INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 9, 2012 through April 11, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cove Forge Behavior Health System at Williamsburg 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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709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) 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:
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Observations
Based upon a review of the facility's Policy and Procedures Manual and Administrative documentation, the facility failed to make an annual report available to the public upon completion of the 2010 fiscal year ending December 31, 2010.The findings include:The Policy & Procedures Manual and Administrative documentation were reviewed as part of an Administrative Review conducted from April 2 - 5, 2012. Per the Policy & Procedures Manual, the fiscal year runs from January 1st to December 31st. Administrative documentation presented to Licensing Staff included two proofs of publication dated October 19, 2011 and October 20, 2011 showing that the annual report was available: however, the report was not made available until nearly 10 months following the end of the fiscal year. The findings were reviewed with the Project Director during the exit interview.
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Plan of Correction
709.22(e) LICENSURE
Governing Body:
709.22. Governing body. (e) 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:
Plan of Corretction: On April 27, 2012 the Project Director and the Quality Management Director revised the Governing Body policy which includes the time frame for completion of the annual report. On May 21, 2012 the Governing Body approved the policy revisions which state that the annual report will be made available to the general public upon completion of the financial audit for that calendar year. CRC's fiscal year is a calendar year and runs from January 1 through December 31. CRC Corporate offices will complete the 10-K and will file it with the SEC upon completion of the calendar year. The Executive Director will create the annual report after the 10-K is filed. The Governing Body will approve the annual report upon its completion. Upon approval the public will be made aware it is available for review. The Executive Director is responsible for assuring that the Annual Report is completed within the designated time frame. The Quality Management Director will monitor this process via communication with the Executive Director in weekly conference calls as well as through weekly Division conference calls. The Quality Management Director has distributed the aforementioned policy change to all administrators and key staff.
Corrective Action Date is June 30, 2012.
6/20/12-Resubmitting per Gary |
709.26(e)(2) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(2) The employe's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
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Observations
Based upon a review of the facility's Policy and Procedures Manual, the project failed to develop a policy regarding an employee's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.The findings include:The Policy & Procedures Manual was reviewed as part of an Administrative Review conducted from April 2 - 5, 2012. As per the General Work Rules section of the Policy & Procedures Manual, the following documentation was contained in a subsection titled, Employee Personnel Files: "You may inspect your personnel file in the presence of Human Resources or the site Facility Director. You may request copies from your file of any documents that you have previously signed. If you desire, you may add a written statement to your file explaining any disputed item."As developed, the policy failed to inform employees of their right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from their record.The findings were reviewed during the exit interview conducted with the Quality / Training Manager and Project Director.
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Plan of Correction
709.26(e)(2) LICENSURE
Personnel Management:
709.26. Personnel management. (e) The project director shall develop written policies on employee rights and demonstrate the project's efforts toward informing staff of the following: (2) The employee's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
Plan of Correction:
The Human Resource Senior Business Partner will add an addendum to the employee handbook which states an employee may indicate, in writing, that he/she wishes to have a disputed item removed from his/her Human Resource File. The revised Employee Handbook will be delivered to current employees no later than June 30, 2012. In the interim, new employees will receive a statement in their new hire packets indicating one's right to dispute, in writing, information they deem inaccurate within their Human Resource file.
6/20/12-Resubmitting per Gary |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based upon a review of client records, the facility failed to ensure that verbal medication orders were signed by the prescribing physician within 24 hours.The findings include:Seven detox client records, requiring the prescribing physician's signature on verbal medication orders, were reviewed on April 11, 2012. Three of seven records, specifically #'s 5, 6, and 7 failed to include the physician's signature on verbal orders within 24 hours.Client # 5, was admitted on November 29, 2011, and discharged on December 5, 2011. Record # 5 contained documentation of five pages of verbal orders that were received on November 29, 2011, at 23:15 hours. However, the verbal orders were not signed by the prescribing physician until December 1, 2011, between 10:30 - 10:40 hours.Client # 6, was admitted on February 14, 2012, and discharged on February 19, 2012..Record # 5 contained documentation of five pages of verbal orders that were received on February 14, 2012, at 21:00 hours. However, the verbal orders were not signed by the prescribing physician until February 16, 2012, between 13:40 and 14:30 hours.Client # 7, was admitted on February 2, 2012, and discharged on February 7, 2012.Record # 5 contained documentation of five pages of verbal orders that were received on February 2, 2012, at 21:00 hours. However, the verbal orders were not signed by the prescribing physician until February 5, 2012, between 13:45 and 13:50 hours.The findings were for Client # 7 were confirmed by the Director of Nursing. The findings for Client #'s 5 and 6 were not disputed during the exit interview.
