INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 1, 2008 through December 4, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Penn foundation For Mental Health 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 January 5, 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 the review of personnel records, the facility failed to document semiannual performance evaluations in two of three records.
Findings:
Thirteen personal records were reviewed on December 2, 2008. Semiannual performance evaluations were required in two of three records reviewed. The facility did not document semiannual performance evaluations in personnel records #11 and 13. Employee #11 was hired as a counselor assistant on 3/11/08 and the semiannual evaluation was to have been completed by 9/1/08; the facility failed to provided documentation of a completed semiannual staff evaluation. Employee #12 was hired as a counselor assistant on 5/2/08 and semiannual was to have been completed by 11/2/08; the facility failed to provided documentation of a completed semiannual evaluation.
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Plan of Correction
Supervisors have been made aware of the fact that semi-annual evaluations are required on all counselor assistants. Our computer system is set up to notify supervisors when performance evaluations are due. It will be programmed into the system to alert supervisors every six months that evaluations are due on counselor assistants. |
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.
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Observations
Based on the review of the facilities fire drill record, the facility failed to maintain a written fire drill record.
Findings:
During the review of the facility's fire drill record on December 2, 2008, the facility failed to document fire drill information regarding the amount of time it took for evacuation, the number of persons in the facility at the time of the drill and whether the fire alarm or smoke detector was operative during the months of June 2008 through November 2008.
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Plan of Correction
Our fire drill log sheet was changed in June to meet CARF requirements and the person in charge of this change did not keep some of the necessary information on the log form. The form will be adapted again to include the amount of time it took for evacuation, the number of persons in the facility and whether the fire alarm or smoke detector was operative. Director of the Recovery Center will be responsible for overseeing the implementation of new form. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on the review of the facility's fire drill record on December 2, 2008, the facility failed to document if the fire or smoke detector was set off during each fire drill.
Findings:
During the review of the facilities fire drill record on December 2, 2008, the facility failed to document in the fire drill records that a smoke detector or fire alarm were set off during the fire drills during the months of June 2008 through November 2008.
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Plan of Correction
Fire drill form will be adapted to also include the information regarding whether or not the fire alarm or smoke detector was set off during the fire drill. Staff in charge of fire drills will be instructed to indicate whether the smoke detector or fire alarm were set off during the fire drill. Director of the Recovery Center will be responsible for overseeing the implementation of new form and to assure the form is being filled out properly. |
709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to complete personal histories in two of four records reviewed.
Findings:
Twenty records were reviewed on December 3, 2008 and December 4, 2008. Personal histories were required in four client records. In accordance with the facility's policy and procedure manual reviewed on December 1, 2008, the facility will complete the patient social histories by the completion of the second clinical session. Client #10 was admitted on 9/9/08; as of the date of the review there was no documentation of a social history in client # 10's record. Client #11 was admitted on 10/23/08; there is no documentation of a completed social history in the client record.
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Plan of Correction
Outpatient clinical staff is very new and we realize that they need additional training regarding our policy and procedures relating to client records. Outpatient clinical supervisor will hold a mandatory clinical staff meeting in January to educate partial hospital staff as to what is expected in the charts and in the social history. Computer system will be updated to notify supervisor when paperwork is not complete so it can be more closely monitored. Clinical supervisor will oversee this POC. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to complete psychosocial evaluations in three of four client records.
Findings:
Twenty records were reviewed on December 3, 2008 and December 4, 2008. Psychosocial evaluations were required in four client records. The psychosocial evaluations did not include a clinical assessment of the assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and the counselor's impression of the client in client records #10, 11 and 12.
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Plan of Correction
Partial hospital clinical supervisor will hold a mandatory clinical staff meeting to discuss what is expected in the biopsychosocial evaluation. In addition, Director will ammend the BPS form to specifically address the deficient areas. The computer system is able to be programmed to not allow blank areas on the BPS form, so the areas will have to be completed for the BPS to print out. Clinical supervisor will oversee this POC. |
709.82(a)(1) 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:
(1) Short- and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on the review of client records, the facility failed to document completed treatment plans in three of four client records.
