INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 24-26, 2019 and July 30, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, Libertae Family House Libertae, 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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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
A licensing renewal inspection was conducted on July 24-26, 2019 and July 30, 2019. A staffing plan documenting the qualifications and training of staff was submitted to the department licensing representative at the beginning of the licensing process. The initial staffing plan was incomplete and its' deficiencies were brought to the attention of facility staff at the beginning of the onsite inspection. The facility was required to re-submit a revised staffing plan multiple times throughout the onsite inspection, as each revised plan did not document all required information. The final accepted version of the staffing plan was completed at the end of the onsite licensing process. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In order to maintain staffing in compliance with licensing, Libertae's staff are required to adhere to the agency's policy regarding submission of documents indicating that they meet qualifications for positions held, and certifications of annual mandatory trainings completed. In readiness for annual licensing inspections, the administrative assistant of Libertae will process staff documents as follows:
1. Prior to commencement of employment, the administrative assistant will obtain copies of all diplomas, degrees and practice licenses, where applicable, of all prospective hires.
2. During the first two weeks of employment, new hires will meet with their respective supervisors to review the annual mandatory training requirements. A staff training form will be completed and submitted by the supervisor to the administrative assistant.
3. The administrative assistant will enter this information into the employee's electronic personnel file, which contains a list of all mandatory trainings and will set up reminders.
4. The administrative assistant has developed a spreadsheet of all employees to track agency compliance with training requirements. She will update this monthly and submit to her supervisor for review.
In order to maintain this correction, the Fiscal Administrator of Libertae will review this policy with all agency staff by October 15, 2019. All hiring supervisors will report personnel changes at monthly management team meetings, which will be attended by the Fiscal Administrator and the Clinical Director who monitors the ratio of clients to counselors. The compliance plan will be reviewed quarterly in the Quality Assurance meeting and any deficiencies will be addressed at that time. By May 15, 2020, the Fiscal Administrator will review the annual staff compliance plan in advance of submitting a licensing report and inspection. The administrative assistant will submit all forms completed to her supervisor, the Fiscal Administrator, for review of completeness and accuracy, prior to submission to the licensing office.
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
One clinical supervisor position was reviewed for documentation of supervisory meetings, during the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. For employee record # 5, the facility failed to fully document monthly supervision meetings for the first 6 months of their employment in the clinical supervisor position. Employee # 5 was hired by the project on September 14, 2016 and had begun employment in the clinical supervisor position on August 1, 2018. Documentation of monthly supervisory meetings was required for the period of August 2018 - January 2019. The facility only provided documentation of one monthly supervisory meeting with the employee, conducted in December 2018. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In the case of a new hire of a clinical supervisor, documentation of supervisory meetings, which shall be held monthly for at least the first 6 months of their employment in the position, is the responsibility of the Director of Clinical Services.
The deficiency was isolated to the absence of the prior Director of Clinical Services, who was hospitalized and subsequently expired by the time the deficiency was uncovered.
The deficiency has been remedied by the hiring of a new Director of Clinical Services, whose duties include supervision and documentation of same of the clinical supervisor. In the case of a new hire of a clinical supervisor, the project will ensure adherence to this requirement by a specific review of supervision documentation on a monthly basis by the project director. |
704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
A licensing renewal inspection was conducted on July 24-26, 2019 and July 30, 2019. Based on a review of administrative records and facility training documentation, the facility failed to provide documentation of an overall plan for addressing staff training needs for the July 1, 2019 - June 30, 2020 training year. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected. The project director in collaboration with the clinical director has completed an assessment of staff training needs for the current year. The assessment included questionnaires completed by all staff to identify needs. The data was compiled and summarized. An overall formal plan for addressing these needs has been completed. A number of the trainings identified have already been held. Staff are currently engaged in a county initiative that is also part of the training plan. Every training module includes a feedback form that shall be submitted to the project's administrative assistant in order to receive a certificate of completion for the training session. The administrative assistant shall submit these to the project director and clinical director quarterly for review and assessment of the trainings.
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704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
A licensing renewal inspection was conducted on July 24-26, 2019 and July 30, 2019. Based on a review of administrative records and facility training documentation, the facility failed to provide documentation of an annual evaluation of the overall training plan for the July 1, 2018 - June 30, 2019 training year. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The project director in collaboration with the clinical director will conduct an annual evaluation of the overall training plan. The evaluation shall determine the extent to which the plan addressed the identified needs, including a determination of the extent to which implementing the plan eliminated or satisfied the identified needs. Data collected on Staff Training and Course Evaluation Forms after each training will be submitted to the administrative assistant who will tally results of each training and furnish to the project and clinical directors for monthly review. A final assessment will be made in May 2020 when questionnaires are completed by all staff, which will include individual evaluations of the preceding trainings and suggestions for upcoming trainings.
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
A licensing renewal inspection was conducted on July 24-26, 2019 and July 30, 2019. Based on a review of personnel records and facility training documentation, the facility failed to develop annual individual training plans for all facility personnel. This finding was reviewed with facility staff during the licensing process. This is a repeat citation. The facility was cited for non-compliance of this regulation during the previous licensing renewal inspection completed on July 12, 2017.
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Plan of Correction
Correction of Deficiency will be achieved by November 15, 2019.
The project has employed an electronic personnel system whereby all mandatory trainings are entered into a drop-down menu. It can be customized to include other trainings as needed.
The supervisory staff are now proficient in utilizing the system for performance evaluations, of which individual training plans are a component. The administrative assistant of the project has developed a worksheet of the trainings required of all personnel and has distributed this to each supervisor.
The supervisory staff are responsible for conducting a supervision session with each employee by November 8, 2019, in order to develop a training plan. The supervisory staff in conjunction with the administrative assistant are responsible for completing entering the training plan in the personnel file of each employee by November 15, 2019.
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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.
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Observations
Seven personnel records were reviewed for documentation of HIV/AIDS and TB/STD training, during the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. The facility failed to provide documentation of the required trainings for employee records # 1, 3, 4, 6, 7, 8, and 9. Employee # 1 was hired by the project on May 4, 2015 and is employed as both the project director and facility director. The employee was required to complete HIV/AIDS training by no later than May 4, 2017. The facility failed to provide documentation of this training for this personnel record. Employee # 3 was hired by project on June 21, 2017 as a counselor. The employee was required to complete HIV/AIDS training by no later than June 21, 2018. The facility failed to provide documentation of this training for this personnel record. Employee # 4 was hired by the project on April 2, 2018 as a counselor. The employee was required to complete HIV/AIDS and TB/STD trainings by no later than April 2, 2019. The facility failed to provide documentation of these trainings for this personnel record. Employee # 6 was hired by the project on March 15, 2017 as a counselor. The employee was required to complete HIV/AIDS training by no later than March 15, 2018. The facility failed to provide documentation of this training for this personnel record. Employee # 7 was hired by the project on September 15, 2008 and is employed as a childcare aide. The employee was required to complete HIV/AIDS and TB/STD trainings by no later than September 15, 2010. The facility failed to provide documentation of these trainings for this personnel record. Employee # 8 was hired by the project on July 17, 2014 and is employed as a treatment tech. The employee was required to complete HIV/AIDS and TB/STD trainings by no later than July 17, 2016. The facility failed to provide documentation of these trainings for this personnel record. Employee # 9 was hired by the project on March 29, 2017 and is employed as a treatment tech. The employee was required to complete TB/STD training by no later than March 29, 2018. The facility failed to provide documentation of this training for this personnel record. These findings were reviewed with facility staff during the licensing process. This is a repeat citation. The facility was cited for non-compliance of this regulation during preceding licensing renewal inspections completed on July 12, 2017 and June 16, 2016.
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Plan of Correction
The deficiency has been corrected. Personnel who have not met training requirements have been registered to attend. Personnel who have completed trainings have submitted documentation to the program to be filed in personnel records.
Employee #1, HIV/AIDS training is registered 11/13/19.
Employee #3, HIV/AIDS training was completed 6/13/18.
Employee #4, HIV/AIDS is registered 10/22/19; TB/STD is registered 11/15/19.
Employee #6, no longer with the facility
Employee #7, HIV/AIDS completed 6/13/19; TB/STD registered 12/10/19.
Employee #8, TB/STD completed 4/7/16.
Employee #9, no longer with the facility
In order to ensure that the deficiency does not reoccur, the Administrative Assistant is responsible to monitor the compliance of all staff with attendance at mandatory communicable disease training within the required time frames. Oversight of the staff development program is the responsibility of the supervisor of the Administrative Assistant of the project.
The corrective actions will be completed and all staff will be in compliance with the mandatory training requirement of HIV/AIDS and TB/STD by 12/10/19.
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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
One personnel record was reviewed for the project director and facility director positions, during the licensing renewal inspection conducted on July 24-16, 2019 and July 30, 2019. The facility training year of July 1, 2018 - June 30, 2019 was reviewed for this inspection. The facility failed to document the completion of at least 12 annual training hours for employee record # 1. Employee # 1 was hired by the project on May 4, 2015 and is employed as both the project director and facility director. Documentation in the employee's personnel record indicated that 3.5 annual training hours were completed for the reviewed training year. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected. The administrative assistant of the project has developed a spreadsheet of all employees to track agency compliance with training requirements. She posts announcements of training availability and registers staff for same. She updates the spreadsheet monthly and reviews this with her supervisor and reports to department supervisors for further action.