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Plan of Correction
709.32(b) LICENSURE
Medication Control:
709.32. Medication control. (b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
Plan of Correction:
Verbal medication orders are accepted and put into writing and signed 24 hours thereafter by the prescribing physician.
The Assistant Administrator will be responsible for informing the physician of the deficiency noted. This will be done verbally and in writing by 6/1/12.
Nursing Coordinator will re-educate the nurses via email and at nurses meeting about flagging all verbal orders and reminding the physicians to sign them. This will be completed by 6/1/12.
Random auditing of the patient records to monitor for compliance will occur monthly by the Nursing Coordinator/Designee.
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709.32(c)(1) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication.
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Observations
Based upon a review of the facility's Policy and Procedures Manual, the facility's policy on the administration of medication failed to address limitations of individuals authorized to administer medications. The findings include:The Policy & Procedures Manual was reviewed as part of an Administrative Review conducted from April 2 - 5, 2012. The project's policy regarding the administration of medication states: "In the PA Department of Health D&A licensed facilities staff authorized to perform medication administration are licensed medical staff, licensed nursing staff, and consulting pharmacists."In Pennsylvania, pharmacists are permitted to administer medications but only under limited circumstances; however, the policy fails to delineate those limited circumstances. As of the time of inspection, the consulting pharmacists were not limited in their administration of medication. The findings were reviewed with the Project Director during the exit interview.
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Plan of Correction
709.32(c)(1) LICENSURE
Medication Control:
709.32. Medication control. (c) The project shall have a written policy regarding all medications used by clients which shall include, but not be limited to: (1) Administration of medication.
Plan of Correction:
On April 27, 2012 the Project Director approved the Medication Labeling, Preparation, Administration and Documentation policy revisions. The consulting pharmacist has been removed from the list of designated staff that can administer medications.
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705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based upon the physical plant inspection, the facility failed to maintain all structures on the grounds of the facility so as to be free from any danger to health and safety.The findings include:The physical plant inspection for Discovery House, a two story male residence, was conducted on April 9, 2012, at approximately 11:15am. A section of the rear roof of Discovery house, to the left side of the second floor exit, was in disrepair and posed a potential safety and health danger. Licensing Staff observed the following:1) several roof rafters had rotten ends2) a section of rain gutter was partially attached and the end was turned to the side3) a piece of insulation was exposed4) a section of roof shingles starting at the bottom edge of the roof, and a minimum of 10 feet long and 2 feet wide, were buckledThe physical plant inspection for Hope House, a two story male residence, was conducted on April 10, 2012, at approximately 3:00pm. At the rear of Hope House is a wooden landing and staircase that are part of the exit from the second floor. Upon inspecting the landing area and the steps that lead down to the ground, Licensing Staff observed that a section of the 2nd tread was no longer attached and was laying on another section of the staircase. The missing tread presented a danger to anyone utilizing the staircase.The findings were reviewed and confirmed during the exit interview with the Facility Director.
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Plan of Correction
705.2 (1) LICENSURE
Building exterior and grounds.:
705.2. Building exterior and grounds. The residential facility shall: (1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
Plan of Correction:
On 04/12/12 an architect came to inspect Discovery House to assure the building was safe for occupancy.
On 04/24/12 the rafters were repaired, gutter was replaced, sheeting was replaced, all the soffit and fascia was replaced, and the whole house was shingled with new shingling. A complete roof restoration was done.
On 04/25/12 pictures as well as a copy of the letter from the Architect was sent to the licensing surveyor.
All work was performed under the supervision of the Facility Director.
Maintenance staff will conduct monthly regular routine building inspections and all inspection findings will be reported directly to the Facility Director. The Facility Director will then inspect and take the findings to the Risk & Safety Officer and the Regional Director for approval to fix the problem and to follow whatever other course of action may be deemed necessary for the safety and wellbeing of clients, staff and visitors.
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based upon the physical plant inspection, the facility failed to ventilate toilet and wash rooms by exhaust fan or window.The findings include:The physical plant inspection was conducted on April 9, 2012, at approximately 11:15am. The bathroom located within the nurses station in Detox B did not contain an exhaust fan or a window.The findings were confirmed by the Maintenance Supervisor during the physical plant inspection.