Findings:
Twenty records were reviewed on December 3, 2008 and December 4, 2008. Treatment plans were required in four client records. The treatment plans failed to document action steps in records, 11, 12 and 13.
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Plan of Correction
Partial hospital clinical supervisor will hold a mandatory clinical staff meeting to discuss what is expected in the treatment plan. Staff will be informed what constitutes an action step and what is necessary to be included on the treatment plans. Clinical supervisor will oversee this POC to assure that treatment plans are being completed with action steps. |
709.83(a)(6) 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:
(6) Aftercare plans, if applicable.
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Observations
Based on the review of client records, the facility failed to document aftercare plans in one of four client records.
Findings:
Twenty records were reviewed on December 3, 2008 and December 4, 2008. Aftercare plans were required in four client records. The facility failed to document aftercare plans in client record #13. Client #13 was discharged on 11/25/08 without an aftercare plan; in accordance with the facility's policy and procedure for aftercare plans, they are to be completed prior to discharge.
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Plan of Correction
Partial hospital clinical supervisor will at the clinical staff meeting in January, discuss with parital hospital staff the Recovery Center's policy and procedure regarding aftercare plans. Staff are not consistently completing the required aftercare plan on partial hospital clients. Clinical supervisor will monitor completion of aftercare plans via the computer, which will alert supervisor of clients needing an aftercare plan and if they have not been completed. |
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 a review of client records, the facility failed to complete progress notes in four of five client records.
Findings:
Twenty records were reviewed on December 3, 2008 and December 4, 2008. Progress notes were required in five client records. The facility failed to document the therapist's assessment in group notes in records #10, 11, 12 and 13.
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Plan of Correction
Partial hospital clinical supervisor will hold a mandatory clinical staff meeting in January to discuss this issue as well. Clinical supervisor will discuss with partial hospital staff what is expected in a group note. Staff will be inserviced regarding the need to document their assessment of both the client and the group in all group notes. Clinical supervisor will oversee this POC by periodically checking charts by all partial hospital staff to assure that the assessment is being included in the group note. |
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 a review of client records, the facility failed to document discharge summaries in two of four client records.
Findings:
Twenty records were reviewed on December 3, 2008 and December 4, 2008. Discharge summaries were required in four client records. In accordance with the facility's policy and procedure manual reviewed on December 1, 2008, the facility had seven days following a patient's discharge to complete the discharge summary. Client # 11 was discharged on 11/13/08; there was no discharge summary documentation in patient record # 11.. Client record #13 was discharge on 11/25/08; there was no discharge summary documentation in patient record #14.
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Plan of Correction
Clinical supervisor of partial hospital program will hold a mandatory clincial staff meeting in January to inservice staff regarding the Recovery Center's policy and procedure regarding discharge summaries. Discharge summaries are to be completed within seven days of discharge and this is not consistently happening. Staff will be informed of the importance of timely completion of discharge summaries. Clinical supervisor will oversee this POC by monitoring completion of paperwork via the computer which will alert supervisor if dc summary is not completed. |
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 a review of client records, the facility failed to document follow-up information in two of four client records.
Findings:
Twenty records were reviewed on December 3, 2008 and December 4, 2008. Follow-up information was required in four client records. In accordance with the facility's policy and procedure that was reviewed on December 1, 2008, the facility had seven days to perform follow-up for their discharged patients. Client #11 was discharged on 11/13/08; there was no documentation of follow-up information in the client's record. Client #13 was discharged on 11/25/08; there was no documentation of follow-up in the client's record.
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Plan of Correction
Parial hospital clinical supervisor will have a mandatory clinical staff meeting in January. One of the issues discussed will be the facility's policy and procedure regarding follow up with partial hospital clients. It has been made clear that follow ups are not consistently happening and being documented. Staff will be informed of the need to complete these in a timely manner. Clinical supervisor will oversee this POC by periodic chart check and via the computer system alerting supervisor of this not being completed. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in six of twenty client records.
Findings:
Twenty client records were reviewed on December 3, 2008 and December 4, 2008. Consent to release information forms were required in twenty client records.
Record #6 had a consent to release form for his sister, but the client did not the witness sign or date the form. There was no documentation that identified the client was unable to sign the
document.
