INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 9-12, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Pocono Mountain Recovery 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:
|
Plan of Correction
|
704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
|
Observations
Based on an interview with Employee number 3 on January 10, 2018, the facility was to keep copies of feedback forms completed by employees and develop a report on attended trainings. Employee number 3 indicated that there were no feedback forms on file.
These findings were discussed with facilty staff.
|
Plan of Correction
It is the policy that all staff that attend trainings complete a feedback form on the training. Employee #3 did fail to fill out a feedback form for a training he attended.
On 1/29/18 during a staff meeting, Clinical Director re-trained staff and all staff are required to fill out an evaluation form for any training the attend that also includes, internal trainings, external trainings, web-based training or webinars. The evaluation form that also includes future trainings staff has suggestions on.
Clinical Director and Human Resource Director will monitor monthly to assure compliance by staff in completing training feedback forms. All feedback forms will be placed in personal files.
|
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.
|
Observations
Based on a review of the staffing requirements facility summary (SRFS) report and an interview with human resources on January 9-12, 2018, the facility failed to ensure that staff other than clinical staff completed the mandatory trainings within the first 2 years of employment.
The following was noted:
Staff #12 was hired on 1/6/2016 and there was no documentation of STD/TB training as of the date of the inspection.
Staff # 13 was hired on 1/4/2016 and there was no documentation of STD/TB training as of the date of the inspection.
Staff #14 was hired on 6/16/2013 and there was no documentation of HIV/AIDS and STD/TB training as of the date of the inspection.
Staff #15 was hired on 8/14/2014 and there was no documentation of HIV/AIDS and STD/TB training as of the date of the inspection.
These findings were discussed with facilty staff.
This is a repeat deficiency, the facility was previously cited during the licensure inspections conducted on December 16, 2016 and the December 29, 2015.
|
Plan of Correction
Employees #12, #13, #14, and #15 in fact did not attend the required training's within their first 2 years of hiring. The Clinical Director and Human Resource Director will assume the role of auditing employee's training manuals. These manuals will be audited once a month. Therefore, training manuals will have been inspected 12 times annually. This will ensure that all employees have attended not only the necessary training's but also training's required for new employees.
The Clinical Director and Human Resource Director have scheduled STD/TB Trainings and Basic HIV/AIDS trainings for the second week of March 2018 for those who have not attended the required trainings and any new employees hired.
The Clinical Director and Human Resource Director will continue to schedule TB/STD and Basic HIV/AIDS in March and September yearly.
|
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.
|
Observations
Based upon a review of personnel records on January 9, 2018, the facility failed to ensure that clinical staff received the required number of training hours.
One out of one counselor records requiring documentation of 25 training hours only had documentation of 20 training hours.
These findings were discussed with facilty staff.
|
Plan of Correction
Beginning 2/01/2018 the Clinical Director and Human Resource Director will meet monthly to keep track of all employees, the number of training hours needed for the year, and number of hours completed. Human Resource Director and Clinical Director will continually check employee training files to ensure staff are attending required trainings. Clinical Director will also remind all staff on training needs throughout the training year, and document any non-compliance issues in their employee record.
|
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
|
Observations
Based upon a review of personnel records on January 9, 2018, the facility failed to ensure that clinical staff received the required number of training hours.
One out of one counselor assistant records requiring documentation of 30 training hours only had documentation of 11 training hours.
These findings were discussed with facilty staff.
|
Plan of Correction
Beginning 02/01/2018 the Clinical Director and Human Resource Director will meet monthly will keep track of all employees, the number of training hours needed for the year, and number of hours completed. Human Resource Director and Clinical Director will continually check employee' training files to ensure staff are attending required trainings. Clinical Director will also remind all staff on training needs throughout the training year, and document any non-compliance issues in their employee record. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
|
Observations
Based on a physical plant inspection conducted on January 11 & 12, 2018, the facility failed to maintain the grounds of the facility in good repair.
The hand railing/post of client Cottage #2 was observed to be deteriorating and had signs of wood rot.
The gym floor (sub flooring under the mat) by the weight bench was observed to be damaged, creating a tripping hazard.
