INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 17, 18 and 19, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, BGI of Brandywine, Inc. was found not to be in compliance with the applicable chapters of 28 Pa Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on July 15, 2008.
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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 administrative policies and procedures, the facility failed to document a comprehensive staff development program. The staff development policy did not include a policy and procedure on the completion of an evaluation of the overall training plan.
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Plan of Correction
Current policy in revision for approval by Regional QI department. Will be in place by 7/25/08.
Individual training plans and evaluation of overall training plan will be done on an annual basis and monitored for comliane by BGB HR Representative. |
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 staff interview, the facility failed to develop an individual training plan for each employee in seven of twelve personnel records reviewed, #3, 4, 5, 6, 7, 11 and 12. The document used as an individual training plan did not include dates of training or available resources. The document used as an individual training plan was an assessment of training needs rather than a training plan.
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Plan of Correction
BGB HR representative working with Regional QI department to adopt regional protocol including new forms which will include all necessary information to meet the standard.
Individual training plans will be done for all emloyees at the beginning of each calendar year rather than at everyone's annual evaluation which will allow the monitoring process to be easier.
Responsible Party: HR Representative |
704.12(a)(1)(i) LICENSURE Client/couns ratios
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.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
Based on a review of facility schedules and staff interview, the facility failed to ensure a client to staff ratio of seven to one for the inpatient non-hospital detoxification activity. The client to staff ratio was eight to one on the following dates: 5/23/08 from midnight to 7:00 AM; 5/24/08 from midnight to 7:00 AM and from 8:00 AM to 11:00 PM; 5/25/08 from midnight to 11:00 PM; 6/6/08 from 5:00 PM to 8:00 PM and midnight to 7:00 AM; 6/7/08 from midnight to 11:00 PM; 6/8/08 from 8:00 PM to 11:00 PM; 6/10/08 from midnight to 7:00 AM and 11:00 PM to midnight; 6/12/08 from 8:00 AM to 3:00 PM; 6/12/08 from 8:00 PM to 9:00 PM and midnight to 7:00 AM; and 6/14/08 from 8:00 PM to 11:00 PM.
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Plan of Correction
In-service was held 7/18/08 with admissions staff, nursing and after hours call center as to the staff/ratio standards. Nursing staff will notify the Admissions Director when an expected rehab referral needs detox upon arrival. Admissions Director will determine if we have a detox bed or need to refer the patient to another facility. Admissions Director will monitor the number of detox admissions on a daily basis to assure ongoing compliance.
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704.12(a)(3)(i) LICENSURE NonHosp Rehab
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.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on a review of administrative materials presented, the facility failed to ensure a client to staff ratio of eight to one for the inpatient nonhospital treatment activity. The client to staff ratio was nine to one.
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Plan of Correction
Two new staff were hired on: June 16, 2008. As of 6/30/08, they are currently trained and have a caseload. Caseloads will be monitored daily by clinical director.
If a staff shortage occurs in the future, incoming client #'s will be reduced to meet staffing ratio's.
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705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on the physical plant inspection on June 18, 2008, the facility failed to provide slip-resistant surfaces in 12 showers.
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Plan of Correction
All missing slip-resistant surfaces have been replaced as of 6/20/08.
Daily checks are being done by Housekeeping staff during daily rounds to assure these remain in place.
Maintenance supervisor will do weekly check to assure ongoing compliance with this standard. |
705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on the physical plant inspection on June 18, 2008, the facility failed to store utensils in a clean, enclosed area.
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Plan of Correction
In-service will be held for all dietary staff by 7/18/08 instructing them that all utensils must be covered when not in use.
This standard will be monitored by daily walk throughs done by Dietary Manager or designee.
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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on the physical plant inspection on June 18, 2008, the facility failed to keep cold food at or below 40 degrees Fahrenheit and frozen food at or below 0 degrees Fahrenheit. The refrigerator temperature log showed one day in June where the temperature was over 40 degrees Fahrenheit. The temperature log for freezer #1 documented five days in June over 0 degrees Fahrenheit. The temperature log for freezer #2 documented twelve days in June over 0 degrees Fahrenheit.
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Plan of Correction
Local electrician has been called to service/recalibrate freezers to maintain at or below 0 degrees F.