Record #7, 10, 11 and 14 consent to release form for the Bucks County Drug and Alcohol Case Management Service Unit exceeded 255.5 by requesting:
Medical /social/occupational and family histories.
Treatment plans
Referral contacts
Consultation and conversation with service provider
Copies of correspondence
Clients record of Service
Record #14 and 15 consent to release form for the Bucks County Council of Alcoholism and Drug Dependence exceeded 255.5 by requesting:
Clarifying or getting feedback on treatment related issues
Discharge summary
Copy of assessment and DUI requirements
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Plan of Correction
Clincial supervisor will meet with all staff to review confidentiality policy and procedure in January. Staff will be reminded of the importance of making sure clients sign and date all release forms.
Additionally, the director is working with Bucks County to see if there is a solution to the conflict of their paperwork. The county's paperwork, required to fund clients, exceeds 255.5. Director of our facility and of the SAC are in the process of discussing this issue and attempting to come to a resolution that will resolve this issue for us now and in the future. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to complete psychosocial evaluations in two of three client records.
Findings:
Twenty records were reviewed on December 3, 2008 and December 4, 2008. Psychosocial evaluations were required in three client records. The psychosocial evaluations did not include clinical assessments of the assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and the counselor's impression of the client in client records #1 and 2.
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Plan of Correction
Inpatient/Detox clinical supervisor will hold a mandatory clincial staff meeting to discuss several major issues. One of the issues discussed will be what information is expected to be on the biopsychosocial evalation. Additionally, the director will ammend the BPS form to include specific sections for the missing information. BPS will not be able to print out with missing information, so this should not be an issue in the future. Clinical supervisor will oversee this POC to assure BPS's are being completed accurately and completely. |
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 on a review of client records, the facility failed to document discharge summaries in two of three client records.
Findings:
Twenty records were reviewed on December 3, 2008 and December 4, 2008. Discharge summaries were required in three client records. In accordance with the facility's policy and procedures, reviewed on December 1, 2008, a client's discharge summary will be completed within seven days of their discharge. The discharge summary was not document in record #2. Client # 2 was discharged on 11/21/08; there was no discharge summary in the client record. Additionally, client #3 was discharged on 7/4/08; the discharge summary was not completed until 7/21/08, seventeen days following discharge.
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Plan of Correction
Inpatient/Detox clinical supervisor will discuss at the mandatory clinical staff meeting in January the facility's policy and procedure regarding dc summaries for the detox program. Staff will be reminded of the importance of timely completion of dc summaries. Clinical supervisor will oversee this POC by period chart checking and via the computer system which will alert supervisor if paperwork is not completed by due date. |
709.63(a)(8) LICENSURE Follow-up Information
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:
(8) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in two of three client records.
Findings:
Twenty records were reviewed on December 3, 2008 and December 4, 2008. Follow-up information was required in three client records. In accordance with the facility's policy and procedure manual reviewed on December 1, 2008, the facility had seven days to complete a follow-up once a client is discharged. Client #3 was discharged on 7/4/08; the record did not contain follow-up information.
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Plan of Correction
Inpatient/Detox clinical supervisor will hold a mandatory staff meeting in January to review the facility's policy and procedure for follow ups. Staff will be reminded of the importance of timely completion of follow ups for all clients discharged from the detox program. Clinical supervisor will oversee this POC by periodic chart check and computer monitoring of paperwork completion. |
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 a review of client records, the facility failed to complete psychosocial evaluations in three of six client records.
Findings:
Twenty records were reviewed on December 3, 2008 and December 4, 2008. Psychosocial evaluations were required in six client records. The psychosocial evaluations failed to document a clinical assessment of the assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and the counselor's impression of the client in client records #4, 5 and 6.
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Plan of Correction
Inpatient clinical supervisor will hold a mandatory clincal staff meeting in January to discuss what information is to be included on the BPS. Clinical staff will be reminded of the importance of accuretly and completely evaluating the client. Additionally, the director will add sections to the current BPS form to include to missing sections. BPS will not be able to print with missing information, assuring the record will be complete. Clinical supervisor will oversee this POC by period chart check and via the computer system. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 a review of client records, the facility failed to complete treatment plans in three of six client records.