Personnel who are not meeting training requirements on schedule are reminded to register for upcoming trainings. Personnel who have completed trainings are instructed to submit documentation to the administrative assistant to be filed in personnel records.
In order to ensure that the deficiency does not reoccur, the administrative assistant is responsible to monitor the compliance of all staff with completing annual training requirements per number of hours needed.
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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.
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Observations
Four personnel records were reviewed for the counselor position, during the licensing renewal inspection conducted on July 24-16, 2019 and July 30, 2019. The facility training year of July 1, 2018 - June 30, 2019 was reviewed for this inspection. The facility failed to document the completion of at least 25 annual training hours for employee records # 2, 3, 4, and 6. Employee # 2 was hired by the project on February 17, 2005 and was employed as a counselor until their promotion to the clinical supervisor position on July 22, 2019. The employee was required to complete at least 25 annual training hours for the reviewed training year. Documentation in the employee's personnel record indicated 3.5 annual training hours were completed for the reviewed training year. Employee # 3 was hired by the project on June 21, 2017 as a counselor. Documentation in the employee's record indicated that 17 annual training hours were completed for the reviewed training year. Employee # 4 was hired by the project on April 2, 2018 as a counselor. Documentation in the employee's record indicated that 7.5 annual training hours were completed for the reviewed training year. Employee # 6 was hired by the project on March 15, 2017 as a counselor. Documentation in the employee's record indicated that the employee did not complete any annual training hours for the reviewed training year. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected. The administrative assistant of the project has developed a spreadsheet of all employees to track agency compliance with training requirements. She posts announcements of training availability and registers staff for same. She updates the spreadsheet monthly and reviews this with her supervisor and reports to department supervisors for further action.
Personnel who are not meeting training requirements on schedule are reminded to register for upcoming trainings. Personnel who have completed trainings are instructed to submit documentation to the administrative assistant to be filed in personnel records.
In order to ensure that the deficiency does not reoccur, the administrative assistant is responsible to monitor the compliance of all staff with completing annual training requirements per number of hours needed.
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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
A licensing renewal inspection was conducted on July 24-26, 2019 and July 30, 2019. Based on a review of the the Staffing Requirements Facility Summary Report completed by the facility, during the licensing process, the facility failed to ensure that staff caseloads remain at or under 35:1. Based on the total number of hours per week devoted to clients, and the facility's standard work week of 40 hours, employees # 5 and 6 exceeded the allowable maximum 35:1 caseload.-As reported on the Staffing Requirements Facility Summary Report, the number of hours per week devoted by Employee # 5 to outpatient client treatment was 15 hours per week. The employee had 30 active clients as of July 24, 2019. -Employee # 5 (15/40 = .375 FTE *** 30 clients/.375 FTE = 80/1 caseload)-As reported on the Staffing Requirements Facility Summary Report, the number of hours per week devoted by Employee # 6 to outpatient client treatment was 40 hours per week. The employee had 42 active clients as of July 24, 2019. -Employee # 6 (40/40 = 1 FTE *** 42 clients/1 FTE = 42/1 caseload)These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected. According to DDAP Licensing Alert 01-14 of September 2014, "Some long-term active clients are receiving regular and predetermined direct counseling services but at a frequency of less than twice per month. These long-term active clients who are not receiving direct counseling services at least twice per month will not be included in the counselor caseload computations..."
The project will adhere to the above directive in that any client who is not receiving direct counseling services on a regular basis at least twice per month will not be included as a client on a counselor's caseload. The project will still consider the client to be active according to the licensing department's approved capacity, and include that same client on a listing of active clients at any given. However, the maximum caseload for a full-time equivalent/(FTE) counselor for counseling in the outpatient programs will not exceed 35 clients.
To ensure that the deficiency does not reoccur, the manager of the outpatient program will review attendance of each client at the end of every month. The assignment of new clients to each counselor will be made in accordance with the mandated ratio. Outpatient utilization will be reviewed monthly at Quality Assurance Committee meetings.
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
A physical plant inspection was conducted on July 30, 2019, at approximately 11:00 am. The following deficiencies were identified during this inspection: -A dumpster located near the kitchen area was found to be uncovered. -Two trash receptacles located in the main dining room were found to be uncovered. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected. All trash receptacles in the main dining room are now covered. Waste Management Services has moved the dumpster located near the kitchen area so that the cover can be closed.
It is the responsibility of Assistant Director of Operations to ensure that all trash, garbage and rubbish is stored in covered containers, and removed at least once every week. The facility contracts with Waste Management Services for weekly trash removal.
The Assistant Manager of Operations has developed a checklist for every area of buildings and grounds (exterior and interior) for monthly inspection. This includes inspection of trash disposal containers. The first quarterly facility inspection report (all buildings and grounds) of September 2019 has been submitted to the CEO by the Assistant Manager of Operations.
This corrective action plan will become part of facility's policy. The plan will consist of a seven-step process to ensure all maintenance issues are addressed in the following manner:
Step 1: Identify the problem
Step 2: Interim plan
Step 3: Identify the root cause
Step 4: Permanent action to be taken
Step 5: Verification
Step 6: Control
Step 7: Prevention
In order to ensure that the deficiency does not occur again, the Assistant Manager of Operations will conduct a quarterly inspection of all buildings and grounds and note any hazards, need for maintenance and repairs and/or replacement of furnishings and equipment. Inspections will be done the third week of September, December, March and June, commencing September 18, 2019. A report of this inspection will be filed with the Director of Operations and copied to the CEO. In turn, a status report of buildings and grounds will be included in the quarterly Quality Assurance report made to the Board of Directors. The next Quality Assurance meeting of the Board of Directors is scheduled for November 18, 2019.
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705.5 (a) (3) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(3) A storage area for clothing.
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Observations
A physical plant inspection was conducted on July 30, 2019, at approximately 11:00 am. Residential bedroom # 4, located on the 2nd floor, was for the use of two clients, but only had enough storage space for one client. A single wardrobe closet was the only storage area available in this bedroom. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected. All residential bedrooms have been inspected and each resident has use of a separate individual storage space designated for clothing. All current staff have been trained in the use of NetFacilities where identified issues are entered as they are encountered. The Assistant Manager of Operations has completed an inventory of all furnishings in each client bedroom which includes the condition and replacement date for each. The first quarterly inspection report of September 2019 has been submitted to the CEO by the Assistant Manager of Operations.
This corrective action plan will become part of facility's policy. The plan will consist of a seven-step process to ensure all maintenance issues are addressed in the following manner:
Step 1: Identify the problem
Step 2: Interim plan
Step 3: Identify the root cause
Step 4: Permanent action to be taken
Step 5: Verification
Step 6: Control
Step 7: Prevention
Example:
1. Identify the problem: Inadequate furnishings in residential rooms.
2. Interim plan: Discontinue use of room/bed until completely furnished.
3. Identify root cause: Furniture was in disrepair/discarded and not replaced.
4. Permanent Action: Need for repair or replacement furniture shall be entered into Netfacilities Preventive Maintenance profile to notify the Assistant Operations Manager on a monthly basis to have maintenance personnel inspect all residential bedrooms to ensure furnishings are in place and in good repair.
5. Verification: Verify over a three-month period that the permanent action plan has eliminated the problem (lack of adequate furnishings). If not, recommend and revise plan.
6. Control: To control future bedroom furniture inventory issues. The Assistant Operations Manager shall maintain, revise, and/or adjust all measures set forth in the maintenance corrective action plan to ensure all clients' bedrooms meet licensure standards for sleeping accommodations regarding furnishings.
7. Prevention: All new/employees shall be trained in Libertae's corrective action plan procedure, and in the use of our maintenance software Netfacilities. To ensure that all maintenance issues are addressed in a timely manner, the goal will be to address issues within 24 hours of discovery and/or notification of issue (depending on severity of issue).
In order to ensure that the deficiency does not occur again, the Assistant Manager of Operations will conduct a quarterly inspection of all buildings and grounds and note any hazards, need for maintenance and repairs and/or replacement of furnishings and equipment. Inspections will be done the third week of September, December, March and June, commencing September 18, 2019. A report of this inspection will be filed with the Director of Operations and copied to the CEO. In turn, a status report of buildings and grounds will be included in the quarterly Quality Assurance report made to the Board of Directors.
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
A physical plant inspection was conducted on July 30, 2019, at approximately 11:00 am. The following deficiencies were identified during this inspection: -In the shared bathroom for residential bedrooms # 18 and # 19, located on the 3rd floor, substantial mold growth was observed on caulking in the shower/tub. - In the shared bathroom for residential bedrooms # 20 and # 21, located on the 3rd floor, substantial mold growth was observed on caulking in the shower/tub. In addition, the entire shower/tub was observed to have a significant build-up of grime. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected. All residential bathtubs and showers cited have been caulked and new shower curtains are installed.
