INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 12, 2024 through September 13, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Hope ' s Destiny 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:
|
Plan of Correction
|
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
|
Observations
Based on the review of four personnel records, the project failed to ensure that a clinical supervisor that has not functioned for two years as a supervisor in the provision of clinical services complete a core curriculum in clinical supervision.
Employee #2 was hired as a clinical supervisor on July 8, 2024, and was current in that position at the time of the inspection. Employee #2 had not functioned for two-years as a supervisor in the provision of clinical services and as of the time of the inspection had not completed a core curriculum in clinical supervision.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
- The Clinical Supervisor completed part 1 of the DDAP Clinical supervision training on 9/25/24.
- Clinical Supervisor registered for Part 2 of the Clinical Supervision training that is scheduled for 11/1/2024
- In the event of a new clinical supervisor onboarding, they will have completed the Clinical Supervision requirements within 90 days of employment.
|
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
|
Observations
Based on the review of four personnel records, the project failed to ensure that a clinical supervisor participated in documented monthly meetings with their supervisor to discuss their duties and performance for the first six months of employment in that position.
Employee #2 was hired as a clinical supervisor on July 8, 2024, and was current in that position at the time of the inspection. There was no documentation that Employee #2 had participated in monthly meetings with their supervisor for the months of July 2024 and August 2024.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
- The COO met with the Clinical Supervisor on 10/14/24 to discuss performance, areas for improvement, duties, and any training needs.
- Ongoing meetings are scheduled monthly for the next 6 months.
- In the event of a new clinical supervisor onboarding, they will have monthly supervision meetings scheduled out for their first 6 months of employment in the role, with the COO responsible for conducting the supervision and maintaining record of the meetings.
|
704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
|
Observations
Based on a review of administrative documents, the project director failed to 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 an assessment of staff training needs.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The facility director will update the staff development program for agency personnel to include an assessment of staff training need and development of an overall plan for addressing these needs by December 15, 2024. The facility director will provide a training on the updated procedures within two weeks of the policy development. The project director will ensure the policy is updated and suitable prior to the training. The project director will attend the training to ensure all questions are answered. |
704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
|
Observations
Based on a review of administrative documents, the project director failed to 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 an overall plan for addressing staff training needs.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The facility director and clinical supervisor will update the staff development program for agency personnel to include an assessment of staff training need and development of an overall plan for addressing these needs by December 15, 2024. The facility director will provide a training on the updated procedures within two weeks of the policy development. The project director will ensure the policy is updated and suitable prior to the training. The project director will attend the training to ensure all questions are answered. |
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.
|
Observations
Based on the review of four personnel records, the project failed to document a written initial individual training plan for each employee, appropriate to that employee's skill level with input from both the employee and the supervisor in four out of four records reviewed.
Employee #1 was hired on May 28, 2024, and was to have an initial individual training plan documented by June 28, 2024; however, it was not documented in the personnel record until August 26, 2024.
Employee #2 was hired on July 8, 2024, and was to have an initial individual training plan documented by August 8, 2024; however, it was not documented in the personnel record until August 26, 2024.
Employee #3 was hired on June 25, 2024, and was to have an initial individual training plan documented by July 25, 2024; however, it was not documented in the personnel record until August 26, 2024.
Employee #4 was hired on May 15, 2024, and was to have an initial individual training plan documented by June 15, 2024; however, it was not documented in the personnel record until August 26, 2024.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
- Relias was implemented on 8/22/24 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 8/26/24 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 Relias that they would like to complete for their benefit. All current staff will be required to identify these trainings by 10/31/24. All new hires will be required to identify the three trainings within their first 30 days of employment.
- Chief Operating Officer (COO) 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.
|
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
|
Observations
Based on the review of personnel records, staff schedules and the Staffing Requirement Facility Summary Report (SRFSR), the project failed to ensure that at least one person trained in CPR and first aid was onsite during the project's hours of operation.
On Mondays, Wednesdays and Fridays, there was no staff member with a current CPR/First Aid Certification onsite between the hours of 8:00 AM and 7:00 PM during the months of February 2024, March 2024, April 2024, and May 2024.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
- A CPR certification course is scheduled for facility staff on 10/21/24 and will ensure a sufficient number of staff persons are onsite during the project's hours of operation.
- All new hires will be required to either present current CPR certification or will be registered for CPR certification class within 30 days of employment.
- The COO will be responsible for ensuring compliance with adequate number of staff remaining CPR certified during program hours.
|
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.
|
Observations
Based on the review of four personnel records and staff training records, the project failed to instruct all staff in the use of the fire extinguisher upon employment.
