INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 26, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, PWS Wayne LLC dba Amwell Recovery of Wayne 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 provide a written individual training plan for each employee, that documented it was developed annually with input from both the employee and the supervisor in four of four applicable personnel records reviewed.
Employee # 1 was hired as the Project and Facility Director on November 13, 2023 and was current in that position at the time of the inspection. Employee # 1 should have had an initial individual training plan developed within 30 days of the date of hire, however a written individual training plan was not developed until June 25, 2024.
Employee # 2 was hired as the Clinical Supervisor on May 20, 2024 and was current in that position at the time of the inspection. The individual training plan had no documentation that the plan was developed with input from the employee.
Employee # 3 was hired as a counselor on April 29, 2024 and was current in that position at the time of the inspection. Employee # 3 should have had an initial individual training plan developed within 30 days of the date of hire, however a written individual training plan was not developed until June 25, 2024. Additionally, the individual training plan had no documentation that the plan was developed with input from the employee.
Employee # 5 was hired as a counselor on January 8, 2024 and was current in that position at the time of the inspection. Employee # 5 should have had an initial individual training plan developed within 30 days of the date of hire, however a written individual training plan was not developed until June 25, 2024. Additionally, the individual training plan had no documentation that the plan was developed with input from the employee.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
- Medtrainer was implemented on 6/25/24 in order to provide individualized training plans for all staff upon hire as well as annually.
- All current employees were assigned annual training plans on 6/25/24 and all new staff moving forward will be assigned new hire training plans to ensure training in all required areas.
- All new hires will be required to identify at least three trainings per year in Medtrainer that they would like to complete for their benefit. All current staff will be required to identify these trainings by 8/30/24. All new hires will be required to identify the three trainings within their first 30 days of employment.
- Executive Director (ED) will monitor progress on completion of required trainings (both upon hire and annually) of all staff on a monthly basis. Automatic emails will be sent to all staff identifying upcoming trainings that are due along with overdue trainings.
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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection on June 26, 2024, the facility failed to ensure that exits from rooms are unobstructed. The door to the group room in the rear of the building was unable to be opened by two staff members. A third staff member was able to open the door after about two minutes.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
- Building owner and maintenance crew were notified via email on 6/27/24 about the issue with the door sticking and the need to immediately fix this issue. Maintenance came to the office and worked on the problem and the door was fixed to ensure it did not stick by the end of business on 6/28/24.
- ED and other staff will monitor all doors within the building to ensure that they are not sticking. If any door sticks, the maintenance crew will be notified immediately to fix the problem.
- Should a door stick, that room will not be used until the door is fixed to ensure patient and staff safety.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of five personnel records, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in four records reviewed.
Employee # 1 was hired as the Project and Facility Director on November 13, 2023 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until May 30, 2024.
Employee # 2 was hired as the Clinical Supervisor on May 20, 2024 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until May 30, 2024.
Employee # 3 was hired as a counselor on April 29, 2024 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until May 30, 2024.
Employee # 5 was hired as a counselor on January 8, 2024 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until May 30, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- Medtrainer was implemented on 6/25/24 in order to provide required new hire trainings.
- All current employees were assigned annual training plans on 6/25/24 and all new staff moving forward will be assigned new hire training plans to ensure training in all required areas to be completed within 30 days of their start date.
- Fire extinguisher training is to be completed upon hire so will be added to the new hire orientation packet to be completed on an employees first day of employment.
- Executive Director (ED) will monitor progress on completion of required new hire trainings of all new staff on a monthly basis. Automatic emails will be sent to all staff identifying upcoming trainings that are due along with overdue trainings.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of five personnel records, the facility failed to ensure that four applicable staff members were trained to perform assigned tasks during emergencies prior to being on shift.
Employee # 1 was hired as the Project and Facility Director on November 13, 2023 and is current in that position. Employee # 1 began working shifts on November 13, 2023, but was not trained to perform assigned tasks during emergencies until May 30, 2024.