It is the responsibility of Treatment Techs to ensure that client bedrooms and bathrooms are cleaned and sanitary conditions are maintained to facility standards while occupied by clients. Once a room/bed is vacated, the Treatment Tech on duty will make an entry in NetFacilities so that bedrooms and bathrooms can be cleaned and inspected for repairs before new admissions move into that room. It is the responsibility of the maintenance crew to clean the bedrooms and bathrooms that are vacated the same day. All current staff have been trained in the use of NetFacilities where identified issues are entered as they are encountered. The Assistant Manager of Operations has developed a checklist for each client bedroom/bathroom for monthly inspection. The first quarterly facility inspection report (all buildings and grounds) of September 2019 has been submitted to the CEO by the Assistant Manager of Operations.
This corrective action plan will become part of facility's policy. The plan will consist of a seven-step process to ensure all maintenance issues are addressed in the following manner:
Step 1: Identify the problem
Step 2: Interim plan
Step 3: Identify the root cause
Step 4: Permanent action to be taken
Step 5: Verification
Step 6: Control
Step 7: Prevention
Example:
1. Identify the problem: Mold growing in residents' bathtubs/showers.
2. Interim plan: Discontinue use of bathroom until completely corrected.
3. Identify root cause: Poor ventilation in bathroom.
4. Permanent Action: Need for repair or replacement of caulk in bathrooms and/or shower curtains shall be entered into Netfacilities Preventive Maintenance profile to notify the Assistant Operations Manager on a monthly basis to have maintenance personnel inspect all residential bathrooms to ensure bathrooms are free of mold.
5. Verification: Verify over a three-month period that the permanent action plan has eliminated the problem (mold in showers). If not, recommend and revise plan.
6. Control: To control future mold issues in residents' bathtubs. The Assistant Operations Manager shall maintain, revise, and/or adjust all measures set forth in the maintenance corrective action plan to ensure all clients' bathrooms meet licensure standards for cleanliness and sanitary conditions.
7. Prevention: All new/employees shall be trained in Libertae's corrective action plan procedure, and in the use of our maintenance software Netfacilities. To ensure that all maintenance issues are addressed in a timely manner, the goal will be to address issues within 24 hours of discovery and/or notification of issue (depending on severity of issue).
In order to ensure that the deficiency does not occur again, the Assistant Manager of Operations will conduct a quarterly inspection of all buildings and grounds and note any hazards, need for maintenance and repairs and/or replacement of furnishings and equipment. Inspections will be done the third week of September, December, March and June, commencing September 18, 2019. A report of this inspection will be filed with the Director of Operations and copied to the CEO. In turn, a status report of buildings and grounds will be included in the quarterly Quality Assurance report made to the Board of Directors.
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705.7 (b) (4) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(4) Ensure that storage areas for foods are free of food particles, dust and dirt.
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Observations
A physical plant inspection was conducted on July 30, 2019, at approximately 11:00 am. The following deficiency was identified during this inspection: -The 2nd and 3rd floor residential laundry rooms contained a mini-refrigerator used to store food and drink items for clients and their children. The mini-refrigerators were observed to be in unsanitary condition, consisting of food and drink spillage, a foul odor, and substantial ice build-up in the freezers. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Libertae is committed to maintaining a safe, comfortable and homelike environment for its residents. Oversight of leaning and maintenance management is the responsibility of the Assistant Manager of Operations. A cleaning system and schedule has been developed, by zone, for all common areas of the facility. Cleaning and housekeeping is performed by both staff and a contracted janitorial service.
The deficiency has been corrected. The mini refrigerators located in the residential units for use by clients and their children are now cleaned on a schedule every Friday by the staff on duty at end of day shift. Any remaining food is disposed and the unit is wiped down. Thermometers have been installed in the mini refrigerators for temperature control to ensure that food does not spoil. A log has been attached to each mini refrigerator to be initialed by staff once the task is complete.
The Assistant Manager of Operations will review the correction and ensure that it is maintained on his weekly facility rounds. The plan will be updated or modified if needed.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility's fire drill record was reviewed on July 26, 2019, for the period of June 2018 - June 2019. The facility failed to record the time of the drill for a fire drill conducted on February 10, 2019. In addition, the facility failed to record the exit route used during a fire drill conducted on July 6, 2019. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
So that all employees, visitors, and clients of Libertae know what to do in the event of a fire, Libertae conducts fire drill practices according to an established schedule and maintains a record of the fire drill practices. It is the responsibility of the Director of Operations to oversee all Fire/Emergency Building Evacuation plans and procedures and to review them periodically to monitor the agency's performance regarding safety and emergency preparedness.
The deficiency has been corrected. Staff in-service training on fire drills was conducted at the regular departmental staff meeting to review all fire drill procedures and recordkeeping requirements. A routine check of the fire drill log indicates that for subsequent drills conducted, all information required, including a record of the time of the drills and the exit routes used, is complete.
The Director of Operations will report to the Quality Assurance Committee on a monthly basis the findings of all fire drill practices held. Any deficiencies discovered will be addressed by in-service training of staff. New staff are trained in facilitating fire drills upon hiring and orientation. Fire drill logs will be available for inspection.
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
The facility's fire drill record was reviewed on July 26, 2019, for the period of July 2018 - July 2019. The facility failed to conduct a fire drill during sleeping hours at least every 6 months. The facility's sleeping hours are from 11:00 pm to 6:00 am. For the reviewed time period, the facility documented one fire drill that was conducted during overnight hours. This fire drill was conducted on June 17, 2019, at 5:20 am. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
So that all employees, visitors, and clients of Libertae know what to do in the event of a fire, Libertae conducts unannounced fire drill practices according to a schedule only aware to the Director of Operations, who maintains a record of the fire drill practices. It is the responsibility of the Director of Operations to oversee all Fire/Emergency Building Evacuation plans and procedures and to review them periodically to monitor the agency's performance regarding safety and emergency preparedness.
The deficiency has been corrected. The fire drill protocol was reviewed. Unannounced fire drills will be held during sleeping hours in the upcoming quarters .
The Director of Operations will report to the Quality Assurance Committee on a monthly basis the findings of all fire drill practices held. Any deficiencies discovered will be addressed by in-service training of staff. New staff are trained in facilitating fire drills upon hiring and orientation. Fire drill logs will be available for inspection.
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709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
A licensing renewal inspection was conducted on July 24-26, 2019 and July 30, 2019. Based on a review of administrative records, the facility failed to make an annual report available to the public. This deficiency was confirmed by the project director. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An annual report will be made available to the public by November 15, 2019. It will include a disclosure of board governance, financial statement for end of fiscal year, IRS 990 statement, an impact statement and donor list. The report will be prepared by the CEO and published on the agency website. It will be available on Guidestar and a hardcopy will be furnished to the agency's contacts database.
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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
The project's administrative records were reviewed for the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. The project failed to ensure that the project director documented a timely signature on the written policy and procedures manual. The project director's signature was last documented on the comprehensive policy and procedures manual in April 2018. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected. The project director has updated and signed the written manual delineating project policies and procedures.
In order to ensure that the deficiency does not reoccur, it is the responsibility of the administrative assistant to set a calendar reminder for the annual review of the project's policies and procedures and required signature to be updated in the manual. |
709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
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Observations
The project's administrative records were reviewed for the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. Based on a review of the project's written policy and procedures manual, the facility failed to develop a complete policy concerning the utilization of volunteers. The written policy indicated that volunteers are utilized by the project, but it did not specify the capacity or areas in which volunteers serve the project. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected. The policy regarding the utilization of volunteers by the project has been revised to include language indicating that volunteers are utilized to help run projects, raise funds and organize events. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Six personnel records were reviewed for documentation of an annual written performance evaluation, during the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. The facility failed to provide documentation of an annual performance evaluation for employee records # 1, 2, 3, and 5. Employee # 1 was hired by the project on May 4, 2015 and is employed as both the project director and facility director. An annual performance evaluation was not documented in the employee's personnel record. Employee # 2 was hired by the project on February 17, 2005 and was employed as a counselor until their promotion to the clinical supervisor position on July 22, 2019. The most recent annual performance evaluation documented in the employee's personnel record dated December 11, 2017. Employee # 3 was hired by the project on June 21, 2017 as a counselor. The most recent annual performance evaluation documented in the employee's personnel record was dated October 24, 2017. Employee # 5 was hired by the project on September 14, 2016 as a counselor and was promoted to the clinical supervisor position on August 1, 2018. An annual performance evaluation was not documented in the employee's personnel record. These findings were reviewed with facility staff during the licensing process. This is a repeat citation. The facility was cited for non-compliance of this regulation during preceding licensing renewal inspections completed on July 12, 2017 and June 16, 2016.
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Plan of Correction
In order to correct the deficiency, the project shall implement procedures that establish an annual performance appraisal timeline as follows:
Purpose
This process serves to implement the project's annual performance review and evaluation process. For the purposes of this procedure, all employees who meet the eligibility requirements for the review cycle will be included.