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Plan of Correction
705.6 (5) LICENSURE
Bathrooms:
705.6. Bathrooms. The residential facility shall: (5) Ventilate toilet and wash rooms by exhaust fan or window.
Plan of Correction:
On 4/09/12 an exhaust fan was installed in the bathroom located within the nurse's station in Detox B by the maintenance staff and was inspected by the licensing surveyor on 4/10/12.
The work was performed under the supervision of the Facility Director.
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705.7 (b) (5) 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:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based upon the physical plant inspection and a review of documentation contained on temperature logs, the facility failed to keep frozen food at or below 0F.The findings include:The physical plant inspection was conducted on April 9, 2012, at approximately 11:15am. Licensing Staff noted that the walk-in freezer located outside the rear exit of the kitchen registered 10F at the time of inspection. The walk-in freezer's temperature was checked again on April 11, 2012, at approximately 10:30am. The temperature at that time was10F.Temperatures logs for the walk-in freezer, for the months of January 2012 to March 2012, were also reviewed on April 11, 2012. The following documentation was included on the logs: Temperatures ranged from +2 to + 10 degrees Fahrenheit for 31 of 31 days, from January 1, 2012, to January 31, 2012. Temperatures ranged from +6 to + 10 degrees Fahrenheit for 29 of 29 days, from February 1, 2012, to February 29, 2012.Temperatures ranged from +6 to + 10 degrees Fahrenheit for 31 of 31 days, from March 1, 2012, to March 31, 2012.The findings were confirmed during the exit interview conducted with the Facility Director.
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Plan of Correction
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: (5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
Plan of Correction:
On 04/13/12, Cove Forge Maintenance staff checked the freezer. They removed the built up ice from the compressor. It did not resolve the problem. On 5/01/12, The plumbing/heating/air conditioner contractor found that the low pressure control was out of calibration. It was recalibrated. The temperature will continue to be monitored by dietary staff on a daily basis to make sure the temperature stays in proper range.
The Dietary supervisor will be responsible for notifying
maintenance staff immediately if the temperature is not correct.
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705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based upon the physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.The findings include:The physical plant inspection for Hope House, a two story male residence, was conducted on April 10, 2012, at approximately 3:00pm. The secondary exit from the first floor of Hope House is located through a group room, on the right side of the house. When Licensing Staff checked the exit, the exit was locked and could not be opened until the lock was disengaged. In addition, a male resident was inside Hope House during the inspection and would not have been able to use the secondary exit until it was unlocked. The Adult Program Director confirmed that the secondary exit from the first floor of Hope House was locked.
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Plan of Correction
705.10 (a) (1) (i) LICENSURE
Fire safety.:
705.10. Fire safety. (a) Exits. (1) The residential facility shall: (i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
Plan of Correction:
A new push bar was installed on the secondary exit door of Hope House under the supervision of the Facility Director.
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705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
Based upon the physical plant inspection, the facility failed to maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.The findings include:The physical plant inspection for Knepp House was conducted on April 9, 2012, at approximately 11:15 AM. Knepp House, a two story building for male residents, had an exit on the left side of the building that opened up to an exterior wooden landing and staircase which exceeded two steps and 18 inches in height. The handrail that extended from the building to a corner post was no longer secured and there were exposed nails at the end of the handrail. The physical plant inspection for Hope House was conducted on April 10, 2012, at approximately 3:00pm. Hope House, a two story building for male residents, had an exit on the left side of the building that opened up to a fully enclosed sets of steps that extended approximately two-thirds of the way to the ground and then discharged to a free standing, exterior set of steps that exceeded two steps and 18 inches in height. The remaining section of steps did not have a handrail on the right side.The left side of the front porch of Hope House was elevated and had a drop that ranged from approximately 18 inches in the middle to over 32 inches on the left end. However, there was no railing present for any portion of the left side of the porch as is required.The findings were reviewed with the Facility Director during the exit interview.
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Plan of Correction
705.10 (a) (1) (iii) LICENSURE
Fire safety.:
705.10. Fire safety. (a) Exits. (1) The residential facility shall: (iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
Plan of Correction:
The hand rail at Knepp House was repaired by maintenance staff and was inspected by the licensing surveyor on 4/10/12.