Employee # 2 was hired as the Clinical Supervisor on May 20, 2024 and is current in that position. Employee # 2 began working shifts on May 20, 2024, but was not trained to perform assigned tasks during emergencies until May 30, 2024.
Employee # 3 was hired as a counselor on April 29, 2024 and is current in that position. Employee # 3 began working shifts on April 29, 2024, but was not trained to perform assigned tasks during emergencies until May 30, 2024.
Employee # 5 was hired as a counselor on January 8, 2024 and is current in that position. Employee # 5 began working shifts on January 8, 2024, but was not trained to perform assigned tasks during emergencies until May 30, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- Medtrainer was implemented on 6/25/24 in order to provide required new hire trainings.
- All current employees were assigned annual training plans on 6/25/24 and all new staff moving forward will be assigned new hire training plans to ensure training in all required areas to be completed within 30 days of their start date.
- Emergency Preparedness training is to be completed upon hire so will be added to the new hire orientation packet to be completed on an employees first day of employment.
- Executive Director (ED) will monitor progress on completion of required new hire trainings of all new staff on a monthly basis. Automatic emails will be sent to all staff identifying upcoming trainings that are due along with overdue trainings.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the January 2024 through May 2024 fire drill logs, the facility failed to document the exit route used and whether the smoke detector or fire alarm were operative during each drill conducted.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
- ED updated the Fire Drill template to include an option for alarm sounded or alarm not sounded and an area to identify the evacuation route used during the drill on 6/28/24.
- New fire drill form was implemented in July 2024 and will be utilized for monthly fire drills moving forward.
- Monthly fire drills are completed by the assigned Health and Safety Officer. ED will review all completed fire drill logs to ensure they are completed in their entirety on a monthly basis and sign off on this review. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of nine client records, the facility failed to obtain an informed and voluntary consent to release information form from the client for the disclosure of information contained in eight records reviewed.
Client # 1 was admitted to the Outpatient level of care on February 12, 2024 and was discharged on March 22, 2024. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing.
Client # 2 was admitted to the Outpatient level of care on January 26, 2024 and was discharged on March 19, 2024. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing. Additionally, there was evidence of disclosures to a family member during a family counseling session on February 6, 2024; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
Client # 3 was admitted to the Outpatient level of care on March 6, 2024 and was discharged on May 29, 2024. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing.
Client # 5 was admitted to the Outpatient level of care on April 10, 2024 and was active at the time of the inspection. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing.
Client # 6 was admitted to the Outpatient level of care on May 5, 2024 and was active at the time of the inspection. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing.
Client # 7 was admitted to the Outpatient level of care on May 6, 2024 and was active at the time of the inspection. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing.
Client # 8 was admitted to the Partial level of care on May 31, 2024 and was transferred to a lower level of care on June 17, 2024. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing.
Client # 9 was admitted to the Partial level of care on June 6, 2024 and was transferred to a lower level of care on June 20, 2024. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
- A new informed consent form for the funding source was created and put into the EHR on 8/1/24.
- The billing consent is completed at admission.
- All staff have been trained to complete the form at admission.
- All existing patients will be asked to sign the form with the goal of ensuring all current patients having the form completed by 8/16/24.
- ED and Clinical Director (CD) will review patient charts by end of August to ensure that all patients have the form completed and it is being completed at admission on new patients.
- Random client chart audits will be completed on a monthly basis by the ED and CD to ensure ongoing compliance.
- All staff reviewed in monthly all staff meeting on 8/12/24 the need to complete consent to release information forms for any individual present in a session with a client. It was reviewed the their verbal consent is not sufficient and this form must be completed for each individual participating in their treatment.
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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of nine client records, the facility failed to include documentation of all the required client rights, including that the project, facility, or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record, in nine records reviewed.
Client # 1 was admitted to the Outpatient level of care on February 12, 2024 and was discharged on March 22, 2024.
