INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 8 - 9, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Freedom Healthcare Services, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
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Plan of Correction
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704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
Based on a review of the facility's policy manual and Staffing Requirements Facility Summary Report, the facility failed to document a comprehensive staff development program policy and procedure indicating the time frames for the required components.
The findings include:
The facility's policy and procedure manual was reviewed on March 8, 2012. The facility's policy titled "Staff Development Program" does not document the actual training year of the facility. Based on observation of the Staffing Requirements Facility Summary Report, the facility's training year is from January 1 through December 31.
The policy states that "an assessment of staff training needs and the overall training plan are conducted in the first quarter of each calendar year". Since the training year begins on January 1, the assessment of staff training needs should be conducted prior to the start of the training year. The assessment results should then be utilized to complete the overall training plan by the beginning of the training year on January 1.
The policy regarding collecting training feedback does not indicate a time frame for collecting this information.
The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Since January 1 has already passed, this cannot be corrected this year.
An assessment of staff training needs and an overall training plan were completed by the Clinical Supervisor in March 2012.
The policy will be changed by the Clinical Supervisor by April 1, 2012.
In future years the assessment of staff training and overall training plan will be completed by the Clinical Supervisor by January 1. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to document individual training plans by the onset of the training year in eight of eight personnel records.
The findings include:
Thirteen personnel records were reviewed on March 8 - 9, 2012. Nine personnel training records were reviewed for individual training plans. Per review of the Staffing Requirements Facility Summary Report, the facility's training year is from January 1 through December 31. The facility failed to document individual training plans by the onset of the training year in personnel training records # 1, 2, 3, 5, 6, 8, 9 and 10.
The training plan for employee # 1 was not completed until March 1, 2012. The training plan for employee # 2 was not completed until March 5, 2012. No training plans were documented for employees # 3, 5, 6, 8, 9 and 10, as of March 8 - 9, 2012.
The project/facility director was interviewed throughout the licensing process and confirmed the findings.
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Plan of Correction
Since January 1 has passed, this cannot be corrected this year.
Individual training plans have been completed for all employees at this time.
The policy will be changed by the Clinical Director to indicate that all training plans will be developed by January 1. The Project Director/Facility Director and Clinical Supervisor (jointly responsible for supervision of all employees)will develop training plans by January 1.
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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.
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Observations
Based on a review of personnel training records and the Staffing Requirements Facility Summary Report, the facility failed to provide documentation of communicable disease training in three of three personnel training records.
The findings include:
Thirteen personnel training records were reviewed on March 8, 2012. Three personnel training records were reviewed for documentation of communicable disease training. The facility failed to provide documentation of HIV/AIDS and TB/STD training in personnel training records # 12 and 13. The facility failed to document TB/STD training in personnel training record # 11.
Employee # 11 is a counselor and was hired on February 23, 2009. TB/STD training was due to be completed no later than February 23, 2010. The facility failed to provide documentation of TB/STD training for employee # 11.
Employee # 12 is support staff and was hired on August 18, 2009. HIV/AIDS and TB/STD training was due to be completed no later than August 18, 2011. The facility failed to provide documentation of HIV/AIDS and TB/STD training for employee # 12.
Employee # 13 is support staff and was hired on December 18, 2009. HIV/AIDS and TB/STD training was due to be completed no later than December 18, 2011. The facility failed to provide documentation of HIV/AIDS and TB/STD training for employee # 13.
The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the March 1 - 2, 2011 and January 20 - 21, 2011 licensing inspections.
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Plan of Correction
The Clinical Supervisor has created a training transcript for each counselor. Included on the transcript are the mandatory trainings.Each counselor is responsible for maintaining their own transcript, including documentation of mandatory trainings completed. Clinical Supervisor will review all transcripts quarterly in regular supervision and assure that each counselor has completed mandatory trainings within the described timeframe and submitted the certificate and evaluation form. Project Director will follow the same procedure for other staff. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records, CPR and first aid certification cards, the facility failed to ensure that a sufficient number of staff persons were trained in CPR.
The findings include:
Thirteen personnel records and employee CPR and first aid certification cards were reviewed on March 8 - 9, 2012. Only one full-time employee has CPR certification. If this employee is unavailable to work, the facility does not have any other employees with CPR certification to provide coverage. The facility failed to ensure that a sufficient number of staff persons were trained in CPR.
The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Project Director will schedule a training for a significant number of staff for CPR by June 1, 2012 to assure that a trainer person is on site at all hours of operation.
Staff will be surveyed by the Project Director and Clinical Supervisor to determine if others have First Aid training. Those who do will provide documentation for their personnel file. If a sufficient number do not, additional staff will be trained.