On 4/26/12, the handrails and landing at the exterior door exiting the left side of Hope House were totally replaced and an additional hand rail was added on the right side, and new steps were built.
Banisters and railing will be added to the front porch of Hope House where the porch is elevated and has a drop of over 18 inches in the middle to over 32 inches on the left end. This project will be completed by 05/31/12.
These physical plant repairs will be completed under the supervision of the Facility Director.
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705.10 (b) (1) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(1) Maintain a minimum of one operable, automatic smoke detector on each floor, including the basement and attic.
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Observations
Based upon the physical plant inspection, the facility failed to maintain a minimum of one operable smoke detector in the basement.The findings include:The physical plant inspection for Hope House was conducted on April 10, 2012, at approximately 3:00pm. Hope House is a two story male residence that has a basement. While inspecting the basement area the Licensing Specialist was unable to locate a smoke detector.The Maintenance Supervisor confirmed that there was no smoke detector in the basement of Hope House.
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Plan of Correction
705.10 (b) (1) LICENSURE
Fire safety.:
705.10. Fire safety. (b) Smoke detectors and fire alarms. The residential facility shall: (1) Maintain a minimum of one operable, automatic smoke detector on each floor, including the basement and attic.
Plan of Correction:
A smoke detector was installed in the basement of Hope House under the supervision of the Facility Director.
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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
Based upon a review of client schedules and fire drill logs, the facility failed to provide documentation to demonstrate it conducted a fire drill during sleeping hours at least every 6 months.The findings include:Client schedules were reviewed on April 10, 2012. As per the schedules, sleeping hours for the residents begin at 11:00 PM each night and end at 5:30 AM each morning. Fire drill logs for the months of April 2011 to March 2012, were reviewed on April 10, 2012. Fire drills were conducted on the following dates and at the corresponding times:March 12, 2012 at 5:10 PM August 26, 2011 at 1:10 PM February 16, 2012 at 9:00 AM August 14, 2011 at 5:15 AM January 10, 2012 at 9:15 AM July 23, 2011 at 7:30 AM December 20, 2011 at 4:00 PM June 9, 2011 at 7:00 PMNovember 17, 2011 at 9:00 AM May 10, 2011 at 4:10 PM October 11, 2011 at 2:00 PM April 10, 2011 at 3:00 PMSeptember 21, 2011 at 8:38 PM The only documentation of a fire drill being conducted during sleeping hours was from August 14, 2011. The Maintenance Department was unable to provide documentation of any other fire drill conducted during sleeping hours from January 2011 to December 2011. The findings were confirmed by the Maintenance Supervisor.
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Plan of Correction
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.
Plan of Correction:
The Facility Director will create a quarterly calendar which will be reviewed monthly by the Health Risk and Safety committee to ensure that overnight drills are being conducted between the hours of 11:00pm to 5:00am every six months. The first fire drill conducted during sleeping hours will take place by 6/1/12 under the supervision of the Facility Director.
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709.82(a) LICENSURE Treatment and rehabilitation services
709.82. 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
Based on the review of partial hospitalization client records, the facility failed to document treatment plans that were individualized.The findings include:Four partial hospitalization client records requiring documentation of an individualized treatment and rehabilitation plan were reviewed on April 11, 2012. The facility failed to individualize the treatment plans in three out of four partial hospitalization records, specifically client records # 2P, 3P, and 4PClient #2P was admitted on March 31, 2012. The treatment plan was completed on March 31, 2012. Client #3P was admitted on December 8, 2011 and discharged on December 29, 2011. The treatment plan was completed on December 8, 2011. Client #4P was admitted on February 1, 2012 and discharged on February 27, 2012. The treatment plan was completed on February 3, 2012. The treatment plans in partial hospitalization client records #2P, 3P, and 4P were identical with the exception of the clients' names. The findings were reviewed with the clinical supervisor and facility director prior to the exit interview.
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Plan of Correction
709.82(a) LICENSURE
Treatment and rehabilitation services:
709.82. Treatment and rehabilitation services. (a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
Observations:
Based on the review of partial hospitalization client records, the facility failed to document treatment plans that were individualized.
Plan of Correction:
Assistant Program Director met with the partial hospitalization counselors and reviewed with them that the facility failed to individualize treatment and rehabilitation plans with clients.
The meeting occurred on April 12, 2012.
Discussion focused on the importance of individualizing the treatment plan for partial hospitalization clients.
