INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 28 and 31, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Gaudenzia Inc. West Chester 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records on January 28 and 31, 2020, employee # 6 did not have a qualifying degree to be in the position of counselor.
Employee # 6 was hired as a counselor assistant on August 24, 2015 and promoted to a counselor position on December 10, 2018. The employee was promoted without a qualifying degree.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 2/3/2020 Director completed proper paperwork to reflect position change for employee #6 from Counselor to Counselor Assistant 3. Employee #6 will stay in the position until a Bachelor's degree is obtained later this year. Director will make sure that all clinical positions are lined up with DDAP regulations prior to any promotions. |
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.
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Observations
During an onsite physical plant inspection conducted on January 28 and 31, 2020, the facility failed to maintain 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. Male room # 2 had a hole in the floor against the back wall under the window.
This is repeat citation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/31/2020 Director moved the two members that were residing in dorm #2. On 2/20/2020 dorm #2 floor was replaced. Director has implemented tour checklist that includes all dorms to be checked during tours several times throughout the day. Any issues observed are reported to Director, House Manager Supervisor and a maintenance order is completed so that the issue can be addressed. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection conducted on January 28 and 31, 2020, the facility was unable to ensure privacy so that counseling sessions could not be heard outside the counseling room. While reviewing client records in the physician ' s office, a group session could be heard that was being conducted in another office in the same hallway area.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 2/3/2020 Director ensured that a noise machine is placed outside of every counseling room. The noise machine will help with the privacy of any clinical activity. Director or Designee will make sure that the noise machines are utilized daily by all clinical staff staff. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a physical plant inspection and review of the facility fire drill log on January 28 and 31, 2020, the facility was unable to provide documentation of a fire drill being conducted during sleeping hours at least every six months.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 2/3/2020 Director generated a schedule that includes fire drills for each shift during each quarter. This schedule will ensure that each shift is conducting a fire drill each quarter. The schedule will eliminate the facility to be out of compliant moving forward. Director and/or Designee will check the fire drill log and schedule monthly to make sure the facility is in compliance. |
709.26 (a) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(2) Rules of conduct.
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Observations
Based on a review of the facilities policy and procedure manual on January 28 and 31, 2020, the written project personnel policies and procedures did not specifically include rules of conduct.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director will ensure that a copy of the employee handbook is kept on site. This handbook includes the employee code of conduct. In addition all employees are trained on the Employee Code of Conduct at hire. A copy has has been forwarded for review. |
709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on seven out of seven client records reviewed on January 28 and 31, 2020, the facility failed to provide a consent to release form to the client limiting the information to be released within the limits of 4 Pa. Code 255.5 (b).
Client # 1 was admitted on December 2, 2019 and was still an active client at the time of the inspection. A consent to release form to a funding agency dated December 2, 2019 allowed for the release of psychological/psychiatric evaluations, treatment plans, case consultations, mental health, physical, and medical records, progress notes, and assessments.
Client # 2 was admitted on November 8, 2019 and was still an active client at the time of the inspection. A consent to release form to a funding agency and probation officer dated November 8, 2019 allowed for the release of psychological/psychiatric evaluations, treatment plans, case consultations, mental health, physical, and medical records, progress notes, and assessments.
Client # 3 was admitted on December 19, 2019 and was still an active client at the time of the inspection. A consent to release form to a funding agency and probation officer dated December 19, 2019 allowed for the release of psychological/psychiatric evaluations, treatment plans, case consultations, mental health, physical, and medical records, progress notes, and assessments.
Client # 4 was admitted on January 10, 2020 and was still an active client at the time of the inspection. A consent to release form to a funding agency and probation officer dated January 10, 2020 allowed for the release of psychological/psychiatric evaluations, treatment plans, case consultations, mental health, physical, and medical records, progress notes, and assessments.
Client # 5 was admitted on August 26, 2019 and was discharged on October 24, 2019. A consent to release form to a funding agency and probation officer dated August 26, 2019 allowed for the release of psychological/psychiatric evaluations, treatment plans, case consultations, mental health, physical, and medical records, progress notes, and assessments.