It is to be noted that a physician is on site 4 days/week from 9:00 a.m. to 1:00 p.m., and one evening from 2:00 p.m. to 7:00 p.m. and another 3:00 p.m. to 7:00 p.m. |
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.
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Observations
Based on a review of personnel training records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in two of two personnel records.
The findings include:
Two personnel records pertaining to counselors were reviewed for the completion of 25 clock hours of annual training on March 8, 2012. The facility failed to document 25 clock hours of annual training in personnel records # 9 and 10.
Employee # 9 was hired on January 28, 2010. The facility training year is from January through December. Employee # 9 only completed 20 clock hours of annual training from January 1, 2011 through December 31, 2011.
Employee # 10 was hired on September 28, 2009. The facility training year is from January through December. Personnel record # 10 did not include any documentation of annual training from January 1, 2011 through December 31, 2011.
The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The Clinical Supervisor has created a training transcript for each counselor. Each counselor is responsible for maintaining their own transcript. Clinical Supervisor will review all transcripts quarterly in regular supervision and assure that each counselor has completed a minimum of 25 hours of training by the end of the year and submitted the certificate and evaluation form. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to ensure that staff caseloads remained at or under 35:1.
The findings include:
The Staffing Requirements Facility Summary Report form was reviewed on March 8, 2012. The form listed the project/facility director, clinical supervisor and ten counselors. Only eight of these counselors are listed as having clients on their caseload. The facility failed to maintain counselor caseloads at 35 active clients to one FTE (full-time equivalent) counselor.
The facility's standard work week, as documented on the Staffing Requirements Facility Summary Report, was 35 hours per week.
Based on the total number of hours per week that the facility reported the counselors devoted to their clients, the total number of hours in the facility's standard work week (35), and the total number of clients assigned to the counselors on March 8, 2012, employees # 6, 9, 11 and 14 exceeded the allowable maximum 35:1 caseload.
Employee # 6 is a counselor and was hired on February 27, 2012. Employee # 6 has a caseload of 12 active clients and works 10 hours per week.
Employee # 6 (10 clinical hours/35 standard work week = .286 FTE 12 clients/.286 FTE = 42:1 caseload)
Employee # 9 is a counselor and was hired on January 28, 2010. Employee # 9 has a caseload of 42 active clients and works 40 hours per week.
Employee # 9 (40 clinical hours/35 standard work week = 1.14 FTE 42 clients/1.14 FTE = 37:1 caseload)
Employee # 11 is a counselor and was hired on February 23, 2009. Employee # 11 has a caseload of 45 active clients and works 40 hours per week.
Employee# 11 (40 clinical hours/35 standard work week = 1.14 FTE 45 clients/1.14 FTE = 40:1 caseload)
Employee # 14 is a counselor and was hired on December 2, 2009. Employee # 14 has a caseload of 52 active clients and works 40 hours per week.
Employee # 14 (40 clinical hours/35 standard work week = 1.14 FTE 52 clients/1.14 FTE = 46:1 caseload)
The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Effective immediately,the Clinical Director is monitoring all counselor caseloads weekly for counselor/patient ratios.
The ratio for employee #6 has been brought into complieance through an increase in the hours worked.
To ensure minimal impact on patients, May 1 has been set as the date to address other caseloads. By May 1, the ratios of employees 9, 11 and 14 will be brought into compliance through the following means: attrition and no new assignments, increase in work hours and transfer of patients. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill records, the facility failed to conduct unannounced fire drills at least once a month.
The findings include:
Fire drill records were reviewed for March 2011 through February 2012 on March 8, 2012. The facility failed to document unannounced fire drills for March 2011, October 2011, November 2011, December 2011, January 2012 and February 2012.
The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The Project director shall be responsible for conducting and documenting unannounced fire drills on a monthly basis.
During the fire drills, the smoke alarms will be tested and documented to be in working order. If they are found to be faulty they will be fixed within 3 days.
The fire drills will be documented and a count of staff and patients will be documented along with the exit used and the time taken to vacate the premesis.
The Project Director and the Clinical Director shall work together to make sure all fire drills are completed by the end of the month.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill records, the facility failed to set off a fire alarm or smoke detector during each fire drill.
The findings include:
Fire drill records for March 2011 through February 2012 were reviewed on March 8, 2012. The facility failed to conduct fire drills or set off a fire alarm or smoke detector during the following months: March 2011, October 2011, November 2011, December 2011, January 2012 and February 2012.
The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The Project director shall be responsible for conducting and documenting unannounced fire drills on a monthly basis.