Staff were also reminded of the time lines for completing a treatment plan.
Chart audits will be conducted monthly on at least 10 charts for the next 7 months.
The audits will be completed either by the Assistant Program Director or Director.
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709.83(a)(9) LICENSURE Client records
709.83. 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) Progress notes.
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Observations
Based on the review of partial hospitalization client records, the facility failed to document individualized progress notes.The findings include:Four partial hospitalization records were reviewed on April 11, 2012 for documentation of progress notes. The facility failed to individualized progress notes in four out of four partial hospitalization records reviewed, specifically client records # 1P, 2P, 3P, and 4PThe findings include: Client #1P, admitted on March 8, 2012 and client #2P, admitted on March 31, 2012 had nearly identical group progress notes documented on April 2, 2012. The only variation in the notes was the clients' names. Client #1P, admitted on March 8, 2012 and client #2P, admitted on March 31, 2012 had nearly identical individual progress notes documented on April 6, 2012. The only variation in the notes was the clients' names. Client #1P, admitted on March 8, 2012 and client #2P, admitted on March 31, 2012 had nearly identical group progress notes documented on April 9, 2012. The only variation in the notes was the clients' names. Client #3P was admitted on December 8, 2011 and discharged on December 29, 2011. The progress notes for individual sessions held for client #3P on December 16, 2011 and December 26, 2012 were nearly identical. The only variation being the client's name was documented where previously the word "patient" was used.Client #4P was admitted on February 1, 2012 and discharged on February 27, 2012. The progress notes for individual sessions held for client #4P on February 7, 2012 and February 17, 2012 were nearly identical. The only variation was a single sentence in the "DATA" portion of the February 17, 2012 progress note. The findings were reviewed with the clinical supervisor and facility director prior to the exit interview.
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Plan of Correction
709.83(a)(9) LICENSURE
Client records:
709.83. 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) Progress notes.
Plan of Correction:
On April 12, 2012, the Assistant Program Director reviewed with the partial hospitalization counselors that the facility failed to document individualized progress notes.
Discussion focused on the importance of individualizing progress notes.
Chart audits will be completed on a monthly basis on at least 10 charts for the next 7 months.
Review will be completed by the Assistant Program Director or Director.
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709.83(a)(10) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(10) Discharge summary.
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Observations
Based on the review of partial hospitalization client records, the facility failed to document discharge summaries upon a client's discharge.The findings include:Two partial hospitalization records requiring documentation of discharge summaries were reviewed on April 11, 2012. The facility failed to document discharge summaries upon the clients' discharge in two out of two partial hospitalization client records, specifically client records # 3P and 4PClient #3P was admitted on December 8, 2011 and discharged on December 29, 2011. The discharge summary for client #3P was documented on February 22, 2012. Client #4P was admitted on February 1, 2012 and discharged on February 27, 2012. The discharge summary for client #4P was undated and unsigned by the counselor. The findings were reviewed with the clinical supervisor and facility director prior to the exit interview.
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Plan of Correction
709.83(a)(10) LICENSURE
Client records:
709.83. 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.
Observations:
Based on the review of partial hospitalization client records, the facility failed to document discharge summaries upon a client's discharge.
Plan of Correction:
On April 12, 2012 the Asst. Program Director met with the partial hospitalization counselors and reviewed the findings that the facility failed to document discharge summaries upon the client's discharge.
Focus was on the timeliness and quality of the discharge summaries.
Monthly audits will be conducted with a minimum of 10 charts by the Asst. Program Director for the next 7 months.
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709.83(a)(11) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(11) Follow-up information.
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Observations
Based on the review of partial hospitalization client records and the facility's policies and procedures, the facility failed to document follow-ups in accordance with the facility's policies and procedures.The findings include:The facility's policy regarding follow-ups states: If a referral is made, with the client's consent, the provider is contacted within 7 business days following the patient's scheduled aftercare appointment.If no referral is made (including AMA clients), a contact call will be attempted within 30 business days after discharge.Two partial hospitalization records were reviewed on April 11, 2012 for documentation of follow-ups. The facility failed to document follow-ups according to the facility's policy in one out of two partial hospitalization client records, specifically client record # 4P.Client #4P was admitted on February 1, 2012, discharged on February 27, 2012 and referred to another facility. As of the date of inspection, there was no follow-up documented for client #4PThe findings were confirmed with the clinical supervisor and facility director during the exit interview.