Expected completion date: by 7/18/08.
Daily temperatures will be monitored by Dietary Manager or designee using temperature log for freezers daily. Any pattern of non-compliance will result in call for service. |
709.81(b)(3)(i) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records on June 18 and 19, 2008, the facility failed to document complete medical histories in six of six client records reviewed, #15, 16, 17, 18, 19 and 20. The medical histories did not include a complete family medical history in #15, 16, 17 and 18. The medical histories were missing a family history in #19 and 20. Symptoms were missing in #15, 16, 17, 18, 19 and 20.
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Plan of Correction
Regional Nurse Manager and PA-C will hold in-service for Nursing Staff by 7/28/08 demonstrating correct way to complete medical history. (addressing both quality and quantity of information)
PA-C will review nursing assessment prior to her completing her H & P to assure that information is appropriate. PA-C will report findings to D.O.N. to hold appropriate staff accountable.
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709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to document a complete treatment plan update in three of six records reviewed, #17, 19 and 20. Treatment plan updates were missing in two records #17 and 19. The treatment plan update in client record #20 did not include an assessment of the clients's progress in relationship to the previously stated treatment plan goals.
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Plan of Correction
On JUne 20th, a mandatory staff meeting was held where all paperwork and timeliness of paperwork was reviewed. Staff were given the standards at this time for compliance
During weekly open chart audits TPU will be monitored for timeliness and compliance (15 days for those remaining in treatment less than 30 days and the 30th day for those remaining in rehab longer then 30 days). During monthly close out audits TPU's will be monitored for compliance.
Responsible party: Clinical Director |
709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to provide counseling services according to the individual treatment plan in three of six client records reviewed, #16, 18 and 19. The individual treatment plans indicated individual counseling would be provided twice a week; however individual sessions in client records #16, 18 and 19 only occurred once a week or less.
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Plan of Correction
A mandatory staff meeting was held where all paperwork, timeliness of paperwork and clinical requirements were reviewed. Staff was specifically re/educated on the regulatory standards of the partial program. We have assigned one designated staff for all Partial patients and they will be responsible for all treatment care plans and a min of 2 individual sessions per week.
Weekly open chart audits and monthly closed charts audits will be used to monitor compliance.
Responsible Party: Clincal Director |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to provide individual counseling at least twice weekly in three of six client records reviewed, #16, 18 and 19. Individual counseling occurred one time weekly or less in client records #16, 18 and 19.
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Plan of Correction
A mandatory staff meeting was held where all paperwork, timeliness of paperwork and clinical requirements were reviewed. Staff was specifically re/educated on the regulatory standards of the partial program. We have assigned one designated staff for all Partial patients and they will be responsible for all treatment care plans and a min of 2 individual sessions per week. Weekly open chart audits and monthly closed charts audits will be used to monitor compliance. Responsible Party: Clincal Director
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709.82(e)(5) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(5) Educational.
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Observations
Based on a review of administrative documents and client records, the facility failed to document educational support services.
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Plan of Correction
Administrative Assistant is researching who would be an appropriate agency in our local area to meet this standard. Goal is to have referral agreement in place by 7/31/08. When this is completed, AA will monitor referral agreement book bi-annually to assure all required referral agreements are in place and are timely.
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709.82(e)(6) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(6) Vocational.
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Observations
Based on a review of administrative documents and client records, the facility failed to document vocational supportive services.
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Plan of Correction
As of 7/7/08, OVR Referral agreement in place with verbiage indicating "this agreement is not time limited."
Monitoring of Referral Agreement Book will be done by Adminsitrative Assistant on a bi-annual basis assure all appropriate agreements are in place and are timely. |
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 a review of client records, the facility failed to document complete aftercare plans in three of three records reviewed, #18, 19 and 20. The aftercare plans did not list any goals, nor did the form utilized allow for this. The aftercare plans listed only twelve step meetings as support services. The aftercare plan was missing criteria for re-entry into the project.
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Plan of Correction
In-service occurred for all clinical staff and aftercare specialist 6/08 to review aftercare standards.which included goals, support services and criteria for re-entry in aftercare plans.
During the daily clinical meetings, clinical will report the aftercare plans on all clients to assure all patients have a plan prior to discharge.