Employee #1 was hired as the facility director on May 28, 2024, and was current in that position at the time of the inspection. There was no documentation that this employee was trained in the use of the fire extinguisher upon employment.
Employee #2 was hired as a clinical supervisor on July 8, 2024, and was current in that position at the time of the inspection. There was no documentation that this employee was trained in the use of the fire extinguisher upon employment.
Employee #3 was hired as a counselor on June 25, 2024, and was current in that position at the time of the inspection. There was no documentation that this employee was trained in the use of the fire extinguisher upon employment.
Employee #4 was hired as a counselor on May 15, 2024, and was current in that position at the time of the inspection. There was no documentation that this employee was trained in the use of the fire extinguisher upon employment.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
- Relias was implemented on 8/22/24 in order to provide required new hire trainings, including use of fire extinguishers.
- All current employees were assigned annual training plans on 8/26/24 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 safety procedures and adherence to training plans will be topics covered during all staff on 10/29/24.
- COO 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.
|
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.
|
Observations
Based on the review of four personnel records and staff training records, the project failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
Employee #1 was hired as the facility director on May 28, 2024, and was current in that position at the time of the inspection. There was no documentation that this employee was trained to perform assigned tasks during emergencies.
Employee #2 was hired as a clinical supervisor on July 8, 2024, and was current in that position at the time of the inspection. There was no documentation that this employee was trained to perform assigned tasks during emergencies.
Employee #3 was hired as a counselor on June 25, 2024, and was current in that position at the time of the inspection. There was no documentation that this employee was trained to perform assigned tasks during emergencies.
Employee #4 was hired as a counselor on May 15, 2024, and was current in that position at the time of the inspection. There was no documentation that this employee was trained to perform assigned tasks during emergencies.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
- Relias was implemented on 8/22/24 in order to provide required new hire trainings, including use of fire extinguishers.
- All current employees were assigned annual training plans on 8/26/24 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 safety procedures and performing assigned tasks during emergencies will be topics covered during all staff on 10/29/24.
- COO 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.
|
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.
|
Observations
Based on the review of the fire drill log from January 2024 through August 2024, the facility failed to maintain written fire drill records that included the time of drill, the amount of time it took for evacuation, exit routes used, the number of people in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
These findings were reviewed with project staff during the licensing process.
|
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
- New fire drill form was implemented for drills completed being completed in September 2024 and forward.
- Binder with completed fire drills will be maintained at the reception desk. The Office Manager will be responsible for the oversight of said binder.
|
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.
|
Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in six of nine client records reviewed.
Client #1 was admitted on August 26, 2024, and was a current client at the time of the licensing inspection. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
Client #3 was admitted on March 15, 2024, and was a current client at the time of the licensing inspection. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
Client #6 was admitted on April 16, 2024, and was discharged on June 6, 2024. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
Client #7 was admitted on April 22, 2024, and was discharged on June 7, 2024. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
Client #8 was admitted on April 24, 2024, and was discharged on June 18, 2024. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
Client #9 was admitted on March 12, 2024, and was discharged on April 12, 2024. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
- A new informed consent form for the funding source was created and will be put into the EHR on 10/31/24
- 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 11/20/24.
- COO and Clinical Supervisor (CS) will review patient charts by end of November 2024 to ensure that all patients have the form completed and it is being completed at admission on new patients.
|
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
|
Observations
Based on the review of client records, the project failed to document written acknowledgement by clients that a client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment in nine of nine client records reviewed.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The client handbook handed out upon intake was updated on 10/17/2024 to reflect client rights pertaining to retaining civil rights and liberties except as provided by statute, that no client may be deprived of a civil right solely by reason of treatment. Said excerpt will be integrated into the EMR by 10/31/2024. Any new admissions prior to 10/31/2024 will receive a paper copy of their client rights, will acknowledge via signature and the document will be uploaded in their electronic chart. To ensure compliance with this plan, the Clinical Supervisor will complete a audit of all new admissions between 10/18/2024 and 10/31/2024 to ensure the client right acknowledgement form is signed by the client and uploaded into their record. |
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.
|
Observations
Based on the review of client records, the project failed to document written acknowledgement by clients that the clients have the right to appeal a decision limiting access to their records to the director in nine of nine client records reviewed.
These findings were reviewed with project staff during the licensing process.
|
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 10/21/24.