Client # 2 was admitted to the Outpatient level of care on January 26, 2024 and was discharged on March 19, 2024.
Client # 3 was admitted to the Outpatient level of care on March 6, 2024 and was discharged on May 29, 2024.
Client # 4 was admitted to the Outpatient level of care on March 12, 2024 and was active at the time of the inspection.
Client # 5 was admitted to the Outpatient level of care on April 10, 2024 and was active at the time of the inspection.
Client # 6 was admitted to the Outpatient level of care on May 5, 2024 and was active at the time of the inspection.
Client # 7 was admitted to the Outpatient level of care on May 6, 2024 and was active at the time of the inspection.
Client # 8 was admitted to the Partial level of care on May 31, 2024 and was transferred to a lower level of care on June 17, 2024.
Client # 9 was admitted to the Partial level of care on June 6, 2024 and was transferred to a lower level of care on June 20, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- A new document was implemented into the admission process called "Rights of Individuals" which includes the statement: "The to have access to and obtain a copy of his or her clinical record, in accordance with the program's policies and procedures and applicable Federal and State laws and rules. Clients have the right to inspect their own records. The project, facility, or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record."
- All new patients will complete this form at admission.
- All staff have been trained to complete the form at admission.
- All existing patients will be asked to sign the form with the goal of ensuring all current patients having the form completed by 8/16/24.
- ED and Clinical Director (CD) will review patient charts by end of August to ensure that all patients have the form completed and it is being completed at admission on new patients.
- Random client chart audits will be completed on a monthly basis by the ED and CD to ensure ongoing compliance.
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709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of nine client records, the facility failed to include documentation of all the required client rights, including that clients have the right to appeal a decision limiting access to their records to the director, in nine records reviewed.
Client # 1 was admitted to the Outpatient level of care on February 12, 2024 and was discharged on March 22, 2024.
Client # 2 was admitted to the Outpatient level of care on January 26, 2024 and was discharged on March 19, 2024.
Client # 3 was admitted to the Outpatient level of care on March 6, 2024 and was discharged on May 29, 2024.
Client # 4 was admitted to the Outpatient level of care on March 12, 2024 and was active at the time of the inspection.
Client # 5 was admitted to the Outpatient level of care on April 10, 2024 and was active at the time of the inspection.
Client # 6 was admitted to the Outpatient level of care on May 5, 2024 and was active at the time of the inspection.
Client # 7 was admitted to the Outpatient level of care on May 6, 2024 and was active at the time of the inspection.
Client # 8 was admitted to the Partial level of care on May 31, 2024 and was transferred to a lower level of care on June 17, 2024.
Client # 9 was admitted to the Partial level of care on June 6, 2024 and was transferred to a lower level of care on June 20, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- A new document was implemented into the admission process called "Rights of Individuals" which includes the statement: "The to have access to and obtain a copy of his or her clinical record, in accordance with the program's policies and procedures and applicable Federal and State laws and rules. Clients have the right to inspect their own records. The project, facility, or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record."
- The "Rights of Individuals" form also includes the following statements: "The right to appeal a decision limiting access to their records to the director. The right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records. And The right to submit rebuttal data or memoranda to their own records."
- All new patients will complete this form at admission.
- All staff have been trained to complete the form at admission.
- All existing patients will be asked to sign the form with the goal of ensuring all current patients having the form completed by 8/16/24.
- ED and Clinical Director (CD) will review patient charts by end of August to ensure that all patients have the form completed and it is being completed at admission on new patients.
- Random client chart audits will be completed on a monthly basis by the ED and CD to ensure ongoing compliance.
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709.81(b)(3)(ii) LICENSURE Intake and admission
709.81. 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 and the facility's policies and procedures, the facility failed to document a client's drug or alcohol history within three days of admission, per facility policy, in one of two applicable records reviewed.
