INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from May 10-11, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Kindred House, 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(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, the facility failed to document an individual training plan in accordance with facility policy in two of five records.
The findings include:
The project policy states: "In January of each year, the Program Director, in conjunction with the Supervisor, will conduct needs assessments, via individual training plan forms for all employees, to determine what topics and areas of training should be provided during the coming year."
On May 9, 2012, employee #'s 1 and 3 personnel records were reviewed.
The project failed to develop an individual training plan annually in accordance with policy.
Employee # 1 has been the Project Director since 1988.
Per policy, training plans will be conducted in January of each year.
The facility failed to document an individual training plan in January for employee # 1.
Employee # 3 was hired on April 25, 2005.
Per policy, training plans will be conducted in January of each year.
The facility failed to document an individual training plan in January for employee # 3.
The findings were reviewed with the human resources staff.
The Project was previously cited for noncompliance with this standard during the 2010 licensure inspection.
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Plan of Correction
The Training Department will ensure that an individual training plan is developed and documented for all employees within required timeframes. A reminder of the January 31st deadline for completion will be forwarded to all Managers during the 1st week of December. In addition, the Training Department will coordinate with the Executive Assistant to ensure that development of an Individual Training Plan for the Project Director is a specific agenda item during the Project Director's meeting with the Chairman of the Board during the month of December. A current, signed Individual Training Plan is presently in the Project Director's file." Individual Training Plans will be completed for all employees by January 31st, 2013 as per our policy.
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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 upon a review of the Staffing Requirements Facility Summary Report (SRFSR) and employee training records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually.
The findings include:
The SRFSR and five employee records were reviewed as part of an Administrative Review that was conducted from May 7 - 9, 2012.
The SRFSR specifies that the training year runs from January 1 to December 31.
One of five employee records, specifically record # 3, did not contain documentation of the required number of annual training hours for 2011.
Employee # 3, a counselor, was hired on July 7, 2008, and was required to have 25 clock hours of annual training in 2011. However, the record only included documentation of 16 clock hours for 2011.
The findings were confirmed by the Human Resource Department during the Administrative Review.
This is a repeat citation from May 26, 2011.
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Plan of Correction
The Administrative Coordinator will develope a system through microsoft exel to assist with keeping track of staff trainings. The Coordinatior will review with the staff in a staff meeting mothly hours needed to meet the licensure requirements. Program Director will oversee the system. |
705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based upon the physical plant inspection, the facility failed to maintain all structures so as to be free from any danger to health and safety.
The findings include:
The physical plant inspection was conducted on May 11, 2012.
A water spigot located inside the children's recreational area contained an exposed end that had sharp edges.
The findings were reviewed with the Facility Director during the physical plant inspection.
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Plan of Correction
The Program Director with the Grounds Maintenance Department will assure that the exposed water spigot with sharp edges located in the children;s recreational area will be removed or secured to eliminate danger to the health and safety of everyone. The hole around the spigot is filled in with the foam substance, the wall will be spackeled, the spigot was replaced for a smaller spigot which is more contour to the wall. Maintenance will make weekly runs of the grounds to assure all is safe. |
705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based upon the physical plant inspection, the facility failed to ensure that it was free of insect infestation.
The findings include:
The physical plant inspection was conducted on May 22, 2012.
While inspecting room #7, the Licensing Specialist observed that four of four ceiling mounted lights contained dead wasps, bees, yellow jackets and / or other stinging insects.
The findings were reviewed with the Facility Director during the exit interview.
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Plan of Correction
The Program Director will assure that the local pest control company will inspects and takes care of any/all insects. The visits are scheduled quartley and if warranted will be scheduled on a as needed basis outside of the quartly visits. All paperwork with findings will be kept in a log. The maintenance depatment will inspect the building on a monthy basis to determine if there are indications of insect problems and fix the problem immediately and appropiately. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based upon the physical plant inspection, the facility failed to ensure that exits from rooms and from the residential facility are unobstructed.