These findings were discussed with facility staff.
|
Plan of Correction
Maintenance Staff was made aware of the handrail outside cottage #2 and repairs were made on 1/14/18.
Maintenance Staff evaluated "Gym" sub floor damage and materials to repair was ordered. Sub-floor repair and completion will be completed by 3/1/18.
Maintenance staff will monitor buildings and grounds daily and report their finding to the CEO for the approval if repairs are needed.
The Safety Committee will also conduct weekly inspections of buildings and grounds to ensure all buildings and grounds are maintained.
|
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
|
Observations
During the physical plant tour conducted on January 11, 2018, the exhaust fan in the nurse's bathroom was observed to not be operational. This was the only means of ventilation as there was no window in the bathroom.
These findings were discussed with facilty staff.
|
Plan of Correction
On 1/11/18 during the onsite inspection, it was found that the exhaust fan in the nurse's station was not working. Maintenance Staff was notified and the fan was immediately replaced on 1/11/18. Licensing staff was made aware.
Maintenance staff will monitor buildings and grounds daily and report their finding to the CEO for the approval if repairs are needed.
The Safety will also conduct weekly inspections of buildings and grounds to ensure all buildings and grounds are maintained.
|
705.6 (6) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(6) Provide toilet paper at each toilet at all times.
|
Observations
During a physical plant inspection on January 11, 2018, it was observed that the bathroom door in Client room 22 had holes in both sides of the door. The holes were the size of a softball on each side of the door.
These findings were discussed with the facilty staff.
|
Plan of Correction
Maintenance Staff was made aware of the findings of DDAP licensure in room #22 and repairs were completed on 1/14/18.
Maintenance staff will monitor buildings and grounds daily and report their finding to the CEO for the approval if repairs are needed.
The Safety Committee will also conduct weekly inspections of buildings and grounds to ensure all buildings and grounds are maintained.
|
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.
|
Observations
During a physical plant inspection on January 11, 2018, it was observed that the water faucet in client bathroom # 7 would not turn off and was dripping. Thus causing a rust stain in the bathtub and pitting of fixtures.
During the same physical inspection, there was a hole the size of a softball observed in the bathroom wall of room #8.
These findings were discussed with facilty staff.
|
Plan of Correction
Maintenance Staff was made aware of the findings of DDAP licensure in room #7 the faucet in the bathroom was replaced and repairs were completed on 1/12/18.
Maintenance Staff was made aware of rust stain in the findings of DDAP licensure in room #7. Rust stains and fixture was replaced in bathroom and repairs were completed on 1/15/18.
Maintenance Staff was made aware of holes in walls in room #8 in the findings of DDAP licensure visit. Holes were repaired in room #8 completed on 1/15/18
Maintenance staff will monitor buildings and grounds daily and report their finding to the CEO for the approval if repairs are needed.
The Safety Committee will also conduct weekly inspections of buildings and grounds to ensure all buildings and grounds are maintained.
|
705.10 (a) (1) (ii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
|
Observations
During a physical site inspection on January 11, 2018, it was observed that there was storage in the attic of the detox building (there were items such as a Christmas tree, decorations, a toboggan, a microwave and other items). There were not two exits from the detox attic.
These findings were discussed with facilty staff.
|
Plan of Correction
Maintenance was informed that no items are to be stored in the attic and all items were removed and stored appropriately on 1/27/18.
This area will be locked and only maintenance staff will will have access.
PMRC will be submitting for an exemption for this area not having a second exit.
The Safety Committee will also conduct weekly inspections of buildings and grounds to ensure all buildings and grounds are maintained.
|
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based upon a review of the facilty fire drill log, the facilty failed to conduct unannounced fire drills at least once a month.
Upon review of the yearly fire drills for 2017, there was no fire drill conducted for the month of November 2017.
These findings were discussed with the facilty staff.
|
Plan of Correction
Safety Officer will conduct unannounced fire drills monthly. Director of Compliance will continue and monitor prior to months end, and ensure all drills are conducted monthly. |
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.
|
Observations
Based upon review of the facilities fire drill log for the year 2017, there was no documentation of which escape routes were used for any of the fire drills in 2017.