Client # 8 was admitted on May 31, 2024 and was transferred to a lower level of care on June 17, 2024. The record did not contain a drug or alcohol history.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
- All staff will be trained upon hire of the policies regarding timeframes for documentation completion.
- Documentation timeframes will be reviewed in group clinical supervision on 8/13/24 with all clinical staff.
- CD will perform random chart audits at least quarterly to ensure that full histories are being completed and all necessary information (including a complete drug and alcohol history) is obtained.
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709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a client's personal history within three days of admission, per facility policy, in one of two applicable records reviewed.
Client # 8 was admitted on May 31, 2024 and was transferred to a lower level of care on June 17, 2024. The record did not contain a personal history.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
- All staff will be trained upon hire of the policies regarding timeframes for documentation completion.
- Documentation timeframes will be reviewed in group clinical supervision on 8/13/24 with all clinical staff.
- CD will perform random chart audits at least quarterly to ensure that full histories are being completed and all necessary information (including a complete personal history) is obtained.
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709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation within three days of admission, per facility policy, in two of two applicable records reviewed.
Client # 8 was admitted on May 31, 2024 and was transferred to a lower level of care on June 17, 2024. The record did not contain a psychosocial evaluation.
Client # 9 was admitted on June 6, 2024 and was transferred to a lower level of care on June 20, 2024. The psychosocial evaluation was not completed until June 26, 2024.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
- All staff will be trained upon hire of the policies regarding timeframes for documentation completion.
- Documentation timeframes will be reviewed in group clinical supervision on 8/13/24 with all clinical staff.
- CD will perform random chart audits at least quarterly to ensure that the biopsychosocial is being completed within the appropriate timeframes.
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709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of two client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in two records reviewed.
Client # 8 was admitted on May 31, 2024 and was transferred to a lower level of care on June 17, 2024. The individual treatment and rehabilitation plan was completed on June 5, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 9 was admitted on June 6, 2024 and was transferred to a lower level of care on June 20, 2024. The individual treatment and rehabilitation plan was completed on June 12, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
- All clinical staff will be trained upon hire on how to appropriately document the type and frequency of treatment services each individual will be receiving including documenting the change in type and frequency of treatment services when a patient transitions from one level of care to another.
- All current clinical staff will review appropriate treatment plan documentation including the type and frequency of treatment services in group clinical supervision on 8/13/24.
- CD will perform at least quarterly chart audits to ensure that treatment plans are identifying the type and frequency of treatment services being provided.
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709.82(a)(3) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan in one of two client records reviewed.
Client # 8 was admitted on May 31, 2024 and was transferred to a lower level of care on June 17, 2024. The individual treatment and rehabilitation plan was completed on June 5, 2024; however, the plan did not include documentation of the proposed type of support services.
These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
- All clinical staff will be trained upon hire on how to identify the support service(s) needed for each individual being served and how to appropriately document this in the treatment plan.
- All current clinical staff will review support services and how to document these services in the treatment plan in group clinical supervision on 8/27/24.
- CD will perform at least quarterly chart audits to ensure that treatment plans are identifying the type of support services being monitored.
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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 sessions two times weekly for clients in the partial hospitalization activity in two of two client records reviewed.
Client # 8 was admitted on May 31, 2024 and was transferred to a lower level of care on June 17, 2024. The record contained documentation of only one individual counseling session for the weeks of May 31, 2024 and June 7, 2024.
Client # 9 was admitted on June 6, 2024 and was transferred to a lower level of care on June 20, 2024. The record did not contain documentation of an individual counseling session for the treatment week of June 13, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- All staff were provided updated policy training that PHP clients need to have two individual sessions per week on 6/28/24.
- Clinical staff will be trained upon hire about the counseling requirements for each level of care.
- Clinical staff schedules were updated to provide spaces for PHP clients to have two individual sessions per week. Clinical staff schedules were created to maintain a consistent session meeting time for all clients.
- CD will review schedules with clinical staff at least monthly to ensure clients are being met as their program requires.
