training needs of the facility to ensure facility staff meet all regulations and standards. |
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.
|
Observations
Based on a review of personnel and training records, the facility failed to document at least 25 clock hours of training for the 2008 training year for one of seven records reviewed.
Findings:
Seven personnel and training records were reviewed on May 5 and 13, 2009. At least 25 clock hours of training for the 2008 training year was required for one counselor. The facility failed to document at least 25 clock hours of training for the 2008 training year for employee #3.
|
Plan of Correction
A training plan has been developed for employee #3 to recieve 25 hours of training in the DOH counselor outlined requirements. Program Director will audit and review all active employee trainings on a monthly basis to ensure that any staff that is in need of additional trainings hours.
Completed 5/22/09 by Gaudenzia Residential Division Director and C90 Program Director. |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
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.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
|
Observations
Based on a review of the staffing form, the facility failed to ensure that the project had one FTE counselor for every eight clients.
Findings:
The staffing form was reviewed on May 13, 2009. The facility failed to ensure that the project had one FTE counselor for every eight clients. The client/staff ratio was 10/1.
|
Plan of Correction
Program Director and Division Director have hired a Program Supervisor as of 7/19/09. Also hired was one FTE counselor. Program Supervisor will assign no more than eight clients per counselor to be in compliance with standard. In the event of counselor turnover the Program Supervisor/Program Director will ensure compliance by taking on clients to maintain 8/1 ratio. This will be review and monitored by the Program Director on an ongoing basis. |
705.10 (b) (2) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(2) On floors with resident bedrooms, maintain a smoke detector which shall be located within 15 feet of each bedroom door. On floors with no resident bedrooms, the smoke detection device shall be located in a common area or hallway. All detection devices shall be interconnected.
|
Observations
Based on the physical plant inspection, the facility failed to ensure that a smoke detector was located within 15 feet of each bedroom door.
Findings:
The physical plant inspection was conducted on May 14, 2009 between 10:00 and 10:30 AM. The facility failed to ensure that a smoke detector was located within 15 feet of bedroom #111 and #113. Bedroom #111 was located 23 feet from the smoke detector. Bedroom #113 was located 16 feet from the smoke detector.
|
Plan of Correction
Program Director and Facility Maintenence Manager will ensure that smoke detectors will be located within 15' of bedrooms # 111 and 113. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a review of the fire drill records, the facility failed to document the use of alternate exit routes during fire drills.
Findings:
The fire drill records were reviewed on May 14, 2009. The facility failed to document the use of alternate exit routes from December 2008 through April 2009. The fire drill records document the use of "all" exits during fire drills conducted during this time period.
|
Plan of Correction
Program Director ensured that alternate routes were identified and have been reflected in the fire drill grid. During fire drills these alternate routes will be utilized by staff and residents. The alternate routes will then be documented. Each fire drill will utilize a different alternate route. This will be monitored by the facility fire and safety staff as well as monitored on a weekly basis by the Program Director. These changes will occur beginning 6-1-09. |
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:
|
Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in three of twelve client records reviewed.
Findings:
Twelve client records were reviewed on May 14 and 15, 2009. An informed and voluntary consent was required in seven client records. The facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client records #1, 2 and 3. In client record #1, a consent to release information was signed by the client for a southeastern County Assistance Office but information was released to a different County Assistance Office. In client record #2, a consent to release information was signed by the client but the name of the person or agency to whom disclosure would be made was left blank. In client record #3, information was released to a government agency without a consent being signed.
|
Plan of Correction
There has been a documentation training for all staff addressing the confidentiality regulations and the completeness of a request for confidential information form. This training was held on July 15th & 16th 2009. It was conducted by a qualified Gaudenzia Institute trainer. The Program Supervisor will conduct monthly chart audits for six months. If the facility is found to be in compliance within that time frame the Program Supervisor will then conduct random audits that will continue on a monthly basis. These audits will begin on 7-13-09. |
709.28(c)(2) 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:
(2) Specific information disclosed.
|
Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include the specific information disclosed in three of twelve client records reviewed.