These findings were discussed with the facilty staff.
|
Plan of Correction
Director of Compliance has updated fire drill procedure. Safety Officer was trained on 1/31/18.
New fire drill documentation will indicate, date and time of the drill, evacuation time, exit route used, problems encountered, and what exit was blocked during the drill
All staff will be trained on new drill procedure by 3/1/18 and training will also be a part of orientation for all new employees.
Director of Compliance will monitor fire drills and documentation to ensure ongoing compliance.
|
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.
|
Observations
Based upon a review of facility fire drill logs for year 2017, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
There was only documentation of one fire drill conducted during sleeping hours, which was on 10/29/2017 at 4:24am.
These findings were discussed with the facilty staff.
|
Plan of Correction
Safety Officer will conduct unannounced fire drills monthly. Director of Compliance will monitor to ensure drills are conducted during sleeping hours at least once every 6 months |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
|
Observations
During a review of the fire drills conducted during the year 2017, it was not noted which exit routes were used during any of the fire drills that occured.
These findings were discussed with the facilty staff.
|
Plan of Correction
Director of Compliance has updated fire drill procedure. Safety Officer was trained on 1/31/18.
New fire drill documentation will indicate, date and time of the drill, evacuation time, exit route used, problems encountered, and what exit was blocked during the drill
All staff will be trained on new drill procedure by 3/1/18 and training will also be a part of orientation for all new employees.
Director of Compliance will monitor fire drills and documentation to ensure ongoing compliance.
|
705.10 (d) (7) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
|
Observations
Based on a review of the facilities fire drill log submitted for the year 2017, the facility failed to vary the days of the week for fire drills.
It was noted that there were five fire drills completed on Sundays and five fire drills completed on Mondays.
These findings were discussed with the facilty staff.
|
Plan of Correction
Safety Officer will conduct unannounced fire drills monthly. Safety Officer trained on randomizing drills. Drills will be conducted on different days of the week and on various shifts.
Director of Compliance will monitor fire drills and documentation to ensure ongoing compliance.
|
705.21 (3) LICENSURE General req. for nonresidential facilities.
705.21. General requirements for nonresidential facilities.
The nonresidential facility shall:
(3) Comply with applicable Federal, State and local laws and ordinances.
|
Observations
Based on observation during physical plant inspection on 1/12/18, the facility failed to comply with Federal, State and local laws and ordinances. The facility was not in compliance with the national electrical code.
The facility was missing covers on two of the panel boxes in the basement.
The facility was missing a junction box cover on the large box located on the baasement wall accross from the stairs to the right of the panel box.
The facility was missing a junction box cover on a small junction box located on the left side of the stairs as you come down the stairs.
There was an unsecured electrical outlet without a cover hanging from one of the joints near the stairs in the basement.
These findings were discussed with the facilty staff.
|
Plan of Correction
Upon the conclusion of the DDAP licensing visit, maintenance was made aware of the issues and repairs were made. On 1/28/18 ? Panel Boxes were covered and secured.
Upon the conclusion of the DDAP licensing visit, maintenance was made aware of the issues and repairs were made. On 1/28/18 ? junction box was secured along with electrical outlet secured.
The Safety Committee will also conduct weekly inspections of buildings and grounds to ensure all buildings and grounds are maintained.
|
705.28 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
|
Observations
It was observed during the physical site inspection of the outpatient building on 1/12/18 that the basement was being used for storage (Christmas tree, wading pools, table, chairs, etc) and there was only one exit.
These findings were discussed with the facilty staff.
|
Plan of Correction
Maintenance was informed of the issues and all items were removed and stored appropriately on 1/27/18. Access to the basement will be restricted to maintenance personnel.
This area will be remained locked and maintenance staff will have access.
PMRC will be submitting for an exception to DDAP for the second exit. |
705.28 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential 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.
|
Observations
During a physical site inspection of the outpatient building on 1/12/18, it was noted that the interior stairway going to the second floor had no secured handrail from the landing to the second floor. The original handrail was embedded into the wall.
These findings were discussed with the facilty staff.
|
Plan of Correction
Maintenance staff was made aware and installation of handrail was completed on 1/28/18.