Monthly closed chart audits will be utilized to monitor compliance. Have added this item to our monthly chart audit tool.
Responsible Party: Clinical Director |
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 that follow-up was completed within the required timeframe in three of three client records reviewed, #18, 19 and 20. The policy and procedure manual stated that all follow-up would be documented within seven days of discharge and the documentation provided did not indicate the date on which follow-up was completed.
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Plan of Correction
Follow up log book form changed to include a column for when follow up form was sent out.
This was put into practice as of 6/20/08.
Timely follow ups will be monitored by Medical Records Supervisor on a weekly. |
709.23(b)(1) 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:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of administrative documents on June 17, 2008, the facility failed to document time frames and available resources for the 2008 Strategic Plan.
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Plan of Correction
Update of Q3 Strategic Plan will include time frames and resources available. Will share this deficiency with Regional VP to adjust template used for Strategic plan to assure all proper elements are in place for 2009.
Responsible Party: Executive Director and Regional VP. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of facility policy and client records on June 18 and 19, 2008, the facility failed to document vital signs for clients in the detoxification level of care as per policy in six of six records reviewed, #1, 2, 3, 4, 5 and 6. The facility submitted a plan of correction on April 17, 2008 that indicated the facility's policy would be changed to require vital signs to be taken every four hours. The facility's policy and procedure manual did not reflect this change. Documentation showed that vital signs were taken every five to eight hours in three of three active client records reviewed, #1, 2 and 3. Additionally, in three of three closed client records reviewed, #4, 5 and 6, vital signs were not taken every six hours which was the policy in effect until April 16, 2008.
Based on a review of administrative documents and a conversation with the facility director on June 17, 2008, the facility failed to document written procedures to ensure that services for each licensed activity were separate. The facility combined clients in two distinct levels of care, inpatient non-hospital residential and partial hospitalization, into the same group therapy sessions.
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Plan of Correction
Inservice done 6/08: Policy and procedure reviewed to Nursing Staff and Nursing Assistant staff after staff changed protocols without management approval.
Manual was also updated to include proper policy for vital signs. (referenced below)
Effective 6/20/08, protocol but BACK into place for vitals q 4 hours for all patients in detox to include temperatures.
Medical Secretary is responsible for reviewing detox sheets daily to assure these were done prior day report findings to Excecutive Director and/or Director of Nursing.
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709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on the physical plant inspection on June 18, 2008, the facility failed to secure client records within locked storage containers. The active client records were stored in an unlocked room adjacent to the medical records office in unlocked storage containers.
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Plan of Correction
In-service held 6/20/08 for Medical Records Dept re-educating them that door leading to actual files must be locked even when they are actively working during the day.
This standard will be monitored by Executive Director and Medical Records supervisor by daily walk-through/checks of door throughout each day.
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709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
Based on a review of medication administrative documents on June 17, 2008, the facility failed to document the pharmacist's quarterly inspection record for 2008.
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Plan of Correction
Contracted Pharmacy admitted to not completing these audits for us in 2 quarters.
Audit completed 7/11/08 and will be done quarterly thereafter per our pharmacy contract.
Unit Secretary responsible for assuring pharmacy is scheduled each quarter. |
709.32(c)(6) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(6) Inventories.
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Observations
Based on a review of medication administrative documents on June 18, 2008, the facility failed to document the inventory record for 2008.
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Plan of Correction
Contracted Pharmacy admitted to not completing these audits for us in 2 quarters.
Audit completed 7/11/08 and will be done quarterly thereafter per our pharmacy contract.
Unit Secretary responsible for assuring pharmacy is scheduled each quarter. |
709.62(c)(3)(i) LICENSURE Medical history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records on June 18 and 19, 2008, the facility failed to document complete medical histories in six of six client records reviewed, #1, 2, 3, 4, 5 and 6. The medical histories did not include complete personal and family medical history in five records, #1, 2, 3, 5 and 6. Additionally, symptoms were missing in six records, #1, 2, 3, 4, 5 and 6.
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Plan of Correction
Regional Nurse Manager and Physician Assistant will hold in-service for Nursing Staff by 7/28/08 demonstrating correct way to complete medical history. (addressing both quality and quantity of information)
Physician Assistant will review nursing assessment prior to her completing her History and Physical to assure that information is appropriate. Physician Assistant will report findings to director of nursing to hold appropriate staff accountable.
