INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 15-16.2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Open Door was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
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Plan of Correction
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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on the review of personnel records, the facility failed to document performance evaluations per policy, in three of seven personnel records.
The findings include:
Seven personnel records were reviewed on April 15-16, 2013. Per agency policy, performance evaluations are to be completed at 30 and 90 days and then annually by June 30. Performance evaluations were not documented per policy in personnel records # 5, 6 and 7.
Employee # 5 was hired on November 20, 2012. The performance evaluation which was to completed by December 20, 2012 was completed on January 14, 2013.
Employee # 6 was hired on April 18, 2012. The performance evaluation which was to completed by May 18, 2012 was not documented.
Employee # 7 was hired in May 1998. The performance evaluation which was to completed by May 2012 was completed on July 18, 2012.
The Project/Facility Director was interviewed on April 16, 2013 and confirmed the findings.
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Plan of Correction
Annual evaluations will be completed by the Clinical Supervisor on or before June 30th of each year. Additionally, 30-day and 90-day evaluations for new staff and 180-day reviews for counselor assistants will be completed by the Clinical Supervisor on or before respective due dates. Should the employee not meet with the Clinical Supervisor on or before this date each year to review and sign her/his annual performance evaluation, the rationale will be documented and signed by both the Clinical Supervisor and the employee and placed in the employee's personnel file. This will go into effect immediately and be first evidenced by June 30, 2013. |
709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a complete discharge summary that included the services offered and/or the client's response to treatment in four of six client records.
The findings include:
Ten client records were reviewed on April 15-16, 2013. Six client records were reviewed for discharge summaries. The discharge summaries did not document the services offered and/or the client's response to treatment in client records # 7, 8, 9 and 10.
Client # 7 was admitted on May 12, 2012 and discharged on October 15, 2012. The discharge summary, completed on October 15, 2012, did not document the services offered nor the client's response to treatment.
Client # 8 was admitted on November 28, 2012 and discharged on February 28, 2013. The discharge summary, completed on February 28, 2013 did not document the services offered to the client.
Client # 9 was admitted on March 9, 2012 and discharged on July 23, 2012. The discharge summary, completed on July 23, 2012, did not document the services offered nor the client's response to treatment.
Client # 10 was admitted on April 24, 2012 and discharged on July 25, 2012. The discharge summary, completed on July 25, 2012, did not document the services offered nor the client's response to treatment.
The Project/Facility Director was interviewed on April 16, 2013 and did not dispute the findings.
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Plan of Correction
The Clinical Supervisor will review with all clinicians Licensure Regulations and agency policies regarding full completion of discharge summaries including clear and comprehensive descriptions of services offered and client response to treatment or rational for lack of documentation of each of these items will take place during the department meeting scheduled for April 29, 2013.
Review of Licensure Regulations and agency policies regarding full completion of discharge summaries including clear and comprehensive descriptions of services offered and client response to treatment or rationale for lack of documentation of each of these items will take place during individual supervision times scheduled with the Clinical Supervisor as appropriate with specific staff members by May 10, 2013.
Chart audits specifically monitoring for the full completion of discharge summaries in accordance with Regulations and agency policies will begin effective immediately. Complete Date: April 25, 2013.
Chart audits, review of agency policy with the whole department and addressing the full completion of discharge summaries in accordance with Regulations and agency policies within individually scheduled supervisions as needed, will occur on an ongoing basis. Complete Date: Ongoing.
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