Process
Week 1
The Administrative Assistant distributes to managers and supervisors with direct reports the list of employees eligible for review. Each eligible employee will receive performance review forms (or instructions on how to access performance reviews online) and timeline.
Weeks 1-2
Employees complete self-evaluations and forward them to supervisors.
Weeks 3-4
Managers complete their portion of employee evaluation forms. Managers must review ratings to ensure they are fair and consistent in their evaluations and forward to the department head for review.
Week 5
Each department head reviews evaluations. Any questions should be addressed with the manager prior to approval. Department heads then forward evaluations to Supervisor of Administrative Assistant for the final audit. Any ratings that are outside of normal project parameters shall be addressed in a department head report provided to Project Director with evaluations.
Weeks 6-7
Administrative Assistant reviews all submitted materials from department heads, conducts a gap analysis to ensure that all employees have been accounted for and reviews the distribution of performance ratings provided in the review process. Administrative Assistant requests supporting information for reviews that fall outside of normal project parameters when such reviews are not explained in the department heads' reports.
Weeks 8-9
Managers meet with employees to discuss performance reviews. Upon completion of the performance meeting, employee may add any additional comments to the performance evaluation. Employee and supervisor sign the evaluation form. A copy of the form is provided to the employee for his or her records and the original is sent to Administrative Assistant for filing.
Any performance evaluations with an overall rating below average will trigger a performance improvement plan (PIP). All PIPs must be in place within two weeks of the completion of the performance cycle.
This process will go into effect on November 1, 2019. It is the responsibility of the Project Director to review and monitor the process to ensure adherence to the policy and procedures. The corrective actions will be completed by January 1, 2020.
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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.
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Observations
Nine client records were reviewed for the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. The facility failed to obtain an informed and voluntary consent to release information for client record # 6. Client # 6 was admitted into inpatient treatment on April 30, 2019 and was still active in treatment. A consent to release information to the client's active treatment funding source was not documented in the client ' s record. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In order to correct this deficiency, the project will obtain a signed valid consent form from every client which authorizes disclosures to the client's active treatment funding source by name.
The facility is required to adhere to the Rule (Title 42 CFR Part 2 ? Confidentiality of Alcohol and Drug Abuse Patient Records). In order for the facility to disclose any information about a client, the client must authorize the disclosure by signing a valid consent form. The consent form must contain all of the following nine elements to be valid:
1. The name of the client.
2. The name of the program making the disclosure.
3. The recipient of the information (which should not be as general as an entire agency or department, but may describe the recipient's job title and/or job functions).
4. The purpose of the disclosure, which should be narrowly described and should correspond with the information to be released.
5. The information to be released, described as exactly and narrowly as possible.
6. That the client understand the consent maybe revoked at any time, orally or in writing.
7. The date or condition upon which the consent expires, if it has not been revoked earlier.
8. The date the consent form is signed.
9. The signature of the client.
A client should never sign or be requested to sign a consent form before all of the blanks have been filled in. Copies of all consent forms shall be kept in the client's file. Clients will be offered a copy of all consent forms and an acknowledgement of same will be on every consent form.
The Project Administrator will review the policy with all agency managers by October 4, 2019. Each month, Quality Assurance Committee will review a sampling of 50% of new admissions to verify and report any problems to the supervisors of responsible staff for correction. The effectiveness of these measures will be evaluated by the Quality Assurance Committee at each meeting and modified as necessary.
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709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Nine client records were reviewed for the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. The facility failed to obtain an informed and voluntary consent to release information that included the name of the person, agency, or organization to whom disclosure was to be made. This deficiency was identified in client records # 1, 2, 3, 4, 5, and 7. Client # 1 was admitted into inpatient treatment at another facility within the project on February 1, 2019 and was transferred into inpatient treatment at this facility on April 1, 2019. The client was still active in treatment. The client's record contained consent to release information forms, all signed by the client on February 19, 2019, that were designated for the following parties: an OB/GYN, an eye doctor, a primary care physician, and a dental provider. The project failed to specify the names, agencies, or organizations for these parties. Client # 2 was admitted into inpatient treatment on May 6, 2019 and was still active in treatment. The client's record contained a consent to release information form designated for an "infant, children, and youth" agency, signed by the client on May 15, 2019. The facility failed to clearly identify the associated agency. Client # 3 was admitted into inpatient treatment on June 5, 2019 and was still active in treatment. The client's record contained a consent to release information form designated for a "children and youth" agency, signed by the client on June 5, 2019. The facility failed to clearly identify the associated agency. Client # 4 was admitted into inpatient treatment on March 19, 2019 and was discharged on April 2, 2019. The client's record contained a consent to release information form designated for a "children and youth" agency, signed by the client on March 19, 2019. The facility failed to identify the associated agency. Client # 5 was admitted into inpatient treatment on November 2, 2018 and was discharged on April 10, 2019. The client's record contained consent to release information forms, all signed by the client on November 9, 2018, that were designated for the following parties: a primary care physician, a dental provider, and an OB/GYN office. The facility failed to specify the names, agencies, or organizations for these parties. Client # 7 was admitted into inpatient treatment on December 26, 2018 and was discharged on January 18, 2019. A consent to release information form documented in the client's record, signed by the client on December 26, 2018, only specified a county as the party to whom disclosure was to be made. Another consent to release information form, signed by the client on December 26, 2018, identified an individual by the first name only as the party to whom disclosure was to be made. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to correct this deficiency, the project will clearly identify the associated agency or department by name, to which an informed and voluntary consent to release information is authorized by a client.
The facility is required to adhere to the Rule (Title 42 CFR Part 2 ? Confidentiality of Alcohol and Drug Abuse Patient Records). In order for the facility to disclose any information about a client, the client must authorize the disclosure by signing a valid consent form. The consent form must contain all of the following nine elements to be valid:
1. The name of the client.
2. The name of the program making the disclosure.
3. The recipient of the information (which should not be as general as an entire agency or department, but may describe the recipient's job title and/or job functions).
4. The purpose of the disclosure, which should be narrowly described and should correspond with the information to be released.
5. The information to be released, described as exactly and narrowly as possible.
6. That the client understand the consent maybe revoked at any time, orally or in writing.
7. The date or condition upon which the consent expires, if it has not been revoked earlier.
8. The date the consent form is signed.
9. The signature of the client.
A client should never sign or be requested to sign a consent form before all of the blanks have been filled in. Copies of all consent forms shall be kept in the client's file. Clients will be offered a copy of all consent forms and an acknowledgement of same will be on every consent form.
The Project Administrator will review the policy with all agency managers by October 4, 2019. Each month, Quality Assurance Committee will review a sampling of 50% of new admissions to verify and report any problems to the supervisors of responsible staff for correction. The effectiveness of these measures will be evaluated by the Quality Assurance Committee at each meeting and modified as necessary.
This deficiency will be corrected by
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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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Nine client records were reviewed for the licensing renewal inspection conducted on July 24-26 and July 30, 2019. The facility failed to obtain an informed and voluntary consent to release information that clearly identified the specific information to be disclosed. This deficiency was identified in client record # 2. Client # 2 was admitted into inpatient treatment on May 6, 2019 and was still active in treatment. The client's record contained a signed consent to release information form for the disclosure of information to an individual. The specific information to be disclosed was only identified as "orientation". This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In order to correct this deficiency, for every informed and voluntary consent to release information, the information to be released will be described as exactly and narrowly as possible in light of the purpose of the release. Releases for "any and all pertinent information" will not be considered valid.
The facility is required to adhere to the Rule (Title 42 CFR Part 2 ? Confidentiality of Alcohol and Drug Abuse Patient Records). In order for the facility to disclose any information about a client, the client must authorize the disclosure by signing a valid consent form. The consent form must contain all of the following nine elements to be valid:
1. The name of the client.
2. The name of the program making the disclosure.
3. The recipient of the information (which should not be as general as an entire agency or department, but may describe the recipient's job title and/or job functions).
4. The purpose of the disclosure, which should be narrowly described and should correspond with the information to be released.
5. The information to be released, described as exactly and narrowly as possible.
6. That the client understand the consent maybe revoked at any time, orally or in writing.
7. The date or condition upon which the consent expires, if it has not been revoked earlier.
8. The date the consent form is signed.
9. The signature of the client.
A client should never sign or be requested to sign a consent form before all of the blanks have been filled in. Copies of all consent forms shall be kept in the client's file. Clients will be offered a copy of all consent forms and an acknowledgement of same will be on every consent form.
The Project Administrator will review the policy with all agency managers by October 4, 2019. Each month, Quality Assurance Committee will review a sampling of 50% of new admissions to verify and report any problems to the supervisors of responsible staff for correction. The effectiveness of these measures will be evaluated by the Quality Assurance Committee at each meeting and modified as necessary.