The findings include:
The physical plant inspection was conducted on May 11, 2012.
When inspecting the first floor exits from the Nelson building, the Licensing Specialist observed that vines were growing in the doorway of the left exit, thus preventing the door from closing. In addition, the vines were growing across the landing of the exit and proceeded down at least two steps. The vines presented an obstruction to safely exiting from the Nelson building.
The findings were confirmed by the Facility Director during the physical plant inspection.
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Plan of Correction
The Program Director and Maintenance Department will assure that all vines growing in the doorway of the exit is removed. The MaintenamceDepartment/Program Directior will inspect exits monthy to prevent the obstruction of exits at the Nelson building. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based upon a review of the facility's Fire Drill Log and dialogue with the Facility Director, the facility failed to provide documentation to demonstrate that it conducted unannounced fire drills at least once a month.
The findings include:
The facility's Fire Drill Log for the period of May 2011 to April 2012, was reviewed on May 11, 2012.
The Fire Drill Log did not include documentation of any fire drills for the month of April 2012.
The findings were confirmed by the Facility Director during the exit interview.
This is a repeat citation from May 26, 2011.
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Plan of Correction
The Program Director will assign one particular staff member with the duty of making sure that Kindred House is in compliance with Licensure concerning fire drills. The Program Director and House Manager Supervisor will inspect and sign off on Fire Drill Log monthly. |
705.11 (2) (iii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based upon the physical plant inspection, the facility failed to maintain protective caps over each electrical outlet.
The findings include:
The physical plant inspection was conducted on May 11, 2012.
The facility admits women with children and is required to maintain protective caps over each electrical outlet.
Room # 6 contained an electrical outlet that was missing both protective caps.
Room # 7 contained an electrical outlet that was missing both protective caps.
In addition, an electrical outlet located next to the sink in the bathroom of room # 7 was missing the upper protective cap.
The children's outside recreational area contained an electrical outlet that was missing both protective caps.
The right side entrance to the Nelson building contained an electrical outlet that was missing both protective caps.
The Facility Director confirmed the findings during the physical plant inspection.
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Plan of Correction
All missing protective caps were replace immediately. The House Manager Supervisor and Program Director will develope and maintain a log to check the outlets in the facility and Nelson Center daily to assure that all outlets have the protective caps. |
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 upon a review of the project's Policy & Procedure (P&P) Manual, the project failed to adopt written plans that are consistent with regard to the development of individualized treatment and rehabilitation plans.
The findings include:
The P&P Manual was reviewed from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" Treatment Plan included the following language:
"The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director(when applicable) within 3-5 client days residential..."
The policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"Completion of the treatment plan will be noted in the counselor's progress note for that day of service, within 3 days of admission (residential)..."
The first policy allows five days to complete the individualized treatment plan while the second policy stipulates it must be completed within three days.
Regarding outpatient facilities, the policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"An individual treatment and rehabilitation plan will be developed with each client after the completion of the client's psychosocial evaluation."
The policy titled, "Intake Process/Paperwork" Treatment Plan included the following language:
"Based on the psychosocial assessment, the Counselor shall formulate an individualized treatment plan ..."The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director (when applicable) ... by the second or third counseling outpatient appointment....."
The policy titled, "Intake Process/Paperwork" Psychosocial Assessment stated:
Upon completion of the psychosocial histories...The assessment shall be submitted promptly ... to the Clinical Supervisor for review and signature ... within 3 individual sessions for outpatient.
The policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"Completion of the treatment plan will be noted in the counselor's progress note for that day of service,... by the third session (outpatient)..."
Each policy relating to the completion of the treatment plans for outpatient contained statements that require the treatment plan be completed in three sessions (regardless of being individual or group) while there are other statements that would indicate that the treatment plan would not be required or allowed to be completed until the third individual session based on the completion of the psychosocial assessment.
