INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 11, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Ridgeview Adolescent Behavioral Health Center at Pittsburgh 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.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of staff records, the facility failed to document a mechanism to collect feedback on completed training, as required.
The findings include:
Eight employee records were reviewed on October 2 -3 and 10, 2012. Seven employee records reviewed required documentation of feedback on completed training. The facility failed to document feedback information after the completion of employee training in employee records # 1, 2, 3, 4, 5, 6 and 7 . Although there was documentation that the employees reviewed had attended training in both 2011 and 2012, there was no documentation provided that the employees completed feedback evaluations on the completed training documented in the personnel or training records.
The Facility Director was interviewed on October 11, 2012 and confirmed the findings.
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Plan of Correction
Beginning October 22, 2012, Human Resource Coordinators will ensure that training evals for all trainings are placed in each individual's employee file. HR Coordinators will monitor employee files quarterly to ensure 100% compliance. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project director in one of one personnel record.
The findings include:
Fifteen personnel records were reviewed on October 4-5, 2012. One personnel record pertained to the project director. The facility's training year is January- December. The facility's 2011 training year was reviewed. One personnel record required the completion of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 1.
Employee # 1 has been the project director since July, 1999. There were no training hours documented for the 2011 training year.
Human resources personnel were interviewed on October 5, 2012 and confirmed the findings.
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Plan of Correction
Project Director will complete 12 hours of training by November 30, 2012. Beginning October 22, 2012, Human Resource Coordinator along with Program Director will ensure that employees receive the appropriate training hours. Human Resource Coordinators will monitor employee files quarterly to ensure 100% compliance. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of letters of agreement, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
The findings include:
The letters of agreement were reviewed on October 11, 2012. There was documentation provided of a 24- hour emergency psychiatric and medical coverage agreement.
The project director was interviewed on October 11, 2012. It was confirmed at that time that no documentation of a 24- hour emergency medical coverage was available.
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Plan of Correction
A written letter of agreement was obtained from Alle -Kiski Medical Center by Office Manager, Amber Kirkpatrick on 10/11/12 to provide 24 hour emergency psychiatric an medical coverage. Program Director to ensure upkeep. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on the review of client records, the facility failed to document that discharge summaries were completed within one week in two of three client records.
The findings include:
Eleven client records were reviewed on October 11, 2012. Seven client records were reviewed as inpatient client records. Three of the seven were reviewed as discharged clients and required documentation of a discharge summary. Discharge summaries are to be completed within one week of discharge. The facility did not document the completion of the discharge summary within one week of discharge in client records # 6 and 7.
Client # 6 was discharged on June 5, 2012. The discharge summary was due to be completed by June 12, 2012. It could not be determined that the discharge summary had been completed within one week of discharge as the discharge summary had not been dated.
Client # 7 was discharged on July 11, 2012. The discharge summary was due to be completed by July 18, 2012. It could not be determined that the discharge summary had been completed within one week of discharge as the discharge summary had not been dated.
The Facility Director was interviewed on October 11, 2012 and confirmed the findings.
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Plan of Correction
Beginning, November 15, 2012, the format of the Discharge Summary will be modified to include date of completion of summary and date of signature. Discharge Summary will be completed within one week of discharge as required. Clinical Supervisor will ensure full compliance through monthly chart audits. |
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.
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Observations
Based on the review of client records, the facility failed to document follow-up information in two of three client records.
The findings include:
Eleven client records were reviewed on October 11, 2012. Seven client records were reviewed as inpatient client records. Three of the seven were reviewed as discharged clients and required documentation of follow-up information. Per agency policy, follow-up is to be completed within 7 days of discharge. The facility did not document the completion of follow-up information within 7 days of discharge in client records # 6 and 7.
Client # 6 was discharged on June 5, 2012. The follow-up information was to be completed by June 12, 2012. There was no documentation of follow-up information.
Client # 7 was discharged on July 11, 2012. The follow-up information was to be completed by July 18, 2012. There was no documentation of follow-up information.
The Facility Director was interviewed on October 11, 2012 and confirmed the findings.
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Plan of Correction
Beginning immediately, all follow-up calls will be completed by Care Coordinator, within 7 days of discharge. Clinical Supervisor will monitor through chart audits to ensure full compliance. |
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, the facility failed to document a psychosocial evaluation that was evaluative in one of three client records.
The findings include:
Eleven client records were reviewed on October 11, 2012. Four client records were reviewed as outpatient client records. Three of the four records reviewed required documentation of a psychosocial evaluation. The facility did not document the completion of a psychosocial evaluation that was evaluative in client record # 8.
Client # 8 was admitted on May 23, 2012. The psychosocial evaluation was completed on May 30, 2012. The psychosocial evaluation did not include an evaluation of the client's assets/strengths, coping mechanisms, support systems, negative factors towards treatment and the counselor conclusions/impressions of the client.
The Facility Director was interviewed on October 11, 2012 and confirmed the findings.
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Plan of Correction
By January 1, 2013, all Counselors will be re-trained on evaluating clients and documenting a clinical evaluation as part of the Psychosocial by Corporate Trainer. Clinical Supervisor will ensure compliance through monitoring training attendance as well as through qualitative monthly chart audits. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document follow-up information in two of three client records.
The findings include:
Eleven client records were reviewed on October 11, 2012. Four client records were reviewed as outpatient client records. Two of the four were reviewed as discharged clients and required documentation of follow-up information. Per agency policy, follow-up is to be completed within 7 days of discharge. The facility did not document the completion of follow-up information within 7 days of discharge in client records # 10 and 11.
Client # 10 was discharged on September 6, 2012. The follow-up information was to be completed by September 13, 2012. There was no documentation of follow-up information.
Client #11 was discharged on August 30, 2012. The follow-up information was to be completed by September 6, 2012. There was no documentation of follow-up information.
The Facility Director was interviewed on October 11, 2012 and confirmed the findings.
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Plan of Correction
Beginning immediately, all follow-up calls will be made by OP Therapist within 7 days of discharge. Program Director will monitor compliance through monthly chart audits. |