During the fire drills, the smoke alarms will be tested and documented to be in working order. If they are found to be faulty they will be fixed within 3 days.
The fire drills will be documented and a count of staff and patients will be documented along with the exit used and the time taken to vacate the premesis.
The Project Director and the Clinical Director shall work together to make sure all fire drills are completed by the end of the month.
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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 on a review of administrative material, the governing body failed to make available to the public the 2010 annual report.
The findings include:
Administrative material was reviewed on March 8, 2012. Per the project/facility director, the facility has received public funds since 2010. The facility failed to document and make available to the public an annual report for 2010.
The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The President shall be responsible for completing an Annual report. The Annual report shall be completed no later than June 30 for the preceding year.
The report for 2011 shall be available by June 30, 2012 and shall be inclusive of that portion of calendar year 2010 from the date the Freedom opened.
The availability of the annual report shall be communicated to the public on our website: www.freedomtreatment.com
The website has been submitted to the PA Dept. of Health and there should be a link from PA Dept of Health.
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709.23(b)(3) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(3) A performance report summarizing the progress towards meeting goals and objectives.
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Observations
Based on a review of administrative material, the facility failed to complete a performance report summarizing the progress towards meeting goals and objectives for the year ended December 31, 2011.
The findings included:
Administrative material was reviewed on March 8, 2012. The project/facility reported the facility operates on a calendar year. The project/facility director confirmed that the facility failed to complete a performance report summarizing the progress towards meeting goals and objectives for the 2011 calendar year.
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Plan of Correction
The Project Director will complete a summary of progress towards 2011 goals shall be completed no later than April 15, 2012.
A summary of progress towards 2012 goals shall be completed no later than December 20, 2012 and prior to December 20th in subsequent years. This shall remain the responsibility of the President/Project Director.
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative material, the project failed to complete an annual audit by fiscal year end, December 31, 2009 and December 31, 2010.
The findings include:
Administrative material was reviewed on March 8 - 9, 2012. The project's fiscal year is from January through December. The facility failed to document an annual audit by fiscal year end, December 31, 2009 and December 31, 2010.
The project/facility director was interviewed throughout the licensing inspection and confirmed that a fiscal audit for 2009 and 2010 has not been completed by the project, as of March 8 - 9, 2012.
This is a repeat citation from the March 1 - 2, 2011 licensing inspection.
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Plan of Correction
Freedom Healthcare will have an independent fiscal audit for fiscal year(s) 2009, 2010 and 2011 completed by June 30 2012.
The President/Project Director shall be responsible for having this completed by June 30 , 2012.
The outside independent firm shall or other accounting firm shall do an independent audit as required in the future. The President/Project Director shall insure that this is completed on an annual or as required basis, whichever is less frequent.
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709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records, the facility failed to document annual performance evaluations, as required by agency policy, in three of three personnel records.
The findings include:
Thirteen personnel records were reviewed on March 8, 2012. Three personnel records were required to include documentation of annual performance evaluations. Per agency policy, performance evaluations are completed annually on the anniversary date of the employee. The facility failed to document annual performance evaluations by the anniversary date of employees # 1, 9 and 10.
Employee # 1 was hired on September 20, 2010. An annual performance evaluation was due to be completed no later than September 20, 2011. Personnel record # 1 did not include documentation on an annual performance evaluation.
Employee # 9 was hired on January 28, 2010. An annual performance evaluation was due to be completed no later than January 28, 2012. The performance evaluation for employee # 9 was not documented until February 29, 2012.
Employee # 10 was hired on September 28, 2009. An annual performance evaluation was due to be completed no later than September 28, 2011. The performance evaluation for employee # 10 was not completed until March 6, 2012.
The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
By June 1, policy will be revised by Project Director to indicate that annual evaluations are due annually, two weeks prior to or after date of hire. A reminder system with date of hire of all employees will be created by the Administrative Assistant. Project Director is responsible for monitoring all performance evaluations. Projector Director, Clinical Supervisor and Medical Director are responsible for completing all evaluations. |
709.26(e) 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:
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Observations
Based on a review of the employee handbook, personnel records and a physical plant inspection, the facility failed to demonstrate efforts toward informing staff of employee rights in four of five personnel records.
The findings include:
Thirteen personnel records were reviewed on March 8, 2012. Five personnel records pertained to a newly hired employees and were reviewed for documentation of employee rights. A review of the facility's employee handbook documented an employee rights policy. New employees are provided an employee handbook during orientation. The employee then signs off that they received a copy of this handbook. The facility failed to inform employees # 2, 5, 6 and 8 of their employee rights.
Employee # 2 was hired on October 20, 2011. Employee record # 2 did not include documentation that employee # 2 received a copy of the handbook containing employee rights.