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709.28 (c) (3) 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 must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Nine client records were reviewed for the licensing renewal inspection conducted on July 24-26 and July 30, 2019. The facility failed to obtain an informed and voluntary consent to release information that specified the purpose of disclosure. This deficiency was identified in client record # 2. Client # 2 was admitted into inpatient treatment on May 6, 2019 and was still active in treatment. The client's record contained a signed consent to release information form for the disclosure of information to an individual. The purpose of disclosure was not specified on the consent form. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In order to correct the deficiency, the facility will ensure that every informed and voluntary consent to release information will specify the purpose of the disclosure. The purpose shall be narrowly described and shall correspond with the information to be released. The purpose shall never be as broad as "for all client care.:
The facility is required to adhere to the Rule (Title 42 CFR Part 2 ? Confidentiality of Alcohol and Drug Abuse Patient Records). In order for the facility to disclose any information about a client, the client must authorize the disclosure by signing a valid consent form. The consent form must contain all of the following nine elements to be valid:
1. The name of the client.
2. The name of the program making the disclosure.
3. The recipient of the information (which should not be as general as an entire agency or department, but may describe the recipient's job title and/or job functions).
4. The purpose of the disclosure, which should be narrowly described and should correspond with the information to be released.
5. The information to be released, described as exactly and narrowly as possible.
6. That the client understand the consent maybe revoked at any time, orally or in writing.
7. The date or condition upon which the consent expires, if it has not been revoked earlier.
8. The date the consent form is signed.
9. The signature of the client.
A client should never sign or be requested to sign a consent form before all of the blanks have been filled in. Copies of all consent forms shall be kept in the client's file. Clients will be offered a copy of all consent forms and an acknowledgement of same will be on every consent form.
The Project Administrator will review the policy with all agency managers by October 4, 2019. Each month, Quality Assurance Committee will review a sampling of 50% of new admissions to verify and report any problems to the supervisors of responsible staff for correction. The effectiveness of these measures will be evaluated by the Quality Assurance Committee at each meeting and modified as necessary.
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709.28 (c) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Nine client records were reviewed for the licensing renewal inspection conducted on July 24-26 and July 30, 2019. The facility failed to obtain an informed and voluntary consent to release information that included the dated signature of the client. This deficiency was identified in client records # 2 and 5. Client # 2 was admitted into inpatient treatment on May 6, 2019 and was still active in treatment. The client's record contained a consent to release information form for the disclosure of information to an individual. The signature of the client was not dated. Client # 5 was admitted into inpatient treatment on November 2, 2018 and was discharged on April 10, 2019. The client's record contained a consent to release information form for the disclosure of information to a personal contact, and also a consent to release information form for the disclosure of information to a laboratory. For both consent forms, the signature of the client was not dated. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to correct this deficiency, the project will ensure that the signature of the client is obtained on every consent to disclose, or the consent form will otherwise not be valid. A client shall never be requested to sign a consent form before all of the blanks have been filled in. If any changes are made to a consent form after a client signs it, the client shall initial the changes when they are made to indicate that the client understands and agrees to the changes.
The facility is required to adhere to the Rule (Title 42 CFR Part 2 ? Confidentiality of Alcohol and Drug Abuse Patient Records). In order for the facility to disclose any information about a client, the client must authorize the disclosure by signing a valid consent form. The consent form must contain all of the following nine elements to be valid:
1. The name of the client.
2. The name of the program making the disclosure.
3. The recipient of the information (which should not be as general as an entire agency or department, but may describe the recipient's job title and/or job functions).
4. The purpose of the disclosure, which should be narrowly described and should correspond with the information to be released.
5. The information to be released, described as exactly and narrowly as possible.
6. That the client understand the consent maybe revoked at any time, orally or in writing.
7. The date or condition upon which the consent expires, if it has not been revoked earlier.
8. The date the consent form is signed.
9. The signature of the client.
A client should never sign or be requested to sign a consent form before all of the blanks have been filled in. Copies of all consent forms shall be kept in the client's file. Clients will be offered a copy of all consent forms and an acknowledgement of same will be on every consent form.
The Project Administrator will review the policy with all agency managers by October 4, 2019. Each month, Quality Assurance Committee will review a sampling of 50% of new admissions to verify and report any problems to the supervisors of responsible staff for correction. The effectiveness of these measures will be evaluated by the Quality Assurance Committee at each meeting and modified as necessary.
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709.28 (c) (5) 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 must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
Nine client records were reviewed for the licensing renewal inspection conducted on July 24-26 and July 30, 2019. The facility failed to obtain an informed and voluntary consent to release information that included the dated signature of the witness. This deficiency was identified in client record # 2. Client # 2 was admitted into inpatient treatment on May 6, 2019 and was still active in treatment. The client's record contained a consent to release information form for the disclosure of information to an individual. The signature of the witness was not dated. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In order to correct this deficiency, the project will obtain the date the consent form is signed by a client at the time the client signs.
The facility is required to adhere to the Rule (Title 42 CFR Part 2 ? Confidentiality of Alcohol and Drug Abuse Patient Records). In order for the facility to disclose any information about a client, the client must authorize the disclosure by signing a valid consent form. The consent form must contain all of the following nine elements to be valid:
1. The name of the client.
2. The name of the program making the disclosure.
3. The recipient of the information (which should not be as general as an entire agency or department, but may describe the recipient's job title and/or job functions).
4. The purpose of the disclosure, which should be narrowly described and should correspond with the information to be released.
5. The information to be released, described as exactly and narrowly as possible.
6. That the client understand the consent maybe revoked at any time, orally or in writing.
7. The date or condition upon which the consent expires, if it has not been revoked earlier.
8. The date the consent form is signed.
9. The signature of the client.
A client should never sign or be requested to sign a consent form before all of the blanks have been filled in. Copies of all consent forms shall be kept in the client's file. Clients will be offered a copy of all consent forms and an acknowledgement of same will be on every consent form.
The Project Administrator will review the policy with all agency managers by October 4, 2019. Each month, Quality Assurance Committee will review a sampling of 50% of new admissions to verify and report any problems to the supervisors of responsible staff for correction. The effectiveness of these measures will be evaluated by the Quality Assurance Committee at each meeting and modified as necessary.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Nine client records were reviewed for the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. The facility failed to document verification that the client was offered a copy of an informed and voluntary consent to release information form. This deficiency was identified in client records # 1, 2, 3, 5, 6, and 9. Client # 1 was admitted into inpatient treatment at another facility within the project on February 1, 2019 and was transferred into inpatient treatment at this facility on April 1, 2019. The client was still active in treatment. For the following consent to release information forms documented in the client's record, there was no documentation that the client was offered a copy of the consent:- A consent to release information to a physican, signed and dated by the client on February 19, 2019. - A consent to release information to a 2nd physician, signed and dated by the client on February 19, 2019. - A consent to release information to a transportation service, signed and dated by the client on February 19, 2019. Client # 2 was admitted into inpatient treatment on May 6, 2019 and was still active in treatment. For the following consent to release information forms documented in the client's record, there was no documentation that the client was offered a copy of the consent:- A consent to release information to a county probation office, signed and dated by the client on June 27, 2019. - A consent to release information to a government agency, signed and dated by the client on May 6, 2019. - A consent to release information to a personal contact; signed by the client, but not dated. Client # 3 was admitted into inpatient treatment on June 5, 2019 and was still active in treatment. The client's record contained a consent to release information for a government agency, signed and dated by the client on June 5, 2019. There was no documentation that the client was offered a copy of the consent. Client # 5 was admitted into inpatient treatment on November 2, 2018 and was discharged on April 10, 2019. For the following consent to release information forms documented in the client's record, there was no documentation that the client was offered a copy of the consent:- A consent to release information to a managed care organization, signed and dated by the client on November 2, 2018. - A consent to release information to a pharmacy, signed and dated by the client on November 2, 2018. - A consent to release information to a personal contact; unsigned by the client, but signed and dated by the witness on November 2, 2018. - A consent to release information to a 2nd personal contact, signed and dated by the client on January 10, 2019. Client # 6 was admitted into inpatient treatment on April 30, 2019 and was still active in treatment. For the following consent to release information forms documented in the client's record, there was no documentation that the client was offered a copy of the consent:- A consent to release information to an attorney, signed and dated by the client on May 1, 2019. - A consent to release information to a representative of a county court, signed and dated by the client on May 13, 2019. Client # 9 was admitted into outpatient treatment on September 20, 2018 and was discharged on January 24, 2019. For the following consent to release information forms documented in the client's record, there was no documentation that the client was offered a copy of the consent: - A consent to release information to a relative, signed and dated by the client on September 20, 2018. - A consent to release information to a managed care organization, signed and dated by the client on September 20, 2018. - A consent to release information to a laboratory, signed and dated by the client on September 20, 2018. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to correct this deficiency, the project has modified consent forms to include an acknowledgement that each client has been offered a copy of the informed and voluntary consent to release information form. This form will then be documented in the client's record.
The facility is required to adhere to the Rule (Title 42 CFR Part 2 ? Confidentiality of Alcohol and Drug Abuse Patient Records). In order for the facility to disclose any information about a client, the client must authorize the disclosure by signing a valid consent form. The consent form must contain all of the following nine elements to be valid:
1. The name of the client.
2. The name of the program making the disclosure.
3. The recipient of the information (which should not be as general as an entire agency or department, but may describe the recipient's job title and/or job functions).
4. The purpose of the disclosure, which should be narrowly described and should correspond with the information to be released.