The Safety Committee will also conduct weekly inspections of buildings and grounds to ensure all buildings and grounds are maintained. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
|
Observations
Based upon the physical plant inspection the facility failed to ensure that all fire extinguisher were inspected and approved annually.
It was observed during a licensing inspection on 1/12/18 of the outpatient building that the fire extinguisher in the basement had been last serviced in 2004/2005.
These findings were discussed with the facilty staff.
|
Plan of Correction
Director of Compliance, Safety Officer and Maintenance Staff was made aware. Fire Extinguisher was replaced on 1/15/18. Safety Officer will ensure all fire extinguishers are inspected yearly. Director of Compliance will monitor to ensure ongoing compliance. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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.
|
Observations
Based upon a review of the facility's fire drill log, the facility failed to document the amount of time it took ot evacuate the building or exit routes used.
These findings were discussed with the facilty staff.
|
Plan of Correction
Director of Compliance has updated fire drill procedure. Safety Officer was trained on 1/31/18.
New fire drill documentation will indicate, date and time of the drill, evacuation time, exit route used, problems encountered, and what exit was blocked during the drill. The documentation will also include number
person involved in drill.
All staff will be trained on new drill procedure by 3/1/18 and training will also be a part of orientation for all new employees.
Director of Compliance will monitor fire drills and documentation to ensure ongoing compliance.
|
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.
|
Observations
During the on site inspection on 1/12/18, the facility was unable to provide a signed consent to release information form releasing information to father other than emergency situations as stated in release form. Progress notes dated 10/11/17 and 10/19/17 show communications with the father discussing progress and after care in the program for client #7D.
Client record #8D contained a consent to release information form to the funding source signed by the client; however, the information to be released had not been completed.
During the on site inspection on 1/9/18, the facility was unable to provide a signed consent to release information form releasing information to the mother other than emergency situations as stated in the release form. Progress notes show communication with mother discussing after care and progress in the program for client #4R.
During the on site inspection on 1/9/18, the facility was unable to provide a signed consent to release information form releasing information to the son other than visitation as stated in the release form. Progress notes show communication with son by counselor pertaining to treatment on 12/20/17 for client #6R.
These findings were discussed with facilty staff.
This is a repeat deficiency. The facility was previously cited during the licensure inspection conducted on December 16, 2016.
|
Plan of Correction
The Clinical Director on 2/16/18 will meet with PMRC staff members to provide a training on confidentiality and how to properly complete a consent to release information. This training will continue again every six months from this date. In addition, for staff members who do not attended these trainings they will be required to attend and complete a DDAP approved external training on confidentiality and the application of confidentiality. The Clinical Director and Quality Assurance Coordinator will review client records for accurate and complete consent to release information forms at each site on a weekly basis. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
|
Observations
Based on review of client records the facility failed to ensure that treatment plans were updated at least every 30 days in one of two client records reviewed.
Client record 1P contained an initial treatment plan dated 9/5/17. The treatment plan update in the record was completed on 10/16/17.
These findings were discussed with facility staff.
|
Plan of Correction
Clinical Director conducted a training session on 2/05/18 with PHP and Outpatient Clinical Staff on documentation of clinical services that included the standards for treatment plans and treatment plan updates. Also included in this session was how to utilize the calendar section of the electronic charting to prompt counselor staff 2 days prior an updated treatment plan is due. This will ensure the timely implementation of updated treatment plans.
Clinical Director and Quality Assurance Coordinator will monitor charts weekly to assure ongoing compliance with this standard.
|
709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
During an onsite record review that took place on January 9-12, 2018, the facility failed to provide counseling services in accordance with client 1P's treatment plan.
The treatment plan dated 9/5/17, stated that the client 1P was to have one individual session per week and three group sessions of counseling per week.
During the weeks of 9/18/17, 10/2/17 and 10/13/17, client 1P only received group therapy two times a week.
These findings were discussed with facility staff.
|
Plan of Correction
Clinical Director conducted a training session on 2/05/18 with PHP and Outpatient Clinical Staff on documentation of clinical services. This training included meeting the minimum required individual sessions in accordance with both DDAP requirements and treatment plan. No Shows will be documented in the patient record and an attempt to reschedule missed sessions will be made.