Findings:
Twenty records were reviewed on December 3, 2008 and December 4, 2008. Treatment plans were required in six client records. The facility's policy and procedure reviewed on December 1, 2008 stated that treatment plans are to be completed within 72 hours following admission date. Client # 4 was admitted on 11/10/08; the treatment plan was not completed until 11/24/08. Client #5 was admitted on 11/4/08; the treatment plan was not completed until 11/13/08. Client # 6 was admitted on 11/17/08; the treatment plan was not completed until 11/30/2008.
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Plan of Correction
It became clear during the site visit that for some reason, while being completed on time, the treatment plans are not being printed out and signed in a timely manner. Inpatient clinical supervisor will, at the January clinical meeting, discuss this issue with clinical staff. Clinical staff will be reminded of the importance of timely completion and signing of the treatment plans. Clinical supervisor will oversee this POC by periodic chart check to assure treatment plans are being signed at time of completion. |
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, the facility failed to complete progress notes in three of six client records.
Findings:
Twenty records were reviewed on December 3, 2008 and December 4, 2008. Progress notes were required in six client records. The facility failed to include the therapist's assessment in group notes for client records #4, 5 and 6.
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Plan of Correction
Inpatient clinicians are not consistently documenting individual sessions and are not including adequate assessment of the clients in the group notes. Inpatient clinical supervisor will meet with clinical staff in January to discuss what is expected in a group note, to assure clinicians are aware of the need for more substantial groups notes. Clinical staff will also be reminded of the importance of documenting all interactions with clients and timely completion of individual and group notes. Clinical supervisor will oversee this POC by period chart check and via the computer monitoring system. |
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 a review of client records, the facility failed to document follow-up information in three of six client records.
Findings:
Twenty records were reviewed on December 3, 2008 and December 4, 2008. Follow-up information were required in six client records. In accordance with the facility's policy and procedure manual reviewed on December 1, 2008, the facility has seven days after the client discharge to complete a follow-up inquiry. Client #7 was discharged on 10/17/08; there was no documentation of follow-up efforts in the client record. Client record #8 was discharged on 6/29/08; there was no documentation of follow-up efforts in the client record. Client #9 was discharged on 10/17/08; there was no documentation of follow-up efforts in the client record.
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Plan of Correction
Inpatient clinical supervisor will review with inpatient staff at the January staff meeting the facility's policy and procedure for follow ups. Clinical supervisor will stress the importance of timely completion of all follow ups. Clinical supervisor will oversee this POC by periodic chart check and via computer monitoring. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to complete psychosocial evaluations in two of seven client records.
Findings:
Twenty records were reviewed on December 3, 2008 and December 4, 2008. Psychosocial evaluations were required in seven client records. The psychosocial evaluations failed to include a clinical assessment of the assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor's impression of the client. Client #14 was admitted 9/16/08; review of the documentation in the client's record revealed that the facility failed to document all objectives of the psychosocial evaluation in the patient record. Client #15 was admitted 7/25/08; review of the documentation in the client's record revealed that the facility failed to document all objectives of the psychosocial evaluation in the patient record.
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Plan of Correction
Outpatient clinical supervisor will have a mandatory clinical staff meeting in January to discuss several important issues with outpatient clinical staff. One important issue will be to discuss with staff what information is expected in the biopsychosocial evaluation. Staff will be made aware of the importance of completing BPS. Additionally, the director will update the current form to include sections specifically addressing the missing areas of information. The BPS cannot be printed out with blank sections, thus assuring the completeness of the evaluation. Clinical supervisor will oversee this POC by periodic chart check and monitoring via the computer system. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 a review of client records, the facility failed to complete treatment plans in two of seven client records.
Findings:
Twenty records were reviewed on December 3, 2008 and December 4, 2008. Treatment plans were required in seven client records. In accordance with the facility's policy and procedure manual, treatment plans are to be completed within 30 days of the client's admission. Client #14 was admitted on 9/16/08 and client #15 was admitted on 7/25/08, neither client had a treatment plan.