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Plan of Correction
The relevant policies in the Gaudenzia Policy and Procedure manual will be revised by the Quality Improvement Director to ensure consistency and clarity, and to meet all relevant State, Accreditation, and Funding requirements. Changes to these policies will be reviewed and approved by the Board of Directors. These changes will be reviewed with clinicians at each facility's staff meetings by the Program Director and/or Program Supervisor in order to ensure full understanding and ongoing compliance. Program Supervisors will monitor timely completion of Initial Treatment Plans as part of regular clinical chart reviews, and the findings of these reviews will be discussed in regular clinical supervision as well as staff meetings and monthly CQI analysis." These policies will be revised and approved by July 31st, 2012.
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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 upon the review of Administrative documentation, the project failed to have an annual audit of financial activities associated with the project's drug/alcohol abuse services completed upon conclusion of the fiscal year.
The findings include:
Licensing Staff conducted an Administrative Review from May 7 - 9, 2012.
Administrative documentation specified that the fiscal year runs from July 1 to June 30. However, the project's annual fiscal audit was late as it was completed February 20, 2012.
The findings were reviewed during the exit interview for the Administrative Review and were not disputed.
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Plan of Correction
"At the most recent Audit Committee meeting, the necessity that all future financial audits must be completed within required timeframes was reinforced with the external independent public accountant. These timeframes were acknowledged by the independent public accountant and recorded in the meeting minutes. The Director of Finance and Accounting will maintain oversight throughout the auditing process to ensure completion in a timely manner." The Financial Audit for Fiscal Year 2011-2012 will be completed within 6 months after the June 30th close of Gaudenzia's fiscal year (by December 31st, 2012) as per Chapter 709.25(a).
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709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based upon a review of the facility's Policy & Procedure (P&P) Manual and personnel records, the facility failed to include the results of reference investigations in personnel records.
The findings include:
The facility's P&P Manual was reviewed from May 1 - 2, 2012.
The P& P Manual outlined the following "Admission Criteria (Women & Children)" for the facility:
- "The client will be a 18 years or older woman
- Can be pregnant or have children ( 2 children may live with the mother in treatment)
- Can have a history of homelessness"
The P&P Manual also contained the following documentation:
"Subject: Compliance with Staff Qualifications
Relevant Regulations/Standards: PA 704.4
Revision Date: Jan 2012
In response to PA DOH Notice to Facilities on Required Employment Clearances dated November 2008, all staff who begin working after July 1, 2008, in a position/facility where they would have "significant likelihood of regular contact with children in the form of care, guidance, supervision or training" obtain three background checks as a condition of employment:
1. Pennsylvania State Police Clearance
2. Department of Public Welfare (DPW) Childline Clearance
3. Federal (FBI) Criminal Background Check (using electronic fingerprinting through a vendor to DPW: Cogent Systems)"
Five employee records were also reviewed as part of the Administrative Review. One of five records, specifically record # 4, did not include documentation of the Federal Criminal Background Check.
Employee # 4, a counselor, was hired on January 3, 2012. Since employee # 4 had a significant likelihood of regular contact with children, facility policy required that they obtain an FBI background check. However, at the time of inspection, no results of an FBI background check were included in the file.
The findings were confirmed by the Human Resource Department during the Administrative Review.
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Plan of Correction
Employee #4 hired in January FBI background check recieved and is in the employee file. Every new hire will file for the Federal Criminal Background Check on the first day of hire at the Corporate Office where the Orientation for new hires are conducted on their first day of employment. The new hire will complete the process (fingerprinting) at designated site the following day. The Administrative Coordinator will assist in this process. The employee will not work alone until clearence is seen, and put in personnel chart.The Program Director will oversee process. |
709.26(d)(3) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(3) The verification of training experience and professional licensure or registration, where applicable.
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Observations
Based upon a review of employee personnel records, the facility failed to verify training and / or educational experience, where applicable.
The findings include:
Five employee records were reviewed as part of an Administrative Review that was conducted from May 7 - 9, 2012. One of five records, specifically record # 4, did not include documentation that verified the employee's degree.
Employee # 4, a counselor, was hired on January 3, 2012. The record contained documentation of a degree from another country. However, the record did not contain any documentation that verified what the degree was equivalent to in Pennsylvania.