- COO and Clinical Supervisor (CS) will review patient charts by end of October to ensure that all patients have the form completed and it is being completed at admission on new patients.
|
709.30 (5) 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.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
|
Observations
Based on the review of client records, the project failed to document written acknowledgement by clients that the clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in nine of nine client records reviewed.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The client handbook handed out upon intake was updated to reflect client rights pertaining to the client right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. This update occurred on 10/17/2024. Said excerpt will be integrated into the EMR by 10/31/2024. Any new admissions prior to 10/31/2024 will receive a paper copy of their client rights, will acknowledge via signature and the document will be uploaded in their electronic chart. To ensure compliance with this plan, the Clinical Supervisor will complete a audit of all new admissions between 10/18/2024 and 10/31/2024 to ensure the client right acknowledgement form is signed by the client and uploaded in to their record. |
709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
|
Observations
Based on the review of client records, the project failed to document written acknowledgement by clients that the clients have the right submit a rebuttal data or memoranda to their own records in nine of nine client records reviewed.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The client handbook handed out upon intake was updated to reflect client rights pertaining to the client right to submit rebuttal data or memoranda to their own records. This update occurred on 10/17/2024. Said excerpt will be integrated into the EMR by 10/31/2024. Any new admissions prior to 10/31/2024 will receive a paper copy of their client rights, will acknowledge via signature and the document will be uploaded in their electronic chart. To ensure compliance with this plan, the Clinical Supervisor will complete a audit of all new admissions between 10/18/2024 and 10/31/2024 to ensure the client right acknowledgement form is signed by the client and uploaded in to their record. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on the review of client records, the project failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of one applicable client record reviewed.
Client #2 was admitted on June 21, 2024 and was involuntarily discharged on July 25, 2024. It was not documented in the client record that the client received written notification of the decision to involuntarily terminate the client's treatment.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
By 11/1/24, Clinical Supervisor will retrain clinical staff on the Administrative Discharge Appeal Form. Clinical staff will sign attestations for review of Administrative/ Involuntary Discharge Policy. COO and Clinical Supervisor will continue providing education via treatment teams and supervision regarding utilization of the AD Appeal Form to ensure client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project. Clinical Supervisors will provide education on use of AD Appeal Form in live time. Clinical supervisor will audit AD discharges on a monthly basis. Audits of Administrative Discharges will discontinue after 90 days of 90% compliance. |
709.81(b)(7) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
|
Observations
Based on the review of partial hospitalization client records, the project failed to document a preliminary treatment and rehabilitation plans at intake, per facility policy, in two of two client records reviewed.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
- All staff will be trained upon hire of the policies regarding documentation expectations, including clients needing a preliminary treatment and rehabilitation plan upon intake.
- Documentation expectations/timeframes will be reviewed in group clinical supervision on 10/24/24 with all clinical staff.
- Clinical Supervisor will perform random chart audits at least quarterly to ensure that the group counseling is taking place at least twice weekly and documentation is completed in full and within the appropriate timeframes.
|
709.82(a) 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:
|
Observations
Based on the review of partial hospitalization client records, the project failed to document a comprehensive individual treatment and rehabilitation plan in one of two client records reviewed.
Client #2 was admitted on June 21, 2024 and was discharged on July 25, 2024. A comprehensive individual treatment plan was not documented in the client record.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
- All staff will be trained upon hire of the policies regarding documentation expectations, including clients needing a comprehensive individual treatment and rehabilitation plan.
- Documentation expectations/timeframes will be reviewed in group clinical supervision on 10/24/24 with all clinical staff.
- Clinical Supervisor will perform random chart audits at least quarterly to ensure that the group counseling is taking place at least twice weekly and documentation is completed in full and within the appropriate timeframes.
|
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.
|
Observations
Based on the review of client records, the project failed to document two weekly individual counseling sessions in one of two partial hospitalization clients reviewed.
Client # 1 was admitted on August 26, 2024 and was active at the time of the inspection. The project only documented one individual counseling session for the weeks of August 26. 2024 through August 30, 2024 and September 2, 2024 through September 6, 2024.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
- All staff were provided updated policy training that PHP clients need to have two individual sessions per week on 10/7/2024
- 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.
- Clinical Supervisor will review schedules with clinical staff at least monthly to ensure clients are being met as their program requires.
- COO and Clinical Supervisor will complete weekly patient engagement audits to ensure individuals are being seen the appropriate amount of times per week.
|
709.82(d)(2) 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:
(2) Group counseling, at least twice weekly.
|
Observations
Based on the review of client records, the project failed to document group counseling, at least twice weekly in one of two partial hospitalization clients reviewed.
Client # 1 was admitted on August 26, 2024, and was active at the time of the inspection. The project failed to document any group counseling sessions for the week of August 26. 2024 through August 30, 2024.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
- All staff will be trained upon hire of the policies regarding documentation expectations, including content and timeframes for completion.
- Documentation expectations/timeframes will be reviewed in group clinical supervision on 10/24/24 with all clinical staff.