Client # 6 was admitted on August 21, 2019 and was discharged on October 2, 2019. A consent to release form to a funding agency dated August 21, 2019 allowed for the release of psychological/psychiatric evaluations, treatment plans, case consultations, mental health, physical, and medical records, progress notes, and assessments.
Client # 7 was admitted on September 7, 2019 and was discharged on October 2, 2019. A consent to release form to a funding agency dated September 7, 2019 allowed for the release of psychological/psychiatric evaluations, treatment plans, case consultations, mental health, physical, and medical records, progress notes, and assessments.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director or designee will ensure that all current members have read and signed the orientation sign off form as well as have signed consents to release form requesting only the limited information allowed. Director or designee will review all new intakes by the 3rd day of admission to ensure that all client records include the appropriate consents and release of information for each client. This will also be monitored in regular chart audits both by program management and the CQI team. |
709.32 (c) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
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Observations
Based on a review of the facilities policy and procedure manual on January 28 and 31, 2020, the facility failed to implement a written policy and procedure regarding the use of Vivitrol.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Director will ensure that the written policy and procedure for the use of Vivitrol is available on site. Gaudenzia does have a written policy and procedure regarding medication use by clients. This policy does include the use of Vivitrol. A copy has been forwarded for review. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Based on a review of the project ' s policy and procedure manual on January 28 and 31, 2020, the project failed to provide procedures for responding to a physical assault or sexual assault by staff or a client.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Gaudenzia CQI Director will revise the Gaudenzia Incident policy to address all elements of the 709.34 regulations. This will be completed by 3/14/20 and distributed to staff. The Program Director will review these policy revision with staff in staff meetings, and will immediately implement all changes to procedure. These changes will also be monitored and discussed in the regular monthly CQI meeting to ensure compliance. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on a review of the project ' s policy and procedure manual on January 28 and 31, 2020 the project failed to develop and implement procedures in responding to selling or use of illicit drugs on the premises.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Gaudenzia CQI Director will revise the Gaudenzia Incident policy to address all elements of the 709.34 regulations. This will be completed by 3/14/20 and distributed to staff. The Program Director will review these policy revision with staff in staff meetings, and will immediately implement all changes to procedure. These changes will also be monitored and discussed in the regular monthly CQI meeting to ensure compliance. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
Based on a review of the project ' s policy and procedure manual on January 28 and 31, 2020, the project failed to develop and implement procedures in responding to death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Gaudenzia CQI Director will revise the Gaudenzia Incident policy to address all elements of the 709.34 regulations. This will be completed by 3/14/20 and distributed to staff. The Program Director will review these policy revision with staff in staff meetings, and will immediately implement all changes to procedure. These changes will also be monitored and discussed in the regular monthly CQI meeting to ensure compliance. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on a review of the project ' s policy and procedure manual on January 28 and 31, 2020, the project failed to develop and implement procedures in responding to theft, burglary, break-in or similar incident at the facility.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Gaudenzia CQI Director will revise the Gaudenzia Incident policy to address all elements of the 709.34 regulations. This will be completed by 3/14/20 and distributed to staff. The Program Director will review these policy revision with staff in staff meetings, and will immediately implement all changes to procedure. These changes will also be monitored and discussed in the regular monthly CQI meeting to ensure compliance. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the project ' s policy and procedure manual on January 28 and 31, 2020, the project failed to develop and implement procedures in responding to event at the facility requiring the presence of police, fire or ambulance personnel.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Gaudenzia CQI Director will revise the Gaudenzia Incident policy to address all elements of the 709.34 regulations. This will be completed by 3/14/20 and distributed to staff. The Program Director will review these policy revision with staff in staff meetings, and will immediately implement all changes to procedure. These changes will also be monitored and discussed in the regular monthly CQI meeting to ensure compliance. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
Based on a review of the project ' s policy and procedure manual on January 28 and 31, 2020, the project failed to develop and implement procedures in responding to fire or structural damage to the facility.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Gaudenzia CQI Director will revise the Gaudenzia Incident policy to address all elements of the 709.34 regulations. This will be completed by 3/14/20 and distributed to staff. The Program Director will review these policy revision with staff in staff meetings, and will immediately implement all changes to procedure. These changes will also be monitored and discussed in the regular monthly CQI meeting to ensure compliance. |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
Based on a review of the project ' s policy and procedure manual on January 28 and 31, 2020, the project failed to develop and implement procedures in responding to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Gaudenzia CQI Director will revise the Gaudenzia Incident policy to address all elements of the 709.34 regulations. This will be completed by 3/14/20 and distributed to staff. The Program Director will review these policy revision with staff in staff meetings, and will immediately implement all changes to procedure. These changes will also be monitored and discussed in the regular monthly CQI meeting to ensure compliance. |
709.34 (b) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(1) Documentation of the unusual incident.