5. The information to be released, described as exactly and narrowly as possible.
6. That the client understand the consent maybe revoked at any time, orally or in writing.
7. The date or condition upon which the consent expires, if it has not been revoked earlier.
8. The date the consent form is signed.
9. The signature of the client.
A client should never sign or be requested to sign a consent form before all of the blanks have been filled in. Copies of all consent forms shall be kept in the client's file. Clients will be offered a copy of all consent forms and an acknowledgement of same will be on every consent form.
The Project Administrator will review the policy with all agency managers by October 4, 2019. Each month, Quality Assurance Committee will review a sampling of 50% of new admissions to verify and report any problems to the supervisors of responsible staff for correction. The effectiveness of these measures will be evaluated by the Quality Assurance Committee at each meeting and modified as necessary.
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709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
A licensing renewal inspection was conducted on July 24-26, 2019 and July 30, 2019. The facility utilizes an electronic record keeping system for the management of client records. The electronic records software program used for the management of outpatient client records did not allow for the efficient retrieval of data. Outpatient client records were reviewed on July 26, 2019. The software program crashed numerous times, preventing an adequate review of client records. For example, between 10:30 am and 12:35 pm, the occurrence of multiple software crashes only allowed for one client record to be reviewed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected. The program experienced a power outage and maintenance to all technology was performed upon restoration. The electronic health record undergoes frequent upgrades and maintenance, too.
The electronic health record employed by the project alls for fifteen minute inactivity timeouts. While there are no HIPAA standards for reference, a CMS publication entitled Security Acceptable Risk Safeguards, recommends this time frame.
The electronic health record employed by the project is used in multiple locations, some of those being high activity areas. It is not possible for the provider to set varying timeouts by location.
In order to correct this deficiency, the program shall reset the inactivity timeout to 30 minutes so that record retrieval is efficient. The system shall be tested in advance of a record review to determine in advance that there are no issues.
Additionally, records may be printed in advance of a review in order to eliminate the reoccurrence of the deficiency. |
709.32 (c) (2) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
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Observations
An inspection of the project's medication storage areas was conducted on July 30, 2019. In the nursing office, a refrigerator actively utilized for the storage of Vivitrol was found to also contain employee food items. The facility failed to ensure that Vivitrol was stored separately from food, in accordance with Federal guidelines.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected. Food items have been removed from the refrigerator where medications are stored.
According to the project's policies and procedures all client medications which are centrally stored by the facility are kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medications. Any medication which requires refrigeration shall not be stored in a refrigerator with any food or lab specimens.
In order to audit compliance with this policy a Medication Room Audit form will be completed each quarter by designated staff. The results of the audit shall be reviewed by the program director. Any areas of non-compliance shall be promptly addressed to ensure that the staff is in compliance.
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709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
The project ' s policy and procedures manual was reviewed for the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. The facility failed to develop a complete unusual incidents policy that addressed procedures for responding to all incidents of physical assault or sexual assault by a staff member or a client. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected. A policy and procedure has been developed for the reporting of unusual incidents and staff was educated on the policy and procedures by the Assistant Manager of Operations on September 30, 2019 at a staff in-service meeting.
The project shall file a written unusual incident report with the Department of Licensing within 3 business days following an unusual incident involving a physical or sexual assault by staff or a client. The report shall be completed by the Project Director or her designee and faxed or emailed to the Accountability and Program Improvement Division of the Department of Licensing.
In order to correct this deficiency, the Director of Operations will monitor the facility incident log of the project and alert the Project Director of the need for reporting compliance. A review of facility incidents and concomitant mandated reports shall be a part of Quality Assurance Committee meetings.
The findings will b used to conduct a review of systems and internal process to determine the root cause of the incident and determine if it was caused by unusual, isolated circumstances or a common deficiency that shall be remedied by a revision in policies and procedures. If changes in the system are to occur, plans for development and implementation of a new system will be the responsibility of the project director who will develop the policies and procedures. The program's supervisors will be responsible to in-service and re-educate staff on the new policies and procedures. In the event of an unusual incident that results in policy and procedure changes, this will be put into place within 30 days of the event.
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709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
The project ' s policy and procedure manual was reviewed for the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. The facility failed to develop a complete unusual incidents policy that addressed procedures for the implementation of a timely and appropriate corrective action plan. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The project shall file a written unusual incident report with the Department of Licensing within 3 business days following an unusual incident involving a physical or sexual assault by staff or a client. The report shall be completed by the Project Director or her designee and faxed or emailed to the Accountability and Program Improvement Division of the Department of Licensing.
In order to correct this deficiency, the Director of Operations will monitor the facility incident log of the project and alert the Project Director of the need for reporting compliance. A review of facility incidents and concomitant mandated reports shall be a part of Quality Assurance Committee meetings.
A corrective action plan will be developed whenever there are findings that indicate a deficiency that shall be remedied by a change in the project's practices. A specific action plan to implement which identifies who, what, when and how improvements will be made will be formulated by the management of the project. If changes in the system are to occur, plans for development and implementation of a new system will be the responsibility of the project director who will develop the corrective action plan and communicate it to the program's supervisors who will, in turn, be responsible to in-service and re-educate staff on the new practices.
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709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
The project ' s policy and procedure manual was reviewed for the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. The facility failed to develop a complete unusual incidents policy that addressed procedures implemented for the ongoing monitoring of a corrective action plan. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected. The facility has developed and implemented an updated policy and procedure according to the Licensing Alert 02-2018 "Reporting of Unusual Incidents". The policy has been distributed to all staff and ongoing monitoring of the corrective action plan will occur at the monthly Quality Assurance Committee meetings where the facility incident log will be cross-checked with the submission of incident reports as mandated. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The project ' s incident reporting log was reviewed for the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. The project failed to report to the department events at the facility that required the presence of fire personnel on October 27, 2018 and December 12, 2018. The facility also failed to report to the department events requiring the presence of ambulance personnel. The project director was interviewed about the use of ambulance personnel to transport clients to healthcare facilities, particularly for incidents involving pregnant clients requiring emergency medical treatment. The project director confirmed that events at the facility requiring the presence of ambulance personnel have not been reported to the department. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project shall file a written unusual incident report with the Department of Licensing within 3 business days following any event at the facility that required the presence of fire personnel, ambulance to transport clients to healthcare facilities. The report shall be completed by the Project Director or her designee and faxed or emailed to the Accountability and Program Improvement Division of the Department of Licensing.
In order to correct this deficiency, the Director of Operations will monitor the facility incident log of the project and alert the Project Director of the need for reporting compliance. A review of facility incidents and concomitant mandated reports shall be a part of Quality Assurance Committee meetings. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Six inpatient client records were reviewed for the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. The facility failed to document physical examination results for client records # 1, 2, 3, 4, 5, and 6. Client # 1 was initially admitted into inpatient treatment at another facility within the project on February 1, 2019 and was then transferred into inpatient treatment at this facility on April 1, 2019. The client was still active in treatment. Client # 2 was admitted into inpatient treatment on May 6, 2019 and was still active in treatment. Client # 3 was admitted into inpatient treatment on June 5, 2019 and was still active in treatment. Client # 4 was admitted into inpatient treatment on March 19, 2019 and was discharged on April 2, 2019. Client # 5 was admitted into inpatient treatment on November 2, 2018 and was discharged on April 10, 2019. Client # 6 was admitted into inpatient treatment on April 30, 2019 and was still active in treatment. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the responsibility of the Manager of Admissions to obtain all medical documentation either prior to or upon admission to determine whether or not a physical exam has been completed within the last 30 days. If documentation of an exam is received by the Manager of Admissions before or upon admission, then the Manager of Admissions will file the documented physical examination in the client's record at intake. If the exam has not been completed, documentation of same will be recorded in the chart. In this case, the Manager of Admissions will report to the Case Manager who is responsible for scheduling all medical appointments that the client will need an appointment at a local primary care provider for a physical exam within seven days of admission. Receipt of the documentation of this physical examination is the responsibility of the Case Manager who then is to file same in the client's record. Alternatively, the Case Manager will determine if the client can be seen by the consulting physician to Libertae on a timelier basis for a medication management appointment at the facility, whereby a physical exam will be conducted at this time and recorded in the client's record by the consulting physician.
The Director of Clinical Services, Registered Nurse and Manager of Admissions will participate in monthly Quality Assurance meetings where a report of chart reviews conducted by each member of the committee will be on the agenda, to include completeness of all documentation of physical examinations for clients admitted within the past 30 days. This will ensure that the deficiency will not recur.