Employee # 5 was hired on October 11, 2011. Employee record # 5 did not include documentation that employee # 5 received a copy of the handbook containing employee rights.
Employee # 6 was hired on February 27, 2012. Employee record # 6 did not include documentation that employee # 6 received a copy of the handbook containing employee rights.
Employee # 8 was hired on July 1, 2011. Employee record # 8 did not include documentation that employee # 8 received a copy of the handbook containing employee rights.
A physical plant inspection was conducted on March 9, 2012. During this inspection, employee rights were not observed to be posted in the facility.
The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The project director shall insure that the employee rights form is reviewed and acknowledged by any current employees.
An employee rights form shall be reviewed and acknowledged/signed by any new employees hired after April 1, 2012. This shall be signed by the potential employee when a candidate accepts an offer for employment.
A current employee rights form shall be created by April 1, 2012.
The Project Director shall review all new employee files to insure that all required documents are part of the employee file and sign off that the file is complete within 14 days of the employees hire date.
The project Director shall create a new checklist form for all new employees files prior to April 1, 2010.
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709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based on a review of personnel records, the facility failed to document written job descriptions in four of five personnel records.
The findings include:
Thirteen personnel records were reviewed on March 8, 2012. Five personnel records pertained to newly hired employees and were reviewed for documentation of job descriptions. The facility failed to document job descriptions for employees # 2, 5, 6 and 8.
Employee # 2 was hired on October 20, 2011. Employee record # 2 did not include documentation of a job description.
Employee # 5 was hired on October 11, 2011. Employee record # 5 did not include documentation of a job description.
Employee # 6 was hired on February 27, 2012. Employee record # 6 did not include documentation of a job description.
Employee # 8 was hired on July 1, 2011. Employee record # 8 did not include documentation of a job description.
The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The project director shall insure that a written job description is reviewed and signed by any current employees.
A job Description shall be reviewed and signed by any new employees hired after April 1, 2012. This shall be signed by the potential employee when a candidate accepts an offer for employment.
The Project Director shall review all new employee files to insure that all required documents are part of the employee file and sign off that the file is complete within 14 days of the employees hire date.
The project Director shall create a new checklist form prior to April 1, 2010. |
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 a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in two of six client records.
The findings include:
Twelve client records were reviewed on March 8 - 9, 2012. Six client records were reviewed for documentation of informed and voluntary consents from the client. The facility accessed the Internet site of a funding entity to confirm the client's current insurance coverage. Prior to releasing client information to this funding entity, the facility failed to document an informed and voluntary consent from the client in client records # 2 and 5
The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the March 1 - 2, 2011 licensing inspection.
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Plan of Correction
A new consent specifically for checking insurance coverage and benefits will be incorporated into the consent forms required to be signed by the patient prior to beginning the intake/admission process.
This form was developed on March 26,2012 2012 and will be implemented no later than April 1, 2012.
The Clinical Director shall monitor new patient charts to insure that the form is being utilized and filled out correctly and signed by the patient. |
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 document a psychosocial evaluation that provided a composite picture of the individual in relationship to the collected historical information in six of six client records.
Twelve client records were reviewed on March 8 - 9, 2012. Six client records were reviewed for psychosocial evaluations. The facility failed to provide a composite picture of the individual in relationship to the collected historical information in client records # 1, 2, 3, 4, 5 and 6.
The findings include:
Client # 1 was admitted into treatment on August 18, 2011. The psychosocial evaluation was completed on August 18, 2011. The facility failed to document a psychosocial evaluation that provided a composite picture of the individual in relationship to the collected historical information.
Client # 2 was admitted into treatment on September 21, 2011. The psychosocial evaluation was completed on September 19, 2011. The facility failed to document a psychosocial evaluation that provided a composite picture of the individual in relationship to the collected historical information.
Client # 3 was admitted into treatment on November 3, 2011. The psychosocial evaluation was completed on November 3, 2011. The facility failed to document a psychosocial evaluation that provided a composite picture of the individual in relationship to the collected historical information.
Client # 4 was admitted into treatment on October 6, 2011. The psychosocial evaluation was completed on October 6, 2011. The facility failed to document a psychosocial evaluation that provided a composite picture of the individual in relationship to the collected historical information.
Client # 5 was admitted into treatment on September 20, 2011. The psychosocial evaluation was completed on September 20, 2011. The facility failed to document a psychosocial evaluation that provided a composite picture of the individual in relationship to the collected historical information.
Client # 6 was admitted into treatment on December 22, 2011. The psychosocial evaluation was completed on December 22, 2011. The facility failed to document a psychosocial evaluation that provided a composite picture of the individual in relationship to the collected historical information.