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Observations
Based on a review of the project ' s policy and procedure manual on January 28 and 31, 2020, the manual did not provide a procedure on documenting unusual incidents.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Gaudenzia CQI Director will revise the Gaudenzia Incident policy to address all elements of the 709.34 regulations. This will be completed by 3/14/20 and distributed to staff. The Program Director will review these policy revision with staff in staff meetings, and will immediately implement all changes to procedure. These changes will also be monitored and discussed in the regular monthly CQI meeting to ensure compliance. |
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
Based on a review of the project ' s policy and procedure manual on January 28 and 31, 2020, the manual did not provide a procedure on the prompt review and identification of the causes directly or indirectly responsible unusual incidents.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Gaudenzia CQI Director will revise the Gaudenzia Incident policy to address all elements of the 709.34 regulations. This will be completed by 3/14/20 and distributed to staff. The Program Director will review these policy revision with staff in staff meetings, and will immediately implement all changes to procedure. These changes will also be monitored and discussed in the regular monthly CQI meeting to ensure compliance. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
Based on a review of the project ' s policy and procedure manual on January 28 and 31, 2020, the manual did not provide a procedure on the implementation of a timely and appropriate corrective action plan for an unusual incident, when indicated.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Gaudenzia CQI Director will revise the Gaudenzia Incident policy to address all elements of the 709.34 regulations. This will be completed by 3/14/20 and distributed to staff. The Program Director will review these policy revision with staff in staff meetings, and will immediately implement all changes to procedure. These changes will also be monitored and discussed in the regular monthly CQI meeting to ensure compliance. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
Based on a review of the project ' s policy and procedure manual on January 28 and 31, 2020, the manual did not provide a procedure on the ongoing monitoring of the corrective action plan for an unusual incident.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Gaudenzia CQI Director will revise the Gaudenzia Incident policy to address all elements of the 709.34 regulations. This will be completed by 3/14/20 and distributed to staff. The Program Director will review these policy revision with staff in staff meetings, and will immediately implement all changes to procedure. These changes will also be monitored and discussed in the regular monthly CQI meeting to ensure compliance. |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
Based on a review of the project ' s policy and procedure manual on January 28 and 31, 2020, the manual did not provide a procedure on a reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Gaudenzia CQI Director will revise the Gaudenzia Incident policy to address all elements of the 709.34 regulations. This will be completed by 3/14/20 and distributed to staff. The Program Director will review these policy revision with staff in staff meetings, and will immediately implement all changes to procedure. These changes will also be monitored and discussed in the regular monthly CQI meeting to ensure compliance. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
During a review of the project ' s unusual incident log on January 28 and 31, 2020, the project failed to report incidents at the facility to the department that required the presence of police, fire, or ambulance personnel.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Program Director will, in staff meetings during the week of 3/2/20, review with all staff members the procedure for reporting all incidents requiring the presence of police, fire, or ambulance personnel to the department. Compliance with this regulation will be monitored by the Program Director following each such incident. |
709.51(b)(2)(i) LICENSURE Client Orientation to Project
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(i) Project policies.
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Observations
Based on seven of seven client records reviewed on January 28 and 31, 2020, the facility failed to provide documentation the client was oriented to the project to include project policies.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Director/Designee shall ensure that all clients sign the appropriate acknowledgement for orientation at intake. Director/Designee shall inspect all client records by the 3rd day of admission to ensure that Orientation Checklist is in the electronic medical record. This will also be an item monitored during internal chart audits completed by program managers, and audits completed by CQI personnel. |
709.51(b)(2)(ii) LICENSURE Hours of Operation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(ii) Hours of operation.