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709.62(c)(3)(ii) LICENSURE D & A History
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records on June 18 and 19, 2008, the facility failed to document a complete drug and alcohol history in six of six client records reviewed, #1, 2, 3, 4, 5 and 6 The drug and alcohol histories were missing the patterns of use, the client's perception of use and information on substances abused.
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Plan of Correction
Regional Nurse Manager and Physician Assistant will hold in-service for Nursing Staff by 7/28/08 demonstrating correct way to complete medical and chemical histories. (addressing both quality and quantity of information) Physician Assistant will review nursing assessment prior to her completing her History and Physical to assure that information is appropriate. Physician Assistant will report findings to Director of Nursing to hold appropriate staff accountable.
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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 on June 18 and 19, 2008, two were required to have psychosocial evaluations. The facility failed to document complete psychosocial evaluations in one of two client records reviewed, #6. Psychosocial evaluations did not a clinical assessment of assets/strengths, support systems and negative factors that may inhibit treatment. Evaluations included "client identified" and "client reports" statements rather than a clinical assessment.
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Plan of Correction
A mandatory staff meeting was held 6/30/08 where all paperwork, timeliness of paperwork and clinical requirements were reviewed. Weekly open chart audits and monthly closed charts audits will be used to monitor compliance. Responsible Party: Clincal Director
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709.63(a)(5) LICENSURE Record of Services
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:
(5) Record of services provided.
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Observations
Based on a review of client records on June 18 and 19, 2008, the facility failed to document a record of services provided in three of six client records reviewed, #1, 2 and 3.
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Plan of Correction
A mandatory staff meeting was held 6/30/08 where all paperwork, timeliness of paperwork and clinical requirements were reviewed. Weekly open chart audits and monthly closed charts audits will be used to monitor compliance. Responsible Party: Clincal Director
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709.64(c)(5) LICENSURE Educational support services
709.64. Project management services.
(c) The project shall assist the client in obtaining the following supportive services when necessary:
(5) Educational.
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Observations
Based on a review of administrative documents and client records, the facility failed to document educational support services
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Plan of Correction
Administrative Assistant is researching who would be an appropriate agency in our local area to meet this standard.
Goal is to have referral agreement in place by 7/31/08.
When this is completed, AA will monitor referral agreement book bi-annually to assure all required referral agreements are in place and are timely. |
709.64(c)(6) LICENSURE Vocational support systems
709.64. Project management services.
(c) The project shall assist the client in obtaining the following supportive services when necessary:
(6) Vocational.
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Observations
Based on a review of administrative documents and client records, the facility failed to document vocational supportive services.
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Plan of Correction
As of 7/7/08, OVR Referral agreement in place with verbiage indicating "this agreement is not time limited." Monitoring of Referral Agreement Book will be done by Adminsitrative Assistant on a bi-annual basis assure all appropriate agreements are in place and are timely.
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709.64(e) LICENSURE Follow-up policy
709.64. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of client records on June 18 and 19, 2008, three were required to have follow-up within seven days of discharge. The facility failed to document that follow-up was completed within the required time frame in three of three client records reviewed, #4, 5 and 6. The policy and procedure manual stated that all follow-up would be documented within seven days of discharge and the documentation provided did not indicate the date on which follow-up was completed.
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Plan of Correction
Follow up log book form changed to include a column for when follow up form was sent out. This was put into practice as of 6/20/08. Timely follow ups will be monitored by Medical Records Supervisor on a weekly basis.
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709.51(b)(3)(i) LICENSURE Medical histories
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records on June 18 and 19, 2008, the facility failed to document complete medical histories in seven of eight records reviewed, #7, 8, 9, 11, 12, 13 and 14. The medical histories did not include complete personal and family medical history in five records, #7, 8, 9, 10 and 14. Additionally, symptoms were missing in seven records, #7, 8, 9, 11, 12, 13 and 14.
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Plan of Correction
Regional Nurse Manager and Physician Assistant will hold in-service for Nursing Staff by 7/28/08 demonstrating correct way to complete medical history. (addressing both quality and quantity of information)
Physician Assistant will review nursing assessment prior to her completing her History and Physical to assure that information is appropriate. Physician Assistant will report findings to Director of Nursing to hold appropriate staff accountable.