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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:
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Observations
Six inpatient client records were reviewed for the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. The facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client within an acceptable timeframe. This deficiency was identified in client records # 2, 3, 5, and 6. Client # 2 was admitted into inpatient treatment on May 6, 2019 and was still active in treatment. Documentation in the client's electronic record indicated that the master treatment plan was initially generated for the client's record on May 29, 2019, as indicated by a date stamp. A second date stamp indicated that the treatment plan was later updated on July 18, 2019. The facility was unable to confirm when the treatment plan was finalized, as the dated signature of the counselor who developed the plan was not documented. The facility also failed to document that the treatment plan was developed with the client. Client # 3 was admitted into inpatient treatment on June 5, 2019 and was still active in treatment. Documentation in the client's electronic record indicated that the master treatment plan was initially generated for the client's record on July 1, 2019, as indicated by a date stamp. A second date stamp indicated that the treatment plan was later updated on July 24, 2019. The facility was unable to confirm when the treatment plan was finalized, as the dated signature of the counselor who developed the plan was not documented. The facility also failed to document that the treatment plan was developed with the client. Client # 5 was admitted into inpatient treatment on November 2, 2018 and was discharged on April 10, 2019. Documentation in the client's electronic record indicated that the master treatment plan was initially generated for the client's record on December 5, 2018, as indicated by a date stamp. A second date stamp indicated that the treatment plan was later updated on April 15, 2019. The facility was unable to confirm when the treatment plan was finalized. The facility also failed to document that the treatment plan was developed with the client. Client # 6 was admitted into inpatient treatment on April 30, 2019 and was still active in treatment. Documentation in the client's record indicated that the master treatment plan was initially generated for the client's record on May 21, 2019, as indicated by a date stamp. A second date stamp indicated that the treatment plan was later updated on July 15, 2019. The client electronically signed the treatment plan on June 10, 2019. The counselor who developed the treatment plan electronically signed the document on July 15, 2019. The facility was unable to confirm when the treatment plan was finalized. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The treatment provider shall begin to formulate a preliminary treatment and rehabilitation plan upon intake and assessment. At this time a history is taken and psychosocial evaluation is provided. Documentation of the finalized individual treatment and rehabilitation plan that has been developed in collaboration with the client is to be included in the client record. The treatment plan shall be signed and dated by the individual rendering services. It shall also be documented that the treatment plan was developed with the client.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records. The Clinical Director will review the policy with all agency treatment providers by October 15, 2019. Client records will be reviewed at regularly scheduled supervision meetings with a supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records. Adherence to the requirements regarding client records will be verified and any problems will be reported by the Director of Clinical Services for corrective action.
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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.
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Observations
Six inpatient client records were reviewed for the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. The facility failed to document the provision of a treatment plan update at least every 30 days for client records # 1 and 5. Client # 1 was admitted into inpatient treatment at another facility within the project on February 1, 2019 and was transferred into inpatient treatment at this facility on April 1, 2019. The client was still active in treatment. The most recent treatment plan update documented in the client's record was completed on May 30, 2019. A subsequent treatment plan update was due to be completed by June 29, 2019, and one was not found in the client's record. Client # 5 was admitted into inpatient treatment on November 2, 2018 and was discharged on April 10, 2019. Documentation in the client's electronic record indicated that treatment plan updates were initially generated for client's record on January 11, 2019, February 15, 2019, and March 25, 2019, as indicated by date stamps. Each treatment plan update was marked with a second date stamp that indicated they were later updated on May 1, 2019. The facility was unable to confirm when the treatment plan updates were finalized, as the dated signature of the counselor who developed the plans was not documented. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment and rehabilitation plans shall be reviewed and updated at least every thirty days. The treatment plan update shall include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.
Treatment plan updates shall be signed and dated by the primary counselor and countersigned and dated by the supervisory counselor.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records. The Clinical Director will review the policy with all agency treatment providers by October 15, 2019. Client records will be reviewed at regularly scheduled supervision meetings with a supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records. Adherence to the requirements regarding client records will be verified and any problems will be reported by the Director of Clinical Services for corrective action.
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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.
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Observations
Six inpatient client records were reviewed for the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. The facility failed to assure that counseling services were provided in accordance to individual treatment and rehabilitation plans. This deficiency was identified in client records # 1, 2, 3, and 5. Client # 1 was admitted into inpatient treatment at another facility within the project on February 1, 2019 and was transferred into inpatient treatment at this facility on April 1, 2019. The client was still active in treatment. Documentation on the client's treatment plans indicated that the client was to receive individual counseling as least once weekly, and also group counseling at least once weekly. As of the date of the inspection, the most recent individual counseling session provided to the client was conducted on May 31, 2019. In addition, the most recent group counseling session attended by the client was conducted on July 2, 2019. Client # 2 was admitted into inpatient treatment on May 6, 2019 and was still active in treatment. Documentation on the client's treatment plans indicated that the client was to receive individual counseling at least once weekly. Individual counseling sessions were not provided to the client during the following weeks: - Week of June 9, 2019- Week of June 16, 2019- Week of June 23, 2019- Week of July 7, 2019Client # 3 was admitted into inpatient treatment on June 5, 2019 and was still active in treatment. Documentation on the client's treatment plan indicated that the client was to receive individual counseling at least once weekly. As of the date of the inspection, the most recent individual counseling session provided to the client was conducted on June 21, 2019. Client # 5 was admitted into inpatient treatment on November 2, 2018 and was discharged on April 10, 2019. Documentation on the client's treatment plans indicated that the client was to receive individual counseling as least once weekly. During the month of December 2018, one individual counseling session was provided to the client. This counseling session was conducted on December 31, 2018. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project shall maintain a complete client record on an individual in treatment which includes a record of services provided. In order to ensure that counseling services are provided in accordance with an individual treatment and rehabilitation plan, a record of service will be provided weekly to the Director of Clinical Services. Any gaps in services will be addressed in case conference meetings held each week and in individual supervision meetings with counselors providing treatment services. The root cause of any failure to provide services will be identified and corrected where needed. To further ensure that a client is compliant with her individual treatment plan, the client will be issued a weekly schedule of attendance at groups and individual sessions. The group facilitators will check off the client's attendance and the client will turn the attendance in to her respective counselor.
This corrective action will be implemented by the Director of Clinical Services by October 15, 2019. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Six inpatient client records were reviewed for the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. For client records # 3 and 5, the facility failed to ensure that their progress notes included the following elements: - Data that is to include information presented by the client during the counseling session, counselor observations, and information about the client from other sources. - An assessment based upon both new and previous information, to include the counselor's analysis of the client's current situation. - A plan that should indicate the direction of treatment,and include action steps, counselor plans, and client assignments or tasks. Client # 3 was admitted into inpatient treatment on June 5, 2019 and was still active in treatment. Progress notes documented in the client's record indicated that individual counseling sessions were provided to the client on the following dates: June 5, 2019, June 11, 2019, July 2, 2019, and July 19, 2019. The progress notes did not include data, an assessment, and a plan, as required. Client # 5 was admitted into inpatient treatment on November 2, 2018 and was discharged on April 10, 2019. A progress note documented in the client's record indicated that an individual counseling session was provided to the client on March 22, 2019. The progress note did not include the data, an assessment, and a plan, as required. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
There shall be a progress note after each significant client contact which shall be dated and signed by the individual making the entry. Progress notes shall include data, assessment and plans relative to treatment.
The data shall include information presented by the client during the counseling session, counselor observations and information about the client from other sources.
The assessment is the interpretative statement(s) based upon both new and previous information and includes the counselor's analysis of and conclusions regarding the client's current situation or status.
The plan, or strategies, shall reflect the counselor's actions to be taken in light of the evaluation and indicate the direction of treatment and include action steps, counselor plan(s) and client assignments or tasks.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records. The Clinical Director will review the policy with all agency treatment providers by October 15, 2019. Client records will be reviewed at regularly scheduled supervision meetings with a supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records. Adherence to the requirements regarding client records will be verified and any problems will be reported by the Director of Clinical Services for corrective action.
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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.
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Observations
Six inpatient client records were reviewed for the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. The facility failed to document an aftercare plan for client record # 5. Client # 5 was admitted into inpatient treatment on November 2, 2018 and was discharged on April 10, 2019. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The client record shall contain an aftercare plan, if applicable. The aftercare plan shall be developed for the client to follow after she leaves formal treatment. It is the client's individual plan for the future, including an identification of the client's personal goals and objectives. It shall focus on sustaining and building on the progress achieved during treatment and shall have input from all significant persons, especially the client.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records.
The Clinical Director will review the policy with all agency treatment providers by October 15, 2019. Client records will be reviewed at regularly scheduled supervision meetings with a supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records. Adherence to the requirements regarding client records will be verified and any problems will be reported by the Director of Clinical Services for corrective action.
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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
Six inpatient client records were reviewed for the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. The facility failed to document a discharge summary for client record # 5. Client # 5 was admitted into inpatient treatment on November 2, 2018 and was discharged on April 10, 2019. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Within a week after discharge, the treatment provider shall enter into the client's record a discharge summary describing the reasons for treatment, services offered, response to treatment and client's status or condition upon discharge.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records. The Clinical Director will review the policy with all agency treatment providers by October 15, 2019. Client records will be reviewed at regularly scheduled supervision meetings with a supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records. Adherence to the requirements regarding client records will be verified and any problems will be reported by the Director of Clinical Services for corrective action. |
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
Six inpatient client records were reviewed for the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. The facility failed to document follow-up information for client record # 5. Per the facility's policy and procedure follow-ups are to be conducted within 7 days of the client's discharge date.Client # 5 was admitted into inpatient treatment on November 2, 2018 and was discharged on April 10, 2019. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The client record shall contain follow-up information. When a client has been discharged the project shall, with the written consent of the client and within one week from the day the the client has discharged, attempt to contact the client to determine her disposition one week post-discharge. Once the attempt has been made and documented, the project shall consider its obligation to the individual fulfilled.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records. The Clinical Director will review the policy with all agency treatment providers by October 15, 2019. Client records will be reviewed at regularly scheduled supervision meetings with a supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records. Adherence to the requirements regarding client records will be verified and any problems will be reported by the Director of Clinical Services for corrective action.