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Plan of Correction
709.83(a)(11) LICENSURE
Client records:
709.83. 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.
Plan of Correction:
On 05/14/12, the Assistant Program Director will be meeting with the Case Management department and will discuss the findings.
Focus will be on the timeliness and the purpose of the Follow Up form and documentation in accordance with the facility's policies and procedures.
Monthly audits will be conducted on a minimum of 10 clients for the next 7 months.
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709.62(c)(v) LICENSURE Physical Examination
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(5) Physical examination.
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Observations
Based upon a review of the facility's Policy & Procedures Manual and client records, the facility failed to provide documentation that physical examinations were completed or reviewed, by a physician, within 24 hours of admission.The findings include:The Policy & Procedures Manual was reviewed as part of an Administrative Review conducted from April 2 - 5, 2012. As per the Policy & Procedures Manual, physical examinations are to be completed within 24 hours of admission. Seven records requiring documentation of physical exams were reviewed from April 10 - 11, 2012. Three of seven records, specifically record #'s 2, 5, and 7 contained physical examination forms that were either not signed, or signed late, by the physician.Client # 2 was admitted on April 5, 2012, and discharged on April 10, 2012. Record # 2 contained a physical examination form that was completed and signed by a Physician's Assistant on April 6, 2012. However, at the time of inspection the physical examination contained in record # 2 was not signed by the supervising physician.Client # 5 was admitted on November 29, 2011, and discharged on December 5, 2011. Record # 5 contained a physical examination form that was completed and signed by a Physician's Assistant on November 30, 2011. However, the physical examination contained in record # 5 was not signed by the supervising physician until December 12, 2011, after the client was discharged from the unit.Client # 7 was admitted on February 2, 2012, and discharged on February 7, 2012. Record # 2 contained a physical examination form that was completed and signed by a Physician's Assistant on February 3, 2012. However, the physical examination contained in record # 7 was not signed by the supervising physician until March 5, 2012, after the client was discharged from the unit.The findings were reviewed with the Facility Director during the exit interview.
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Plan of Correction
709.62(c)(5) LICENSURE
Physical Examination:
709.62. Intake and admission. (c) Intake procedures shall include documentation of the following: (5) Physical examination.
Plan of Correction:
The Assistant Administrator will be responsible for informing the physicians and physician assistants that documentation of physical examinations must be completed or reviewed by a physician within 24 hours of admission. This will be done verbally and in writing by 6/1/12.
The Nursing Coordinator will re-educate the physician assistants and nurses to make sure that the physical examination is flagged for the physician to sign. This will be completed by 6/1/12.
Detox Staff will complete daily audits for three months on 100% of the detox charts to make sure the physical examinations are properly flagged for the physician and presented and given to the physician for signature.
The Nursing Coordinator is responsible for ensuring that the daily audits occur.
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709.63(a)(6) LICENSURE Aftercare plan
709.63. 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:
(6) Aftercare plans, if applicable.
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Observations
Based upon the review of the facility's Policy and Procedures Manual and client records, the facility failed to ensure that aftercare plans were completed as applicable.The findings include:The Policy & Procedures Manuals were reviewed as part of an Administrative Review conducted from April 2 - 5, 2012. As per the Policy & Procedures Manual, aftercare plans are to be completed "prior to discharge" and the only times when aftercare plans are not required are when clients:leave treatment Against Medical Advice, are administratively discharged, referred to another facility for further treatment, or refuse to participate in a Continuing Care PlanThree records requiring documentation of aftercare plans were reviewed on April 10, 2012. Two of three records reviewed, specifically record #'s 6D and 7D, did not contain an aftercare plan as required. Client # 6D was admitted on February 14, 2012, and was successfully discharged on February 19, 2012. The facility failed to document an aftercare plan in client #6D's record.Client # 7D was admitted on February 2, 2012, and was successfully discharge on February 7, 2012. The facility failed to document an aftercare plan in client #7D's record.The findings were reviewed with the Facility Director during the exit interview.
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Plan of Correction
709.63(a)(6) LICENSURE
Aftercare plan:
709.63. 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: (6) Aftercare plans, if applicable
Plan of Correction:
The Nursing Coordinator will re-educate the detox counselors on the aftercare plans making sure they are completed right away for clients not transferring to rehab. This will be done verbally and in writing by 06/1/12.