Findings:
Twelve client records were reviewed on May 14 and 15, 2009. An informed and voluntary consent from the client for the disclosure of information contained in the client record to include the specific information disclosed was required in seven client records. The facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client records #1, 2 and 10. In client record #1, the consent to release information for the probation office exceeded Pa Code 255.5 as it included progress reports and after care. In client record #2, the consent to release information to for Social Security disability benefits exceeded Pa Code 255.5 as it included "Multiple Impairment Questionnaire, psych evaluation and medications". In client record #10, a Contact Form completed by the counselor indicated that he spoke to the funding source and discussed "progress and after care plan".
|
Plan of Correction
The regulation of informed consent was reviewed with all staff by the facility Program Director. The Program Supervisor will audit all client charts and all consent forms for a period of three months. Consent forms will be discussed in QI meeting for the the duration of this audit. If after the three month period all consent forms comply with standards, then chart audits will be on a random basis. This process will be followed up on by the Program Director. This chart audit began 7-20-09. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation to include a composite picture, client problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment and/or the counselor's conclusions/impressions in seven of twelve client records reviewed.
Findings:
Twelve client records were reviewed on May 14 and 15, 2009. Psychosocial evaluations were required in seven client records. The facility did not document a psychosocial evaluation to include the client's composite picture, problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment and/or the counselor's conclusions/impressions in client records # 1, 2, 3, 4, 5, 9 and 10.
The facility did not document a psychosocial evaluation to include the client's composite picture in client records #1,3 and 4.
The facility did not document a psychosocial evaluation to include the client's problems/needs in client records #1, 3 and 4.
The facility did not document a psychosocial evaluation to include the client ' s assets/strengths in client records #1, 3, 4, 9 and 10.
The facility did not document a psychosocial evaluation to include the client ' s support systems in client records # 1, 4, 9 and 10.
The facility did not document a psychosocial evaluation to include the client ' s coping mechanisms in client records # 3, 4, 9 and 10.
The facility did not document a psychosocial evaluation to include the client ' s negative factors in client records # 1, 3, 4, 9 and 10.
The facility did not document a psychosocial evaluation to include conclusions regarding the client ' s attitude towards and ability to participate in treatment in client records # 1, 3, 4, 9 and 10.
The facility did not document a psychosocial evaluation to include counselor conclusions/impressions in client records #1, 3, 4, 9 and 10.
Additionally, the facility did not document any psychosocial evaluation in client records #2 and 5.
|
Plan of Correction
1. A two day clinical documentation training will be conducted with all clinical staff by the Director of Training. The Program Director/Supervisor will conduct weekly audits to ensure compliance with this regulation. 2. Data will be presented at the monthly CQI meeting.
3. The strength, needs, abilities and preferences form will be completed by the client and counselor. Clinical chart audit will be completed weekly by the Program Director.
4. The two day clinical documentation training will address the psychsocial evaluation and include the following; composite picture, problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward ability to participate in treatment and counselors impressions. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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:
|
Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan within the required timeframe of 3 days as per facility policy in three of twelve client records reviewed.
Findings:
Twelve client records were reviewed on May 14 and 15, 2009. An individual treatment and rehabilitation plan was required in seven client records. The facility failed to document an individual treatment and rehabilitation plan within the required timeframe of 3 days as per facility policy in client records #2, 5 and 9. Client #2 was admitted on 3/13/09. The facility documented an individual treatment and rehabilitation plan on 4/13/09. Client #5 was admitted on 3/16/09. The facility documented an individual treatment and rehabilitation plan on 4/16/09. Client #9 was admitted on 4/8/09. The facility did not document any individual treatment and rehabilitation plan.,
|
Plan of Correction
1. There will be a two day clinical documemtation training addressing the timeliness, completeness and effectiveness of treatment planning by the Director of Training.
2. The timeliness of treatment plans will be presented for three months at the monthly CQI meeting.
3. The Program Director will conduct weekly chart audits of the counselors files. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of client records, the facility failed to document the type of treatment and rehabilitation services in seven of twelve client records.
Findings:
Twelve client records were reviewed on May 14 and 15, 2009. The type of treatment services was required in seven client records. The facility failed to document the type of treatment and rehabilitation services in client records #1, 2, 3, 4, 5, 9 and 10.
|
Plan of Correction
1. There will be a two day clinical documentation training on timeliness, effectiveness and completeness of treatment planning by the Director of Training.
2. The timeliness of treatment planning will be presented for three months at the monthly CQI meeting.
3. The Program Director will conduct weekly chart audits of the counselors files. |
709.52(a)(3) LICENSURE Support service type
709.52. 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:
(3) Proposed type of support service.
|
Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan to include the proposed type of support services in five of twelve client records.