- ED and CD will complete weekly patient engagement audits to ensure individuals are being seen the appropriate amount of times per week.
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709.83(a)(4) 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:
(4) Case consultation notes.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes, in two of two records reviewed. The facility policy manual indicates that case consultation notes will be completed at level of care changes.
Client # 8 was admitted on May 31, 2024 and was transferred to a lower level of care on June 17, 2024. The record did not contain documentation of a case consultation note.
Client # 9 was admitted on June 6, 2024 and was transferred to a lower level of care on June 20, 2024. The record did not contain documentation of a case consultation note.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- The case consultation policy will be reviewed with all staff in the August all staff meeting on 8/12/24.
- All staff will be trained upon hire on the case consultation policy.
- Case consultation will be completed in group clinical supervisions as required in the policy including at level of care transitions and at least quarterly.
- CD will review patient charts quarterly to ensure case consultation is being completed quarterly at a minimum.
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709.83(a)(9) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(9) Progress notes.
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Observations
Based on a review of client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed before the end of the clinical staff member ' s shift, in one of two records reviewed.
Client # 8 was admitted on May 31, 2024 and was transferred to a lower level of care on June 17, 2024. The record contained a progress note for an individual session occurring on June 14, 2024, that was not completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- All staff will be trained upon hire of the policies regarding timeframes for documentation completion.
- Documentation timeframes will be reviewed in group clinical supervision on 8/13/24 with all clinical staff.
- CD will review notes on a weekly basis to ensure that clinicians are completing progress notes on time and accurately.
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a client's personal history within three days of admission, per facility policy, in four of seven applicable records reviewed.
Client # 1 was admitted on February 12, 2024 and was discharged on March 22, 2024. The personal history was not documented as completed until February 19, 2024.
Client # 3 was admitted on March 6, 2024 and was discharged on May 29, 2024. The personal history was not documented as completed until May 9, 2024.
Client # 4 was admitted on March 12, 2024 and was active at the time of the inspection. The personal history was not documented as completed until May 14, 2024.
Client # 5 was admitted on April 10, 2024 and was active at the time of the inspection. The record did not contain a completed personal history.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
- All staff will be trained upon hire of the policies regarding timeframes for documentation completion.
- Documentation timeframes will be reviewed in group clinical supervision on 8/13/24 with all clinical staff.
- CD will perform random chart audits at least quarterly to ensure that full histories are being completed and all necessary information (including a complete personal history) is obtained.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation within three days of admission, per facility policy, in four of seven applicable records reviewed.
Client # 1 was admitted on February 12, 2024 and was discharged on March 22, 2024. The psychosocial evaluation was not completed until February 19, 2024.
Client # 3 was admitted on March 6, 2024 and was discharged on May 29, 2024. The psychosocial evaluation was not completed until May 9, 2024.
Client # 4 was admitted on March 12, 2024 and was active at the time of the inspection. The psychosocial evaluation was not completed until May 14, 2024.
Client # 5 was admitted on April 10, 2024 and was active at the time of the inspection. The record did not contain a psychosocial evaluation.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
- All staff will be trained upon hire of the policies regarding timeframes for documentation completion.
- Documentation timeframes will be reviewed in group clinical supervision on 8/13/24 with all clinical staff.
- CD will perform random chart audits at least quarterly to ensure that the biopsychosocial is being completed within the appropriate timeframes.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client within 30 days of admission, per the facility policy, in four of five applicable records reviewed.
Client # 3 was admitted on March 6, 2024 and was discharged on May 29, 2024. The individual treatment and rehabilitation plan was due to be completed by April 6, 2024; however, the plan was not documented as completed until May 9, 2024.
Client # 4 was admitted on March 12, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by April 12, 2024; however, the plan was not documented as completed until May 10, 2024.
Client # 5 was admitted on April 10, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by May 10, 2024; however, the plan was not documented as completed prior to the date of the inspection.