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709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records on June 18 and 19, 2008, the facility failed to document a complete drug and alcohol history in seven of eight client records reviewed, #7, 8, 9, 10, 12, 13 and 14. The drug and alcohol histories were missing the patterns of use, the client's perception of use and information on substances abused.
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Plan of Correction
Regional Nurse Manager and Physician Assisant will hold in-service for Nursing Staff by 7/28/08 demonstrating correct way to complete medical and chemical histories. (addressing both quality and quantity of information) Physician Assistant will review nursing assessment prior to her completing her History and Physical to assure that information is appropriate. Physician Assistant will report findings to Director of Nursing to hold appropriate staff accountable.
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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 on June 18 and 19, 2008, the facility failed to document complete psychosocial evaluations in seven of eight client records reviewed, #7, 8, 9, 11, 12, 13 and 14. Psychosocial evaluations did not a clinical assessment of assets/strengths, support systems and negative factors that may inhibit treatment in six records, #7, 8, 11, 12, 13 and 14. Evaluations included "client identified" and "client reports" statements rather than a clinical assessment. The psychosocial evaluation was missing in one record, #9.
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Plan of Correction
A mandatory staff meeting was held 6/30/08 where all paperwork, timeliness of paperwork and clinical requirements were reviewed. Weekly open chart audits and monthly closed charts audits will be used to monitor compliance. Responsible Party: Clincal Director
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records on June 18 and 19, 2008, eight were required to have treatment plan updates. The facility failed to document a treatment plan update in two of eight client records reviewed, #7 and 11. The second required treatment plan update was not documented for #8. The treatment plan update did not include an assessment of the client's progress in relationship to the stated goals in the prior treatment plan in one record, #9.
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Plan of Correction
On June 30th, a mandatory staff meeting was held where all paperwork and timeliness of paperwork was reviewed. Staff were given the standards at this time for compliance During weekly open chart audits TPU will be monitored for timeliness and compliance (15 days for those remaining in treatment less than 30 days and the 30th day for those remaining in rehab longer then 30 days). During monthly close out audits TPU's will be monitored for compliance. Responsible party: Clinical Director |
709.51(e)(5) LICENSURE Educational support
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(5) Educational.
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Observations
Based on a review of administrative documents and client records, the facility failed to document educational support services.
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Plan of Correction
Administrative Assistant is researching who would be an appropriate agency in our local area to meet this standard.
Goal is to have referral agreement in place by 7/31/08.
When this is completed, AA will monitor referral agreement book bi-annually to assure all required referral agreements are in place and are timely. |
709.52(e)(6) LICENSURE Vocational Support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(6) Vocational.
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Observations
Based on a review of administrative documents and client records, the facility failed to document vocational supportive services.
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Plan of Correction
As of 7/7/08, OVR Referral agreement in place with verbiage indicating "this agreement is not time limited." Monitoring of Referral Agreement Book will be done by Adminsitrative Assistant on a bi-annual basis assure all appropriate agreements are in place and are timely.
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709.53(a)(8) LICENSURE Case Consultation 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:
(8) Case consultation notes.
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Observations
Based on a review of client records on June 18 and 19, 2008, four were required to have case consultations. The facility failed to document case consultation notes in three of four client records reviewed, #9, 10 and 14. Case consultations were missing.
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Plan of Correction
On June 30th, a mandatory staff meeting was held where all paperwork and timeliness of paperwork was reviewed. Thisincluded Case Consultations and date requirements of documentation. Every chart must have one Case Consultation per treatment experience or at level change.
Weekly open chart and monthly closed chart audits will be used to monitor compliance. Responsible party: Clinical Director |
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 on June 18 and 19, 2008, four were required to have follow-up within seven days of discharge. The facility failed to document follow-up information within the required time frame in four of four client records reviewed, #9, 10, 13 and 14. The policy and procedure manual stated that all follow-up information would be documented within seven days of discharge and the documentation provided did not indicate the date on which follow-up was completed.
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Plan of Correction
Follow up log book form changed to include a column for when follow up form was sent out. This was put into practice as of 6/20/08. Timely follow ups will be monitored by Medical Records Supervisor on a weekly basis. |