Clinical Director and Quality Assurance Coordinator will monitor charts weekly to assure ongoing compliance with this standard.
|
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
|
Observations
Based on a review of client records on January 9-12, 2018, the faciltiy failed to provide individual counseling, at least twice weekly as per the regulations in two of two records reviewed.
Treatment plans in client records 1P and 2P only listed one individual session per week.
These findings were discussed with facilty staff.
|
Plan of Correction
Clinical Director conducted a training session on 2/05/18 with PHP and Outpatient Clinical Staff on documentation of clinical services. This training included meeting the minimum required individual sessions in accordance with both DDAP requirements and treatment plan. No Shows will be documented in the patient record and an attempt to reschedule missed sessions will be made.
Clinical Director and Quality Assurance Coordinator will monitor charts weekly to assure ongoing compliance with this standard.
|
709.62(c)(2)(i) LICENSURE Orientation Proj policies
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(2) Client orientation to the project which includes, but is not limited to a familiarization with:
(i) Project policies, which include the following:
|
Observations
Based on review of client records January 9-12, 2018, the facility failed to provide communication of client orientation to the project in one of the three client records reviewed.
There was no documentation verifying the client was oriented to the project in client record # 8D.
These findings were discussed with facility staff.
|
Plan of Correction
It is the Policy of Pocono Mountain Recovery Center that all patient are orientation to the project. PMRC has immediately implemented "New Patient Orientation Group" be conducted 3 times weekly, (Monday, Wednesday and Friday). This will ensure that all new patient's entering treatment will be orientated to the program. All new patient's will be required to sign and orientation sheet that will be scanned into their electronic chart.
Clinical Director and Quality Assurance Coordinator will monitor charts weekly to assure ongoing compliance with this standard.
|
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.
|
Observations
During onsite inspection on January 12, 2018, facility was unable to provide documentation that a follow up call was made to the phone number provided on the face sheet for the client #3.
These findings were discussed with facility staff.
|
Plan of Correction
To adhere to this standard the PMRC on 02/01/2018 PMRC case manager was trained to conduct follow-up phone calls and the documentation needed. To ensure the accuracy of information provided by the patient, case manager will meet with patients prior to discharge and review information. After discharge case manager will call patients for follow-up information. Clinical Director and Quality Assurance Coordinator will have ongoing monitoring of follow-up to ensue this standard is met. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of client records, the facility failed to ensure that counseling services were provided in accordance with the treatment plan in one of two records reviewed.
The treatment plan in client record # 1 O, dated 10/16/17, stated that client # 1 O was to have 1 individual session and 3 group sessions per week.
In November, it was documented that client # 1 O received only two individual counseling sessions. One on 11/3/17 and the other on 11/22/17.
It was documented that client # 1 O attended group therapy 1 time in the month of November. In December 2017, it was documented that client # 1 O attended one individual counseling session on 12/15/17. Client # 1 O was a no call/no show for 12/1/17, 12/6/17 and 12/22/17. It was documented that client # 1 O attended group twice a week in December.
There was no documentation for client # 1 O for the month of January 2018, as of 1/11/18.
These findings were discussed with facility staff.
|
Plan of Correction
Clinical Director conducted a training session on 2/05/18 with PHP and Outpatient Clinical Staff on documentation of clinical services. This training included meeting the minimum required individual sessions in accordance with both DDAP requirements and treatment plan. No Shows will be documented in the patient record and an attempt to reschedule missed sessions will be made.
Clinical Director and Quality Assurance Coordinator will monitor charts weekly to assure ongoing compliance with this standard.
|
709.93(a)(3) 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:
(3) Record of services provided.
|
Observations
Based on a review of client records on January 9-12, 2018, the facilty failed to document a record of client services in one of two client records.
There was no documented Record of Service for Client # 1 O for the months of October, November, December or January.
These findings were discussed with facility staff.
|
Plan of Correction
Clinical Director conducted a training session on 2/05/18 with PHP and Outpatient Clinical Staff on documentation of clinical services. This training included documentation of client Record of Service. Weekly census meeting will review all charting including Record of Service for missed appointments.
Clinical Director and Quality Assurance Coordinator will monitor charts weekly to assure ongoing compliance with this standard.
|