Client # 7 was admitted to the Outpatient level of care on May 6, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed by May 15, 2024; however, the record did not contain documentation that the client participated in the development of the plan.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- All staff will be trained upon hire of the policies regarding timeframes for documentation completion.
- Documentation timeframes will be reviewed in group clinical supervision on 8/13/24 with all clinical staff.
- CD will perform random chart audits at least quarterly to ensure that the individual treatment and rehabilitation plan is developed with the client is being completed within the appropriate timeframes.
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709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan in three of five client records reviewed.
Client # 3 was admitted on March 6, 2024 and was discharged on May 29, 2024. The individual treatment and rehabilitation plan completed on May 9, 2024, did not include documentation of the proposed type of support services.
Client # 4 was admitted on March 12, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on May 10, 2024, did not include documentation of the proposed type of support services.
Client # 7 was admitted to the Outpatient level of care on May 6, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on May 15, 2024, did not include documentation of the proposed type of support services.
These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
- All clinical staff will be trained upon hire on how to identify the support service(s) needed for each individual being served and how to appropriately document this in the treatment plan.
- All current clinical staff will review support services and how to document these services in the treatment plan in group clinical supervision on 8/27/24.
- CD will perform at least quarterly chart audits to ensure that treatment plans are identifying the type of support services being monitored.
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709.93(a)(5) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Progress notes.
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Observations
Based on a review of client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed before the end of the clinical staff member ' s shift, in four of seven records reviewed.
Client # 1 was admitted on February 12, 2024 and was discharged on March 22, 2024. The record contained a progress note for an individual session occurring on February 14, 2024, that was not completed until March 25, 2024.
Client # 3 was admitted on March 6, 2024 and was discharged on May 29, 2024. The record contained progress notes for individual sessions occurring on April 17, 2024 and April 24, 2024, that were not completed until June 18, 2024.
Client # 4 was admitted on March 12, 2024 and was active at the time of the inspection. The record contained progress notes for individual sessions occurring on May 2, 2024 and June 6, 2024, that were not completed until June 19, 2024.
Client # 5 was admitted on April 10, 2024 and was active at the time of the inspection. The record contained progress notes for individual sessions occurring on April 12, 2024 and April 16, 2024 and a group session occurring on May 22, 2024, that were not completed until June 17, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- All staff will be trained upon hire of the policies regarding timeframes for documentation completion.
- Documentation timeframes will be reviewed in group clinical supervision on 8/13/24 with all clinical staff.
- CD will review notes on a weekly basis to ensure that clinicians are completing progress notes on time and accurately.
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709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes, in one of one applicable record reviewed. The facility policy manual indicates that case consultation notes will be completed quarterly.
Client # 4 was admitted on March 12, 2024 and was active at the time of the inspection. The record did not contain documentation of a case consultation note.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- The case consultation policy will be reviewed with all staff in the August all staff meeting on 8/12/24.
- All staff will be trained upon hire on the case consultation policy.
- Case consultation will be completed in group clinical supervisions as required in the policy including at level of care transitions and at least quarterly.
- CD will review patient charts quarterly to ensure case consultation is being completed quarterly at a minimum.
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709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in three of three applicable records reviewed.
Client # 1 was admitted on February 12, 2024 and was discharged on March 22, 2024. There was no documentation of follow-up information in the record.
Client # 2 was admitted on January 26, 2024 and was discharged on March 19, 2024. There was no documentation of follow-up information in the record.
Client # 3 was admitted on March 6, 2024 and was discharged on May 29, 2024. There was no documentation of follow-up information in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- Discharge follow up policy and procedures will be reviewed with all staff in September 2024 all staff meeting.
- New workflow for completing follow-up calls to individuals discharged will be implemented by 8/30/24 in which office manager tracks clients who have been discharged and provides list to ED and CD at the beginning of each month with individuals who need to be contacted that month for discharge follow up calls.
- ED and CD will ensure proper documentation is put into the EHR.
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