The findings were confirmed by the Human Resource Department during the Administrative Review.
This is a repeat citation from May 26, 2011.
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Plan of Correction
Employee #4 is in the process of applying for credentialing with WES. The counselor III or Director will co-facilitate groups and individual sessions with employee 4. When and if a person is applying for position with Kindred/Gaudenzia from another country credentialing will need to be done before hire. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based upon a review of the facility's Policy & Procedure (P&P) Manual and client records, the facility failed to document physical examinations as per facility policy.
The findings include:
The P&P Manual was reviewed from May 1 - 2, 2012.
The facility policy titled "Physical Examination Laboratory Studies" states the following:
"A client entering a Gaudenzia (residential) program shall receive a complete physical examination by a qualified physician within 7 days of admission (DOH), except on holiday or weekend."
Eight records requiring documentation of physical examinations were reviewed from May 10 - 11, 2012. Three of eight records, specifically #'s 5, 6, and 8, either contained physical examinations that were not dated or were completed late, or the record did not contain a physical examination at all.
Client # 5 was admitted on April 6, 2012, and the physical examination was due by April 13, 2012. The record contained a physical examination that was not dated.
Client # 6 was admitted on March 9, 2012, and the physical examination was due by March 16, 2012. The record did not contain documentation of a physical examination.
Client # 8 was admitted on October 5, 2011, and the physical examination was due by October 12, 2011. The record contained a physical examination that was dated October 17, 2011.
The findings were reviewed with the Facility Director during the exit interview.
This is a repeat citation from October 26, 2011, May 26, 2011, May 11, 2010, May 20. 2009, and June 20, 2008.
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Plan of Correction
The Nursing Director for the Eastern Region will audit medical files monthly with the facility nurse/CNA to assure that all paperwork especially physicals are in compliance with licensure. Physician, Physician Assistant or CRNP will conduct physicals withing 7 days. |
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 upon a review of client records, the facility failed to ensure that documentation of a psychosocial evaluation was included in client records.
The findings include:
Eight records requiring documentation of a psychosocial evaluation were reviewed from May 10 - 11, 2012. One of eight records, specifically # 6, did not contain a psychosocial evaluation.
Client # 6 was admitted on March 9, 2012, and was discharged on April 23, 2012. As of the date of inspection, the record did not contain documentation of a psychosocial evaluation as required.
The findings were discussed with the Facility Director during the record review.
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Plan of Correction
The Clinical Supervisor and Program Director will review and sign off on the psychosocial which includes the assessment within the 72 hours per the policy. The clinical staff will be reminded of the importance of completing documentation. Policy reviewed with clinical staff. Supervisor/Director will conduct monthy audits to include the psychoscoail assessment. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based upon a review of the facility's Policy & Procedure (P&P) Manual and client records, the facility failed to include documentation of preliminary treatment plans in the client record.
The findings include:
The facility's P&P Manual was reviewed as part of an Administrative Review conducted from May 1 - 2, 2012.
The policy titled, "Clinical Level System - Women with Children" includes the following language, which specifies the timeframe for the completion of a preliminary treatment plan.
"The Women with Children programs manage client treatment through the use of a clinical level system. The following is a description of that system:
# 12. Complete the screening/bio-psycho-social/client list and initial treatment plan by day 3."
Six records requiring documentation of a preliminary treatment plan were reviewed from May 10 - 11, 2012. Three of six records, specifically #'s 2, 3, and 6, did not contain a preliminary treatment plan as required.
Client # 2 was admitted on February 6, 2012, and a preliminary treatment plan was due by February 9, 2012. As of the date of inspection, the record did not contain a preliminary treatment plan.
Client # 3 was admitted on February 16, 2012, and a preliminary treatment plan was due by February 19, 2012. As of the date of inspection, the record did not contain a preliminary treatment plan.
Client # 6 was admitted on March 9, 2012, and discharged on April 23, 2012. A preliminary treatment plan was due by March 12, 2012, however, the record did not include one.