Findings:
Twelve client records were reviewed on May 14 and 15, 2009. An individual treatment and rehabilitation plan to include the proposed type of support services was required in seven client records. The facility failed to document an individual treatment and rehabilitation plan to include the proposed type of support services in client records #1, 3, 4, 9 and 10.
|
Plan of Correction
1. The two day clinical documentation training facilitated by the Director of Training will address identification of support services.
2. The Program Director will conduct weekly chart audits to ensure compliance. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Based on a review of client records, the facility failed to document a treatment and rehabilitation plan update at least every 30 days in five of twelve client records reviewed.
Findings:
Twelve client records were reviewed on May 14 and 15, 2009. A treatment plan update at least every 30 days was required in six client records. The facility failed to document a treatment and rehabilitation plan update at least every 30 days in four of six client records reviewed, #1, 2, 3, 4 and 10.
Client #1 date of admission 2/26/09. The comprehensive treatment plan was developed 3/1/09. The treatment plan update not completed until 4/26/09.
Client #2 date of admission 3/13/09. The comprehensive treatment plan was developed 4/13/09. The treatment plan update was due 5/13/09 but was not completed as of the ending date of this inspection.
Client #3 date of admission 2/2/09. The comprehensive treatment plan was developed 2/3/09. The treatment plan was due 3/3/09 but was not completed.
Client #4 date of admission 4/6/09. The comprehensive treatment plan was developed 4/10/09. The treatment plan update was due 4/10/09 but was not completed as of the ending date of this inspection.
Client #10 date of admission 1/7/09. The comprehensive treatment plan was completed on 1/7/09. The treatment plan update was completed on 2/18/09.
The facility failed to document a review of progress on goals in the prior treatment plan in client records #1, 3, and 10.
|
Plan of Correction
1. The Program Director will conduct weekly chart audits to ensure that treatment plan and treatment plan updates are completed in a timely manner per regulations.
2. Counselors will submit treatment plan and treatment plan updates for review. |
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.
|
Observations
Based on a review of client records and an interview with the facility director and clinical supervisor, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in six of twelve client records.
Findings:
Twelve client records were reviewed on May 14 and 15, 2009. An interview with the facility director and clinical supervisor was conducted on May 14, 2009. The facility director and clinical supervisor confirmed that the clients are to receive one individual and five therapeutic group sessions per week. Counseling services provided according to the individual treatment and rehabilitation plan were required in seven client records. The facility failed to document, either in the record of services or progress notes, that counseling services were provided according to the individual treatment and rehabilitation plan in client records #1, 2, 3, 4, 5 and 10.
In client record #1 the facility documented therapeutic group sessions on 3/8, 3/15, 3/25, 4/9, 4/29, 5/1, 5/3 and 5/6/09. The facility documented individual sessions for client #2 on 3/18 and 3/22/09. Group therapeutic sessions were documented on 4/29 and 5/6/09. For client #3, the facility documented individual sessions on 3/4 and 3/11/09. No group therapeutic sessions were documented for April 2008. For client #4, the facility documented individual sessions on 4/13, 4/20 and 5/7/09. On group therapeutic session was documented on 4/9/09 and one on 5/6/09. For client #5, the facility documented group therapeutic sessions on 3/16, 3/25 and 4/9/09. For client #10, the facility documented group sessions on 2/2, 2/6, 2/16, 2/18, 2/19, 2/23, 3/6, 3/9, 3/16 and 3/25/09.
|
Plan of Correction
1. Program Director will ensure that the record of service will document all clinical activities.
2. The Program Director will monitor that the clinical schedule of five groups and one individual session per week are conducted. |
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.
|
Observations
Based on a review of client records, the facility failed to document that counseling was provided to a client on a regular and scheduled basis in six of twelve client records.
Findings:
Twelve client records were reviewed on May 13, 14 and 15, 2009. Counseling provided to a client on a regular and scheduled basis was required in seven client records. The facility failed to document at least one individual session each week and five therapeutic group sessions was scheduled and provided each week in client records #1, 2, 3, 4, 5 and 10.
|
Plan of Correction
1. The Program Director will ensure that the program will document on the record of service and in a progress note that 1/1 sessions are held weekly at Concept 90.