The Nursing Coordinator will re-educate the nurses on making sure that the aftercare plans are completed "prior to discharge" and that the client receives the copy of the aftercare plan and that the original stays in the client chart. This will be done verbally and in writing by 06/01/12.
The Adult Program Director reviewed the findings with the counseling department.
The focus was reviewing aftercare plan procedure and stressing the importance of completing the aftercare form with the clients when appropriate.
This occurred on April 12th, 2012.
Monthly chart audits will be conducted by either the Asst. Program Director or Director.
Minimum of 10 charts for the next 7 months.
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709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
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Observations
Based upon a review of client records, the facility failed to ensure that discharge summaries were completed upon a client's discharge.The findings include:Three records requiring documentation of discharge summaries were reviewed on April 10, 2012. Three of three records reviewed, specifically record #'s 5D, 6D, and 7D, contained Discharge Summaries that was completed late.Client # 5D was admitted on November 29, 2011, and discharged on December 5, 2011. Record # 5D contained two discharge summaries: one was signed and dated by the clinician on January 30, 2012, and the second was signed and dated on February 14, 2012.Client # 6D was admitted on February 14, 2012, and discharged on February 19, 2012. Record # 6D contained a discharge summary that was signed and dated by the clinician on April 10, 2012.Client # 7D was admitted on February 2, 2012, and discharged on February 7, 2012. Record # 7D contained a discharge summary that was signed and dated by the clinician on February 24, 2012.The findings were reviewed with the Facility Director during the exit interview.
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Plan of Correction
709.63(a)(7) LICENSURE
Discharge summary:
709.63. 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: (7) Discharge summary. Cove Fore failed to ensure that discharge summaries were completed.
Plan of Correction:
The Nursing Coordinator will re-educate the detox counselors on completing discharge summaries on all clients within seven days. This will be done in writing and verbally by 06/01/12.
Medical Records staff will conduct ongoing monitoring of discharge summaries and report to the Nursing Coordinator when detox counselors are not turning them in in a timely manner. Communication to occur between the Medical Records Coordinator and Nursing Coordinator.
On April 12th, the Program Director reviewed the findings with the counselors.
The focus was the timeliness of completing discharge summaries.
The Assistant Program Director/Program Director will complete chart audits with a focus on discharge summaries A minimum of 10 charts will be monitored monthly for the next 7 months.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of inpatient client records and the facility's policies and procedures, the facility failed to document biopsychosocial evaluations in accordance to the facility's policies and procedures.The findings include:In reference to biopsychosocial evaluations, the facility's policy states: Biopsychosocial evaluations are to be completed within 72 hours of client's admission into treatment.Ten inpatient client records were reviewed on April 9, 2012 for documentation of biopsychosocial evaluations. The facility failed to document biopsychosocial evaluations within 72 hours of admission in six out of ten inpatient client records, specifically client records # 2R, 3R, 6R, 7R, 8R, and 10R.Client #2R was admitted on March 24, 2012. The biopsychosocial evaluation was completed on March 30, 2012 for client #2R. Client #3R was admitted on March 27, 2012. The biopsychosocial evaluation was completed on April 1, 2012 for client #3R. Client #6R was admitted on March 25, 2012. The biopsychosocial evaluation was completed on March 30, 2012 for client #6R. Client #7R was admitted on January 4, 2012 and discharged on January 19, 2012. The biopsychosocial evaluation was completed on January 8, 2012 for client #7R. Client #8R was admitted on January 24, 2012 and discharged on February 20, 2012. The biopsychosocial evaluation was completed on January 30, 2012 for client #8R. Client #10R was admitted on February 14, 2012 and discharged on March 8, 2012. The biopsychosocial evaluation was completed on February 22, 2012 for client #10R. The findings were discussed with the clinical supervisor and facility director during the exit interview.
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Plan of Correction
709.51(b)(6) LICENSURE
Psychosocial evaluation:
709.51. Intake and admission. (b) Intake procedures shall include documentation of: (6) Psychosocial evaluation. Cove Forge failed to document biopsychosocial evaluations in accordance to the facility's policies and procedures.
Biopsychosocial evaluations are to be completed within 72 hours of client's admission into treatment.
Plan of Correction:
On April 12th, the findings were reviewed with the counselor assessment staff.
Discussion focused on the timeliness and the quality of the
biopsychosocial evaluations.
Assistant Program Director/Program Director will review a minimum of 10 charts monthly for the next 7 months.
