INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 9, 2009 and September 10, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Catholic Charities Diocese of Harrisburg, PA Inc. 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 and a plan of correction is due on October 9, 2009.
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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 a review of personnel records the facility failed to demonstrate that performance evaluations were conducted semi-annually for the counselor assistant.
The findings were:
Thirteen employee records were reviewed on September 9, 2009. One employee record required semi-annual performance evaluations. Employee record #4 was hired on 5/10/2007. The employee record only contained annual evaluations that were conducted May 2008 and May 2009.
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Plan of Correction
CORRECTION DUE BY 11/10/09:
A new semi-annual evaluation form will be developed by the Program Director and a new police will be written by the Program Director describing the procedure in which a semi-annual performance evaluation will be used by the Program Director or a Counselor who meets the staffing requirements of the Department of Health and who is directly supervising the counselor assistant. The policy will also describe any other uses for a semi-annual evaluation at Evergreen House. The semi-annual evaluation will measure performance and expectations as it relates to promoting and retaining an employee for whom it is conducted. The next semi-annual report for employee #4 will be completed by 11/10/09. Semi annual dates will be placed on a tickler system, monitored by the program Director, in order to avoid missing any evaluations.
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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
Based on a review of the project director's personnel record it was determined that the facility failed ensure that the project director completed 12 clock hours of annual training.
The findings were:
A review of personnel record #1 was conducted September 9, 2009. There were no training hours documented in personnel record #1.
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Plan of Correction
CORRECTION DUE BY 3/10/10:
The Project Director, employee #1, who is the CEO of the overall agency does not have direct contact with the program being inspected, therefore, being unaware of the DOH regulations of compliance. The Program Associate Director will be assigned as the Project Director due to the direct supervision of the Program Director of the program being inspected. The Program Associate Director will complete the core training requirements as well as maintain 12 clock hours of training specified in the DOH regulations in order to satisfy the annual training requirements. These changes will be documented on the next Staffing Requirements Form submitted each year to Licensure. Core training requirements will be completed within a year (9/10/2010) as allowed in the DOH regulations, as trainings are available through the state and other outside agencies. The Program Director will distribute training availability to the Project Director to schedule. The Project Director as well as the Program Director will schedule and monitor the training requirements each year through the regular tickler system each year to avoid this deficiency again.
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709.32(c)(4) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
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Observations
Based on a review of the medication administration records (MAR's) the facility failed to ensure that the staff signed the MAR indicating they observed the self administration of PRN medications. This is a repeat citation from the licensing inspection conducted on August 7, 2008 to August 8, 2008. Further, client record documentation and MAR information revealed that clients did not show up for medications and were discontinuing their own medications without approval from a medical doctor in five of eight records.
The findings were:
On September 10, 2009 the medication logs were reviewed. A review of the MAR's indicated that the clients were signing the MAR's indicating that they administered their medication; however, in record # 6 staff did not sign off that they observed an over the counter medication that was provided on 12/13/2008 and 1/17/2009.
Also, Clients refused or failed to appear for their medications and there was no documentation of follow-up to identify reasons clients did not take their medication as prescribed, client records # 1, 2, 9 and 10:
Client record #1
Gabapentin 300 mg 1 capsule 3 times a day
August 6, 7, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 25, 26, 27, 28, 30 and 31 of 2009 - MARs were marked at various times for not showing up to take medications.
August 8 only took twice and August 24 only took medication once.
September 4 only took twice.
There was no documentation of staff intervention.
Client record #2
Sertraline 100 mg 1 1/2 tablet daily
September 1, 2, 3, 4, 7, 8 9 and 10 - documentation identified the client refused medications..
September 5, 6 - documentation reflected the client did not not report to receive medications.
There was no documentation of intervention.
Client medical chart #9
Fluoxetine 20 mg 3 capsules daily once
August 24, 25, 29, 30 and 31- documentation indicated the client did not report to take medications.
There was no documentation of intervention.
Client medical chart #10
Trazodone 100 mg 1 tablet at bedtime
September 1, 2, 5 and 8 - documentation identified the patient did not report for medications.
September 3, 4 and 8 - documentation revealed the patient code refused her medications.
There was no documentation of intervention.
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Plan of Correction
CORRECTION DUE BY 12/10/09:
Despite this being a repeated citation for medication, the plan of correction was enforced and did improve the medication errors significantly which was a concern in last year's inspection. In order to further improve the quality of medication control the following steps and policies will be developed and put in place by 12/10/09 by the Program Director.
1. The program Director will write new policies which will address each medication scenario addressed by the DOH including, but not limited to procedures addressing when a client refuses a medication, when a client does not obtain a refill over a period of time, if a client has a repeated behavior of not showing for meds, or a medication is waiting to be discontinued or changed.
2. Various medication forms will be re-designed and simplified in order for staff to decrease misunderstandings leading to errors and incomplete forms.
3. A Medication Non-Compliance Form will be designed for clinical staff to properly document progress of having a doctor discontinue or change a med. This same form will also document therapeutic intervention with clients addressing their refusal or multiple no-shows for medication times.
4. An assigned staff person who currently monitors weekly med errors will be given the additional responsibility to report prescribed meds that are not being taken and included on the report of medication errors which is turned in weekly. This report will generate the Medication Non-Compliance Form which will properly document the progress in addressing the concern as well as unresolved and resolved difficulties.
5. A Medication Training conducted by the Program Director will be conducted by 12/10/09 which will be mandatory for all staff whom have direct medication access. This training will include the proper use of the new forms and review the new procedures.
All of these steps will ensure this deficiency will not occur again and will be monitored by the Program Director, with the assistance of an assigned medication compliance staff person, and quarterly pharmacist. |
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
Based on a review of client records and an interview with the Program Director, the facility failed to complete progress notes in seven of eight client records.
Findings:
Eight records were reviewed on September 10, 2009. Progress notes were required in eight client records. The facility failed to document in group notes in appropriate Data, Assessment, and Plan (DAP) format in client records # 1, 2, 3, 4, 6, 7, and 8.
According to an interview with the Program Director it was discovered that an old form had been used. The old form had been replaced because it did not include all components of a progress note, specifically the plan. Additionally, the progress notes for those included in the client records were general to the treatment of addiction and not specific to the individual needs of the patient.
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Plan of Correction
CORRECTION DUE BY 10/10/2009:
The Project Director will design a new Group Note which is in DAP format. The new form will be given to all clinical staff with the instruction to eliminate any old versions. The data portion of the note will include what the client shared specifically about the subject discussed, while the assessment will continue to include the counselor's assessment of that client. The plan portion of the note will address how the information shared and possibly learned will be used after that group experience as well as any further action needed until next scheduled group. Each counselor will complete the new Group Note properly and will be monitored by the Program Director during monthly chart audits. |