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Observations
Based on seven of seven client records reviewed on January 28 and 31, 2020, the facility failed to provide documentation the client was oriented to the project to include hours of operation.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Director has generated a form that member signs during intake confirming that they have received the orientation manual where the facility hours of operation are listed. This form will be uploaded to the Electronic Health Records (EHR) until the form is generated and appears in EHR. The Director and/or Designee will ensure that the form is uploaded and signed by all new members during random chart audits. |
709.51(b)(2)(iii) LICENSURE Fee Schedule
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iii) Fee schedule.
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Observations
Based on seven of seven client records reviewed on January 28 and 31, 2020, the facility failed to provide documentation the client was oriented to the project to include fee schedule.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Director has generated a form that member signs during intake confirming that they have received the Resident Manual where the facility's fee schedule is also included. his form will be uploaded to the Electronic Health Records (EHR) until the form is generated and appears in EHR. The Director and/or Designee will ensure that the form is uploaded and signed by all new members during random chart audits. |
709.51(b)(2)(iv) LICENSURE Services Provided
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iv) Services provided.
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Observations
Based on seven of seven client records reviewed on January 28 and 31, 2020, the facility failed to provide documentation the client was oriented to the project to include services provided.
The findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
Director has generated a form that member signs during intake confirming that they have received the Resident Manual where it includes services provided in the facility. This form will be uploaded to the Electronic Health Records (EHR) until the form is generated and appears in EHR. The Director and/or Designee will ensure that the form is uploaded and signed by all new members during random chart audits. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on three of three client records reviewed on January 28 and 31, 2020, the facility failed to provide a complete client record to include a discharge summary.
Client # 5 was admitted on August 26, 2019 and was discharged on October 24, 2019. There was no documentation of a discharge summary in the client record.
Client # 6 was admitted on August 21, 2019 and was discharged on October 2, 2019. There was no documentation of a discharge summary in the client record.
Client # 7 was admitted on September 7, 2019 and was discharged on October 2, 2019. There was no documentation of a discharge summary in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/3/2020 Director provided training to all clinical staff to ensure the completion of the discharge summary in addition to the continuum of care/discharge plan that is currently being completed. The discharge summary will be completed for all members that are discharging from the facility. The Director and/or Designee will review all discharges weekly to ensure that the discharge summary is being completed. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on seven of seven client records reviewed on January 28 and 31, 2020, the facility failed to provide a complete client record to include verification that work being done by the client at the project is an integral part of the treatment and rehabilitation plan.
Client # 1 was admitted on December 2, 2019 and was still an active client at the time of the inspection. The treatment and rehabilitation plan did not include work being done by the client as part of the therapeutic process.
Client # 2 was admitted on November 8, 2019 and was still an active client at the time of the inspection. The treatment and rehabilitation plan did not include work being done by the client as part of the therapeutic process.
Client # 3 was admitted on December 19, 2019 and was still an active client at the time of the inspection. The treatment and rehabilitation plan did not include work being done by the client as part of the therapeutic process.
Client # 4 was admitted on January 10, 2020 and was still an active client at the time of the inspection. The treatment and rehabilitation plan did not include work being done by the client as part of the therapeutic process.
Client # 5 was admitted on August 26, 2019 and was discharged on October 24, 2019. The treatment and rehabilitation plan did not include work being done by the client as part of the therapeutic process.
Client # 6 was admitted on August 21, 2019 and was discharged on October 2, 2019. The treatment and rehabilitation plan did not include work being done by the client as part of the therapeutic process.
Client # 7 was admitted on September 7, 2019 and was discharged on October 2, 2019. The treatment and rehabilitation plan did not include work being done by the client as part of the therapeutic process.
This is a repeat citation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director or Designee will randomly review all Electronic
Health Records to make sure that all treatment plans capture the work that the member engages in the community. In the clinical team meeting on 3/2/2020, will attend training that will illustrate how to document work therapy in the treatment plan.
This will ensure that the Counselors understand the purpose of documenting the member's activities while in the program. Director and/or Designee will audit Counselor's caseload during supervision to make sure that member's activities including work therapy are highlighted in the clinical documentation. |