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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
Three outpatient client records were reviewed for the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. The facility failed to document a complete medical history, to be collected during the intake process, for client record # 8. Client # 8 was admitted into outpatient treatment on February 19, 2019 and was still active in treatment. The client's medical history was not documented in their record. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Intake and admissions procedures shall include documentation of a medical history taken, to include the client's personal medical history, family medical history and history of illness and symptoms.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records. The Clinical Director will review the policy with all agency treatment providers by October 15, 2019. Client records will be reviewed at regularly scheduled supervision meetings with a supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records. Adherence to the requirements regarding client records will be verified and any problems will be reported by the Director of Clinical Services for corrective action.
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709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Three outpatient client records were reviewed for the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. The facility failed to document a complete drug and/or alcohol history, to be collected during the intake process, for client records # 7, 8, 9. Client # 7 was admitted into outpatient treatment on December 26, 2018 and was discharged on January 18, 2019. The facility failed to document a drug and alcohol history that included the client ' s complete substance abuse treatment history. Client # 8 was admitted into outpatient treatment on February 19, 2019 and was still active in treatment. The facility failed to document the client ' s drug and/or alcohol history. Client # 9 was admitted into outpatient treatment on September 20, 2018 and was discharged on January 24, 2019. The facility failed to document the client ' s drug and/or alcohol history. These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Intake and admissions procedures shall include documentation of a drug or alcohol history, or both. This history shall document the substances most frequently abused, the length and patterns of use, prior treatment episodes. It shall also note the client's perception of their effect on her social, physical and mental state. Whenever relevant, the substance abuse history within the family, or that of significant others shall be noted.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records. The Clinical Director will review the policy with all agency treatment providers by October 15, 2019. Client records will be reviewed at regularly scheduled supervision meetings with a supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records. Adherence to the requirements regarding client records will be verified and any problems will be reported by the Director of Clinical Services for corrective action.
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Three outpatient client records were reviewed for the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. The facility failed to document the client ' s personal history, to be collected during the intake process, for client record # 9. Client # 9 was admitted into outpatient treatment on September 20, 2018 and was discharged on January 24, 2019. A personal history was not documented in the client ' s record. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Intake and admissions procedures shall include documentation of a client's personal history. Historical and pertinent personal data shall include family, legal, employment/vocational, educational, military, recreational, sexual and others where appropriate.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records. The Clinical Director will review the policy with all agency treatment providers by October 15, 2019. Client records will be reviewed at regularly scheduled supervision meetings with a supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records. Adherence to the requirements regarding client records will be verified and any problems will be reported by the Director of Clinical Services for corrective action.
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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
Three outpatient client records were reviewed for the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. The facility failed to document a complete psychosocial evaluation that provided a composite picture of the client, in relation to historical information collected from the client. This deficiency was identified in client records # 7, 8, and 9. Client # 7 was admitted into outpatient treatment on December 26, 2018 and was discharged on January 18, 2019. Client # 8 was admitted into outpatient treatment on February 19, 2019 and was still active in treatment. Client # 9 was admitted into outpatient treatment on September 20, 2018 and was discharged on January 24, 2019. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Intake and admissions procedures shall include a psychosocial evaluation. The evaluation shall provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records. The Clinical Director will review the policy with all agency treatment providers by October 15, 2019. Client records will be reviewed at regularly scheduled supervision meetings with a supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records. Adherence to the requirements regarding client records will be verified and any problems will be reported by the Director of Clinical Services for corrective action.
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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
Three outpatient client records were reviewed for the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. The facility failed to document a preliminary treatment plan for client records # 7, 8, and 9. Client # 7 was admitted into outpatient treatment on December 26, 2018 and was discharged on January 18, 2019. Client # 8 was admitted into outpatient treatment on February 19, 2019 and was still active in treatment. Client # 9 was admitted into outpatient treatment on September 20, 2018 and was discharged on January 24, 2019. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Intake and admissions procedures shall include a preliminary treatment and rehabilitation plan. The preliminary treatment and rehabilitation plan shall be based upon information derived from the initial interview, psychosocial and other evaluations. This plan should also identify critical client concerns and strategies for their resolution.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records. The Clinical Director will review the policy with all agency treatment providers by October 15, 2019. Client records will be reviewed at regularly scheduled supervision meetings with a supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records. Adherence to the requirements regarding client records will be verified and any problems will be reported by the Director of Clinical Services for corrective action. |
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
Three outpatient client records were reviewed for the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. The facility failed to document a timely individual and rehabilitation treatment plan for client records # 8 and 9. Client # 8 was admitted into outpatient treatment on February 19, 2019 and was still active in treatment. The individual treatment and rehabilitation treatment plan documented in the client's record was completed on July 1, 2019. Client # 9 was admitted into outpatient treatment on September 20, 2018 and was discharged on January 24, 2019. The individual treatment and rehabilitation treatment plan documented in the client's record was completed on November 8, 2018. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The treatment provider shall begin to formulate a preliminary treatment and rehabilitation plan upon intake and assessment. At this time a history is taken and psychosocial evaluation is provided. Documentation of the finalized individual treatment and rehabilitation plan that has been developed in collaboration with the client is to be included in the client record. The treatment plan shall be signed and dated by the individual rendering services. It shall also be documented that the treatment plan was developed with the client.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records.
The Clinical Director will review the policy with all agency treatment providers by October 15, 2019. Client records will be reviewed at regularly scheduled supervision meetings with a supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records. Adherence to the requirements regarding client records will be verified and any problems will be reported by the Director of Clinical Services for corrective action. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Three outpatient client records were reviewed for the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. The facility failed to specify the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan. This deficiency was identified in client record # 8. Client # 8 was admitted into outpatient treatment on February 19, 2019 and was still active in treatment. The master treatment plan documented in the client's record, completed on July 1, 2019, did not specify the type and frequency of counseling therapy. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An individual treatment and rehabilitation plan shall be developed with the client. This plan shall include, but not be limited to type and frequency of treatment and rehabilitation services.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records. The Clinical Director will review the policy with all agency treatment providers by October 15, 2019. Client records will be reviewed at regularly scheduled supervision meetings with a supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records. Adherence to the requirements regarding client records will be verified and any problems will be reported by the Director of Clinical Services for corrective action.
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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
Three outpatient client records were reviewed for the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. The facility failed to document a treatment plan update at least every 60 days for client record # 9. Client # 9 was admitted into outpatient treatment on September 20, 2018 and was discharged on January 24, 2019. An individual treatment and rehabilitation plan was completed for the client on November 8, 2018. A treatment plan update was due to be completed for the client by January 7, 2019, and one was not documented in the client's record. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment and rehabilitation plans shall be reviewed and updated at least every sixty days. The treatment plan update shall include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.
Treatment plan updates shall be signed and dated by the primary counselor and countersigned and dated by the supervisory counselor.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records. The Clinical Director will review the policy with all agency treatment providers by October 15, 2019. Client records will be reviewed at regularly scheduled supervision meetings with a supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records. Adherence to the requirements regarding client records will be verified and any problems will be reported by the Director of Clinical Services for corrective action.
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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
Three outpatient client records were reviewed for the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. The facility failed to document a case consultation for client record # 8. Client # 8 was admitted into outpatient treatment on February 19, 2019 and was still active in treatment. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Each client's progress shall be reviewed at least quarterly, and more frequently if needed, at a case conference attended by a multidisciplinary team. Documentation of the case consultation shall be noted in the client's record by the counselor rendering treatment services.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records. The Clinical Director will review the policy with all agency treatment providers by October 15, 2019. Client records will be reviewed at regularly scheduled supervision meetings with a supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records. Adherence to the requirements regarding client records will be verified and any problems will be reported by the Director of Clinical Services for corrective action.
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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
Three outpatient client records were reviewed for the licensing renewal inspection conducted on July 24-26, 2019 and July 30, 2019. The facility failed to document a discharge summary for client records # 7 and 9. Client # 7 was admitted into outpatient treatment on December 26, 2018 and was discharged on January 18, 2019. Client # 9 was admitted into outpatient treatment on September 20, 2018 and was discharged on January 24, 2019. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Within a week after discharge, the treatment provider shall enter into the client's record a discharge summary describing the reasons for treatment, services offered, response to treatment and client's status or condition upon discharge.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records. The Clinical Director will review the policy with all agency treatment providers by October 15, 2019. Client records will be reviewed at regularly scheduled supervision meetings with a supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records. Adherence to the requirements regarding client records will be verified and any problems will be reported by the Director of Clinical Services for corrective action.
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