2. The Program Director will audit the counselors chart to ensure weekly individual sessions are being conducted. |
709.53(a)(2) LICENSURE Medication records
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:
(2) Medication records.
|
Observations
Based on a review of medication records, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project to include medication records in two of three client records.
Findings:
Twelve client records were reviewed on May 13, 14 and 15, 2009. Medication records were required in three client records. The facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project to include medication records in client records #7 and 8. In client record #7, the facility failed to document the client's missed administration of Atarax on 5/5 through 5/8/09, 5/11 and 5/13/09. In client record #8, the facility failed to document the client's missed administration of Zantac on 5/10/09, of Prilosec on 5/9/09 ad of Augmentin on 5/9/09.
|
Plan of Correction
1. Program Director will have facility nures train all staff on proper procedure for dispensing and documenting medication runs
2. The Program Director and facility nurse will conduct medical chart audits for a period of three months to ensure compliance of medication regimines and documentation.
3. The Program Director will ensure that incidents reports will be reviewed monthly for three months to monitor medication administration and documentation.
4. Any missed medication will be documented in the client record as well as an incident report to be discussed in monthly QI meeting. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
|
Observations
Based on a review of client records, the facility failed to document a complete client record on an individual to include a record of services in five of twelve client records reviewed.
Findings:
Twelve client records were reviewed on May 13, 14 and 15, 2009. A complete client record on an individual to include a record of services was required in eight client records. The facility failed to document a record of services in client records #1, 2, 5, 6 and 9. In client record #1, the facility failed to document the provider of the service on 2/26, 2/28, 3/8, 3/15, 3/25, 4/9 and 5/3/09 and failed to document the duration of the service on 2/26/ and 2/28/09. In client record #2, the facility failed to document service received on 3/18 and 3/22/09. In client record #5, the facility failed to document individual sessions received on 3/25, 4/1, 4/6, 4/22 and 4/28/09. In client record #6, there was documentation of individual sessions on progress notes but no documentation on the record of services. In client record #9, the facility failed to document group and individual sessions on the record of service which were documented on progress notes.
|
Plan of Correction
1. The Program Director will audit the record of service weekly to ensure compliance.
2. Program Director will review with clinical staff the correct procedure for documentation of the record of service.
3. The record of service will be presented for three months in the monthly CQI meeting for timeliness and completeness by the Program Director. |
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.
|
Observations
Based on a review of client records, the facility failed to document a complete client record to include an aftercare plan in two of four client records where required.
Findings:
Twelve client records were reviewed on May 13, 14 and 15, 2009. An aftercare plan was required in four client records. The facility failed to document an aftercare plan in client records #11 and 12.
|
Plan of Correction
1. Clinical staff will attend clinical documentation training 7-15/16-2009, to include aftercare planning and documentation.
2. The Program Supervisor will ensure that all charts will have an aftercare plan included that will be initiated early in the clients treatment.
3. Beginning 7-20-09 the Program Supervisor will conduct weekly chart audits for three months on all completing clients to ensure compliance. |
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.
|
Observations
Based on a review of client records, the facility failed to document a complete client record to include follow-up information in three of three client records where required.
Findings:
Twelve client records were reviewed on May 13, 14 and 15, 2009. Follow-up information was required in three client records. The facility failed to document any follow-up information in client record #9. The facility failed to date the follow-up information in client records #10 and 12 so the specialist was unable to determine if the follow-up information was completed within the timeframe of 30 days as stated in facility policy.
|
Plan of Correction
1. The follow up procedure will be reviewed by the facility Director with all staff to ensure knowledge.
2. Clinical chart audits will be conducted by the Program Director to ensure compliance.
3. All follow up activity will be logged in the follow up binder by the intake counselor. This will be audited by the Program Director |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
|
Observations
Based on the physical plant inspection, the facility failed to notify the Department of the change in maximum capacity.
Findings:
The physical plant inspection was conducted on May 14, 2009 between 9:30 and 10:00 AM. The number of beds set up in residents' bedrooms was 47. The maximum capacity was 42. On May 15, 2009 another bed count was done and the number of beds was reduced to 42.
|
Plan of Correction
The maximum capacity of Concept 90 is forty two beds. The Program Director has ensured that there are forty two beds on site.
The Program Director will make daily rounds and maintain documentation on the number of beds in each facility room for a period of three months. This documentation will identify each room by number.
After a three month period bed checks will be conducted on a random basis.
Any change in capacity will result in immediate notification to the Department of Health. |