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Plan of Correction
Outpatient supervisor will discuss the importance of timely completion of treatment plans with clinical staff at the meeting in January. Clinical staff will be reminded of the facility's policy and procedure regarding the time frame for completion of the treatment plan. Clinical supervisor will oversee this POC by periodic chart check and monitoring via the computer system which will alert supervisor of late paperwork. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to complete progress notes in three of seven client records.
Findings:
Twenty records were reviewed on December 3, 2008 and December 4, 2008. Progress notes were required in seven client records. The facility did not document the therapist's assessment of the client in group notes for records #14, 15 and 16.
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Plan of Correction
Clinical supervisor of the outpatient program will meet with all clinical staff at a mandatory meeting in January. Staff will be informed of what constitutes proper assessment of groups in the group note. Staff will be reminded of the importance of thorough documention in the client record. Clinical supervisor will oversee this POC by periodic chart check and via monitoring of group notes via the computer system. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records and the facilities policy and procedure manual, the facility failed to document case consultation notes in one of seven client records.
Findings:
Twenty client records were reviewed on December 3,2008 and December 4, 2008. Case consultation notes were required in one client record. The facility's policy stated that case consultations are to be completed every 90 days from the clients admit date. The facility did not document case consultation notes in client record #15; client #15 was admitted on 7/25/08 and a case consultation notes was due on 10/25/08.
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Plan of Correction
Outpatient clinical supervisor will discuss with outpatient clinical staff at the mandatory meeting in January the facility's policy and procedure regarding case conferences. The clinical staff will be reminded of the need to complete case conferences every 90 days. Computer system will alert both clinicians and the clinical supervisor when these are due on all clients. Clinical supervisor will oversee this POC by periodic chart check and through the computer monitoring system. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records, the facility failed to document aftercare plans in two of seven client records.
Findings:
Twenty records were reviewed on December 3, 2008 and December 4, 2008. Aftercare plans were required in two seven record. The facility did not document aftercare plans in client record #20. Client #20 was discharged on 9/10/08 and in accordance with the facility's policy and procedure for aftercare plans they were to be completed prior to discharge.
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Plan of Correction
Outpatient clinical supervisor will discuss the facility's policy and procedure for aftercare plans for outpatient clients at the January staff meeting. Staff will be reminded of the importance of timely completion of aftercare plans prior to a client's discharge. Clinical supervisor will oversee this POC by periodic chart check and via computer monitoring system. |
709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document discharge summaries in two of seven client records.
Findings:
Twenty records were reviewed on December 3, 2008 and December 4, 2008. Discharge summaries were required in two of seven records. In accordance with the facility's policy and procedure manual reviewed on December 1, 2008, the facility will complete a discharge summary within seven days of a patient's discharge. Client #17 had a discharge summary completed on 10/2/08 and the client discharge date was 8/8/08. Client #20 had a discharge summary completed on 10/2/08 and the client discharge date was 9/10/08.
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Plan of Correction
Outpatient clinical supervisor will discuss the facility's policy and procedure for discharge summaries for outpatient clients at the mandatory staff meeting in January. Staff will be reminded of the need to complete discharge summaries within seven days. Clinical staff and supervisors will be made aware of due dates of discharge summaries via the computer system which will alert clinicians and the supervisors of due dates. Clinical supervisor will oversee this POC by periodic chart check and via the computer system. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in three of seven client records.
Findings:
Twenty records were reviewed on December 3, 2008 and December 4, 2008. Follow-up information was required in seven client records. In accordance with the facility's policy and procedure manual reviewed on December 1, 2008, the facility was required to perform a follow-up within seven days of a client's discharge. Client record #17 was discharged on 08/08/08; there was no documentation of follow-up. Client record #18 was discharged on 8/28/08; there was no documentation of follow-up. Client record #19 was discharged on 6/18/08; there was no documentation of follow-up.
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Plan of Correction
Clinical supervisor will review with outpatient staff at the January staff meeting, the facility's policy and procedure for follow ups for outpatient clients. Staff will be reminded of the importance of timely completion of client follow ups. Due dates will be made aware to clinicians and supervisors via computer system. Clinical supervisor of outpatient program will oversee this POC by periodic chart check and via the computer monitoring system. |