The findings were reviewed with the Facility Director during the exit interview.
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Plan of Correction
The Clincial Supervisor, Program Director will conduct chart audits bi-weekly to assure the treatment plans are complete and in the clinical chart. There will be documentation of chart audit data. The Program Director will review the policy proceedure with the clinical staff. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based upon a review of the facility's Policy & Procedure (P&P) Manual and client records, the facility failed to develop individual treatment and rehabilitation plans as per their policy.
The findings include:
The P&P Manual was reviewed as part of an Administrative Review that was conducted from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" included the following language, which specified the timeframe for the completion of treatment plans.
"The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director (when applicable) within 3-5 client days residential...."
Six client records requiring documentation of individualized treatment plans were reviewed from May 10 - 11, 2012. Two of six records, specifically #'s 2 and 6, contained treatment plans that were late.
Client # 2 was admitted on February 6, 2012, and the individualized treatment plan was due by February 11, 2012. The record contained a treatment plan that was signed by the client on February 13, 2012.
Client # 6 was admitted on March 9, 2012, and the individualized treatment plan was due by March 14, 2012. The record contained a treatment plan that was signed by the client on March 23, 2012.
The findings were reviewed with the Facility Director during the record review.
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Plan of Correction
The Clincial Supervisor, Program Director will develope a tracking system to track when client treatment plans are due, therefore . The Supervisor/Director will follow up with clinical staff to assure treatment plans are complete, comprehensive and measurable with the Supervisor/Directors signature. |
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 upon a review of client records, the facility failed to ensure that treatment plans were reviewed and updated at least every 30 days.
The findings include:
Five records requiring documentation of treatment plan updates were reviewed from May 10-11, 2012. Two of five records, specifically #'s 1 and 4, did not contain treatment plan updates as required.
Client # 1 was admitted on November 18, 2011. The record contained an updated treatment plan that was signed by the client on March 17, 2012. As of the date of inspection, the next updated treatment plan, which was due on or by April 16, 2012, was not included in the record.
Client # 4 was admitted on March 30, 2012. The record contained a treatment plan that was signed and dated by the client on April 6, 2012. As of the date of inspection, the next updated treatment plan, which was due on or by May 6, 2012, was not included in the record.
The findings were confirmed by the Facility Director during the record review.
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Plan of Correction
treatment Plan updates were completed for client#4 on 5/6, but was not in chart at time of inspection. The counselor for client#1 resigned therefore no treatment plan update for April was developed. the next treatment plan was 5/20. The Clincial Supervisor, Program Director will develope a tracking system to track when client treatment plans are due initially and updated treatment plans as indicated per policy. The Supervisor/Director will follow up with clinical staff to assure treatment plans are complete, comprehensive and measurable with the Supervisor/Directors signature. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. 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 upon a review of the facility's Policy & Procedure (P&P) Manual and client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan.
The findings include:
The facility's P&P Manual was reviewed from May 1 - 2, 2012.
The policy titled, "Counseling Services" includes the following language:
"Counseling services shall be provided for each client according to the frequency and nature identified on the client's individualized treatment and rehabilitation plan."
-and-
"Individual counseling shall occur at least one (1) hour weekly, generally divided into two 30 minute sessions, and shall be documented in the client record in an Individual Counseling Progress Note. (Residential DOH, PA)"
Five records requiring documentation of counseling services were reviewed from May 10 - 11, 2012. One of five records, specifically record # 1, did not contain documentation that verified that counseling services were provided according to the individual treatment plan.
Client # 1 was admitted on November 18, 2011, and was still an active client on the date of inspection. The record contained an Initial Treatment Plan that was signed and dated on November 21, 2011, and an Updated Treatment Plan that was signed and dated on March 17, 2012. Both the Initial and Updated Treatment Plan specified that Individual Counseling Sessions be conducted one time per week. However, the record did not contain documentation of any Individual sessions for the weeks of:
April 15-21, 2012
April 22-28, 2012
April 29-May 5, 2012
The findings were reviewed with the Facility Director during the record review.