The project/facility director was interviewed throughout the licensing process and confirmed the findings.
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Plan of Correction
The format for the psychosocial evaluation was revised. A new form was created. Staff was trained in using the new psychosocial on 3/12/12 and it was implemented the same day. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type of treatment and rehabilitation services in four of six client records.
The findings include:
Twelve client records were reviewed on March 8 - 9, 2012. Six individual treatment and rehabilitation plans were reviewed for the type of treatment services. The facility failed to document the type of treatment and rehabilitation services in client records # 1, 2, 3, 4 and 5.
Client # 1 was admitted into treatment on August 18, 2011. An individual treatment and rehabilitation plan was developed with the client on September 15, 2011. The treatment plan did not specify the type of treatment and rehabilitation services.
Client # 2 was admitted into treatment on September 21, 2011. An individual treatment and rehabilitation plan was developed with the client on October 19, 2011. The treatment plan did not specify the type of treatment and rehabilitation services.
Client # 3 was admitted into treatment on November 3, 2011. An individual treatment and rehabilitation plan was developed with the client on December 8, 2011. The treatment plan did not specify the type of treatment and rehabilitation services.
Client # 4 was admitted into treatment on October 6, 2011. An individual treatment and rehabilitation plan was developed with the client on November 4, 2011. The treatment plan did not specify the type of treatment and rehabilitation services.
Client # 5 was admitted into treatment on September 20, 2011. An individual treatment and rehabilitation plan was developed with the client on October 20, 2011. The treatment plan did not specify the type of treatment and rehabilitation services.
The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The Clinical Supervisor reviewed with the staff on 3/12/2012 the correct way to document type and frequency of treatment services. Staff were directed to complete treatment plans in the described manner from that day forward. Clinical Supervisor will monitor upon signing each treatment plan |
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 the facility's policy and procedure manual and client records, the facility failed to document follow-up information in six of six client records.
The findings include:
Twelve client records were reviewed on March 8 - 9, 2012. Six client records were closed and required documentation of a follow-up attempt. Per agency policy, a follow-up will be conducted within 90 days of discharge. The facility failed to conduct a follow-up within 90 days of discharge in client records # 7, 8, 9, 10, 11 and 12.
Client # 7 was admitted into treatment on June 24, 2011 and discharged on September 30, 2011. A follow-up attempt was due to be completed no later than December 30, 2011. The facility failed to provide documentation of a follow-up attempt as of March 8 - 9, 2012.
Client # 8 was admitted into treatment on September 22, 2011 and discharged on November 17, 2011. A follow-up attempt was due to be completed no later than February 17, 2012. The facility failed to provide documentation of a follow-up attempt as of March 8 - 9, 2012.
Client # 9 was admitted into treatment on August 4, 2011 and discharged on September 9, 2011. A follow-up attempt was due to be completed no later than December 9, 2011. The facility failed to provide documentation of a follow-up attempt as of March 8 - 9, 2012.
Client # 10 was admitted into treatment on July 28, 2011 and discharged on October 7, 2011. A follow-up attempt was due to be completed no later than January 7, 2012. The facility failed to provide documentation of a follow-up attempt as of March 8 - 9, 2012.
Client # 11 was admitted into treatment on August 22, 2011 and discharged on October 7, 2011. A follow-up attempt was due to be completed no later than January 7, 2012. The facility failed to provide documentation of a follow-up attempt as of March 8 - 9, 2012.
Client # 12 was admitted into treatment on July 11, 2011 and discharged on October 1, 2011. A follow-up attempt was due to be completed no later than January 1, 2012. The facility failed to provide documentation of a follow-up attempt as of March 8 - 9, 2012.
The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Effective immediately, all patients discharged since 01/01/12 will be contacted for follow up within 90 days by the Clinical Supervisor or her designee. By June 1, 2012, the follow up policy, questionnaire and protocol will be reviewed and revised. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on the review of client census information, the facility failed to comply with the maximum approved capacity for the outpatient treatment activity.
The findings include:
On March 6, 2012, client census information provided by the project/facility director and an interview with the project/facility director confirmed that the current census for active clients receiving outpatient other chemotherapy was at 221. The maximum approved capacity on the day of the inspection for outpatient other chemotherapy clients was 200.
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Plan of Correction
Today, Freedom received a license for Outpatient Detox (15), Outpatient Drug-Free (35)Outpatient and Other Chemotherapy (235). Today's census is 226. Freedom is in compliance with the maximum approved capacity.
The Clinical Director will daily monitor the census and assure future compliance.
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