INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 29, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Penn Presbyterian Medical Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
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Plan of Correction
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705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
The findings include:
The personnel record of one newly hired staff member was reviewed on July 29, 2011 for documentation of training to perform assigned tasks during emergencies. The facility did not document that this training was provided upon employment in personnel record # 3.
Personnel # 3 was hired on 4/25/11, but verification of this training was not documented until 5/10/11.
This was reviewed with the facility director on July 29, 2011, and the findings were not disputed.
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Plan of Correction
Immediate Action Taken:
An analysis of the orientation program for new hires was completed by the nurse manager of the unit. The Univeristy of Penn Health System (UPHS) orientation program did include emergency training for personnel #3. The training however, did not include documentation of training to perform assigned tasks during emergencies within the required 7 day timeframe.
Plan to Sustain Compliance:
All new employees will be trained regarding their assigned tasks during emergencies within their first 7 days of employment. A unit specific checklist was designed to capture this documentation.
Performance Improvement:
Compliance with this Fire Safety and Emergency Training will be reported to the Behavioral Health Clinical Effectiveness and Quality Improvement committee for the remainder of the calendar year to assure sustained compliance. |
711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document follow-up information in three of three records.
The findings include:
On July 29, 2011, follow-up information was reviewed in three client records, specifically records # 6, 7 and 8. The facility did not document follow-up information in client records # 6, 7 and 8.
Client # 6 was discharged on 5/16/11, but the client ' s record did not contain follow-up information.
Client # 7 was discharged on 5/24/11, but the client ' s record did not contain follow-up information.
Client # 8 was discharged on 4/24/11, but the client ' s record did not contain follow-up information.
This was reviewed with the facility director on July 29, 2011, and the findings were not disputed.
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Plan of Correction
Immediate Action Taken:
A review of client records #6, #7 and #8 indicated the charts had follow-up documented however this was not within the 30 day time frame per unit policy. The nurse manager reviewed the charts with the clinical supervisor to reinformce the program standard which must be met.
Plan to Sustain compliance:
Education on the policy, finding, and requirement related to follow-up documentation was conducted at the team meetings with clinicians. The clinical supervisor will be responsible for ensuring that follow-up information is documented in the chart as per policy with feedback to staff.
Performance Improvement:
A random audit will be conducted by the clinical supervisor to review chart documentation related to follow-up information. The supervisor will audit 15 records a month until 3 consecutive months of compliance can be sustained at 100%, beginning September 2011. |