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Plan of Correction
The Program Director will conduct a training with the staff,specifically the house managers to assure that the record of service is completed for each month before moving forward with the next month. The house managers documenting the record of service will bring it to the Program Directors if documents are not available to file and document. The Supervisor/Director will make the record of service a part of the bi-weekly chart audit |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based upon a review of client records, the facility failed to maintain a complete client record, to include a 'record of services' provided.
The findings include:
Five client records were reviewed from May 10 - 11, 2012, for completion of the 'record of services' provided. Three of five records, specifically #'s 1, 2, and 5, did not contain a complete 'record of services' provided to the client.
Client # 1 was admitted on November 18, 2011, and was still an active client at the time of inspection. The record contained a 'record of services' that was incomplete as it did not include entries for individual sessions that were documented by progress note on the following dates: February 29, March 9, 17, 23, and April 6, 2012.
In addition, the record contained an Initial Treatment Plan that was signed and dated on November 21, 2011, and an Updated Treatment Plan that was signed and dated on March 17, 2012. Both the Initial and Updated Treatment Plan specified that Static Groups, Encounter Groups, and Educational Groups be conducted one time per week. The 'record of services' in record # 1 contained entries dated April 2, 2012, and April 10, 2012. However, there were no entries from April 3 - 9, 2012.
Client # 2 was admitted on February 6, 2012 and was still an active client at the time of inspection. The record contained a 'record of services' that was incomplete as it did not include entries for individual sessions that were documented by progress notes on the following dates: February 6, March 13, 19, and April 24, 2012.
Client # 5 was admitted on April 6, 2012 and was still an active client at the time of inspection. The record contained a 'record of services' that was incomplete as it did not include entries for individual sessions that were documented by progress notes on the following dates: April 10, 19, and 26, 2012
In addition, the 'record of service' in record # 5 contained entries dated April 25, 2012, and May 7, 2012. However, there were no entries on the record of service from April 26 - May 6, 2012.
The findings were reviewed with the Facility Director during the exit interview.
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Plan of Correction
The record of Service for Clients #1,2 amd 5 has been addressed by notes being completed by the staff and filed and recoreded on the Record of Service when applicable previous and recent. All of the staff is aware that the Record of Service should always have an activity for each day, with no blanks. If the person being served is sick or in hospital it should be documented on the record of serviee. Record of Service is being completed by the counselors where appropiate.The Program Director will develope a process with the house managers that are filing and recording on the record of service. If the neccessary paperwork is not in to be filed and documented on the record of service by the end of each month it will be the responsibility of the primary counselor to complete the record of service within 5 days of the next month. The record of service will be a part of the bi-weekly chart audit. |
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 upon a review of the facility ' s Policy & Procedure (P&P) Manual and client records, the facility failed to ensure that case consultations were completed as per facility policy.
The findings include:
The P&P Manual was reviewed from May 1-2, 2012.
The facility policy titled, "Intake Process/Paperwork" Case Consults, contained the following language regarding case consultations.
"Case Consults are performed every 60 days on all active residential cases (90 days for outpatient) (14 days for short-term)."
Four client records requiring documentation of case consultations were reviewed between May 11-12, 2012. One of four records, specifically record # 1, did not contain case consultation notes as required by the policy.
Client # 1 was admitted on November 18, 2011. The first case consultation was due on or by January 17, 2012, and the second case consultation was due on or by March 17, 2012. As of the date of inspection, the record did not contain documentation of any case consultation notes.
The findings were confirmed by the Facility Director during the record review.
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Plan of Correction
Counselors updated and completed the Case Consultations on client 1. The previous counelor of client #1 resigned 5/4/2012, a case consult for the month client #1 recieved a new counselor which was 5/5/12 a case consult is complete. The Clincial Supervisor, Program Director will conduct chart audits bi-weekly that will include the completion of Case Consultations as specified by the policy. There will be documentation of chart audit data. |