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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
Based on the review of inpatient client records, the facility failed to document discharge summaries upon a client's discharge. The findings include:Three inpatient client records were reviewed on April 9, 2012 for documentation of discharge summaries. The facility failed to document discharge summaries upon the clients' discharge in two out of three inpatient client records, specifically client records # 7R and 9R.Client #7R was admitted on January 4, 2012 and discharged on January 19, 2012. The discharge summary for client #7R was completed on March 29, 2012.Client #9R was admitted on November 16, 2011 and discharged on December 1, 2011. The discharge summary for client #9R was completed on February 22, 2012.The findings were reviewed with the clinical supervisor and facility director prior to the exit interview.
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Plan of Correction
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.
Based on the review of inpatient client records, the facility failed to document discharge summaries upon a client's discharge.
Plan of Correction:
On April 12th, 2012 the Program Director reviewed the findings with the Counselors. The
focus was the timeliness and quality of the discharge summaries.
Chart audits will be completed Assistant Program Director/Program Director on a minimum of 10 charts monthly for the next 7 months.
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709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on the review of inpatient client records and the facility's policies and procedures, the facility failed to document follow-ups in accordance with the facility ' s policies and procedures.The findings include:The facility's policy regarding follow-ups states: If a referral is made, with the client's consent, the provider is contacted within 7 business days following the patient's scheduled aftercare appointment.If no referral is made (including AMA clients), a contact call will be attempted within 30 business days after discharge.Three inpatient client records requiring documentation of follow-ups were reviewed on April 9, 2012. The facility failed to document follow-ups in accordance with the facility's policy in three out of three inpatient client records reviewed, specifically client records # 7R, 8R, and 9R.Client #7R was admitted on January 4, 2012 and discharged on January 19, 2012. The client was referred on January 24, 2012. The follow-up was documented on March 26, 2012 for client #7R.Client #8R was admitted on January 24, 2012 and discharged on February 10, 2012. The client was referred on February 15, 2012. The follow-up was documented on March 12, 2012 for client #8R.Client #9R was admitted on November 16, 2011 and discharged on December 1, 2011. The follow-up was documented on March 27, 2012 for client #9R.The findings were confirmed with the clinical supervisor and facility director at the exit interview.
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Plan of Correction
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.
Based on the review of inpatient client records and the facility's policies and procedures, the facility failed to document follow-ups in accordance with the facility ' s policies and procedures.
Plan of Correction:
On 05/14/12, the Assistant Program Director will meet with the Case Management department to discuss the findings.
Focus will be on the timeliness and the purpose of the Follow Up form as well as the facility's policy regarding documentation of follow-up.
Monthly Chart audits will be completed Assistant Program Director/Program Director on a minimum of 10 clients for the next 7 months.
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on the review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position.The findings include:Seven personnel records were reviewed for the position of counselor on April 3, 2012. Two of seven personnel records reviewed did not have documentation of qualifications required for the position of counselor, specifically records #6 and 9.Employee # 6 was hired on December 5, 2011 as a counselor. The employee did not meet the qualifications for the position of counselor based on a Masters of Education. The employee's Bachelor's degree was requested to verify if it qualified him for the position, however it was not provided. Employee # 9 was hired on June 23, 2011 as a counselor. The employee did not meet the qualifications for the position of counselor based on a Bachelor's in Criminology. In addition, a review of the employee's resume verified he also didn't meet because he didn't have the required one year clinical experience required with a Bachelor's degree. The findings were discussed with the QI staff during the exit interview.
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Plan of Correction
Plan of Correction:
Employee #6 resigned and is no longer at Cove Forge.
Employee #9 is now a counselor assistant and will be getting the correct amount of supervision to meet standards. Supervision will be documented and maintained in the QI employee file.
704.7. Qualifications for the position of counselor are determined by the Quality Management Department.
The Quality Management Director has determined and submitted the following plan of correction:
The Program Director and Quality Management Director will meet to review counselor/counselor assistant qualifications. The following steps will be implemented immediately.
1. All potential counselor/counselor assistants will be reviewed by the Quality Management department.
2. The Quality Management Director will determine counselor/counselor assistant qualifications by utilizing Chapter 704, Staffing Requirements for Drug and Alcohol Treatment Activities.
3. The Quality Management Director will then notify the Program Director of counselor vs. counselor assistant status.
Responsible Party: Quality Management Director
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