- Clinical Supervisor will perform random chart audits at least quarterly to ensure that the group counseling is taking place at least twice weekly and documentation is completed in full and within the appropriate timeframes.
|
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.
|
Observations
Based on the review of partial hospitalization client records, the project failed to document a complete client record on an individual that included case consultation notes in two of two client records reviewed.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
- The case consultation policy will be reviewed with all staff in the October all staff meeting on 10/29/24.
- 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.
- Clinical Supervisor will review patient charts quarterly to ensure case consultation is being completed quarterly at a minimum.
|
709.84(c) LICENSURE Project management services
709.84. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
|
Observations
Based on a physical plant inspection on September 13, 2024, the facility failed to display a telephone number conspicuously to the general public for emergency purposes.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
- The COO added a telephone number for emergency purposes to the facility sign on 10/7/2024. This number is located outside the facility, visible to the general public.
|
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
|
Observations
Based on the review of outpatient client records, the project failed to document a preliminary treatment and rehabilitation plans at intake, per facility policy, in seven of seven client records reviewed.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
- All staff will be trained upon hire of the policies regarding documentation expectations, including content and timeframes for completion.
- Documentation timeframes will be reviewed in group clinical supervision on 10/24/24 with all clinical staff.
- Clinical Supervisor 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 in full and within the appropriate timeframes.
|
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:
|
Observations
Based on the review of outpatient client records, the project failed to document an individual treatment and rehabilitation plan was developed with the client in four of seven client records reviewed.
Client #6 was admitted on April 16, 2024 and was discharged on June 6, 2024. An individual treatment and rehabilitation plan dated May 24, 2024, was missing documentation that the plan was developed with the client.
Client #7 was admitted on April 22, 2024 and was discharged on June 7, 2024. An individual treatment and rehabilitation plan dated May 24, 2024, was missing documentation that the plan was developed with the client.
Client #8 was admitted on April 24, 2024 and was discharged on June 18, 2024. An individual treatment and rehabilitation plan dated May 24, 2024, was missing documentation that the plan was developed with the client.
Client #9 was admitted on March 12, 2024 and was discharged on April 12, 2024. An individual treatment and rehabilitation plan was not documented in the client record.
These findings were reviewed with project staff during the licensing process.
|
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 10/24/24 with all clinical staff.
- Clinical Supervisor 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.
|
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of outpatient client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in three of the seven client records reviewed.
Client #3 was admitted on March 15, 2024 and was a current client at the time of the licensing inspection. The individual treatment and rehabilitation plan was completed on April 3, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client #4 was admitted on April 8, 2024 and was a current client at the time of the licensing inspection. The individual treatment and rehabilitation plan was completed on April 16, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client #5 was admitted on May 9, 2024 and was a current client at the time of the licensing inspection. The individual treatment and rehabilitation plan was completed on May 24, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
- All staff will be trained upon hire of the policies regarding documentation expectations as it pertains to content.
- Documentation expectations will be reviewed in group clinical supervision on 10/24/24 with all clinical staff.
- Clinical Supervisor 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 appropriately and in full.
|
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.
|
Observations
Based on the review of outpatient client records, the project failed to document a complete client record on an individual that included case consultation notes in four of seven client records reviewed.
Client #6 was admitted on April 16, 2024 and was discharged on June 6, 2024. Case consultation notes were not documented in the client record.
Client #7 was admitted on April 22, 2024 and was discharged on June 7, 2024. Case consultation notes were not documented in the client record.
Client #8 was admitted on April 24, 2024 and was discharged on June 18, 2024. Case consultation notes were not documented in the client record.
Client #9 was admitted on March 12, 2024 and was discharged on April 12, 2024. Case consultation notes were not documented in the client record.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
- The case consultation policy will be reviewed with all staff in the October all staff meeting on 10/29/2024
- 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.
- Clinical Supervisor will review patient charts quarterly to ensure case consultation is being completed quarterly at a minimum.
|
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.
|
Observations
Based on the review of outpatient client records, the project failed to document a complete client record on an individual that included follow-up information in four of four applicable client records reviewed.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
- Discharge follow up policy and procedures will be reviewed with all staff on 10/29/24 in the all staff meeting.
- New workflow for completing follow-up calls to individuals discharged will be implemented by 11/9/24 in which office manager tracks clients who have been discharged and provides list to COO and Clinical Supervisor (CS) at the beginning of each month with individuals who need to be contacted that month for discharge follow up calls.
- COO and CS will ensure
proper documentation is put into the EHR.
|
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
|
Observations
Based on a physical plant inspection on September 13, 2024, the facility failed to display a telephone number conspicuously to the general public for emergency purposes.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
- The COO added a telephone number for emergency purposes to the facility sign on 10/7/2024. This number is located outside the facility, visible to the general public.
|