INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 27 - 30, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kirkbride Center 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 and a review of the Staffing Requirements Facility Summary Report form, the facility failed to develop an annually written individual training plan for each employee.
The findings include:
Nine personnel records were reviewed on October 27, 2015; in addition to a review of the Staffing Requirements Facility Summary Report form. The facility failed to develop an annually written individual training plan for eight out of nine employees.
Employee # 10, a counselor was hired June 11, 2013. The facility failed to develop an annual written individual training plan for employee # 10. The last documented training plan for employee # 10 was 10/15/2013.
Employee # 11, a counselor was hired September 9, 2013. The facility failed to develop an annual written individual training plan for employee # 11. The last documented training plan for employee # 11 was 7/15/2014.
Employee # 12, a counselor was hired May 31, 2013. The facility failed to develop an annual written individual training plan for employee # 12. The last documented training plan for employee # 12 was 7/18/2014.
Employee # 13, a counselor was hired March 29, 2012. The facility failed to develop an annual written individual training plan for employee # 13. The last documented training plan for employee # 13 was 7/16/2014.
Employee # 14, a counselor was hired January 20, 2013. The facility failed to develop an annual written individual training plan for employee # 14. The last documented training plan for employee # 14 was 4/22/2014.
Employee # 15, a counselor was hired February 10, 2014. The facility failed to develop an annual written individual training plan for employee # 15. The last documented training plan for employee # 15 was 10/27/2014.
Employee # 16, a counselor was hired January 19, 2011. The facility failed to develop an annual written individual training plan for employee # 16. The last documented training plan for employee # 16 was 7/16/2014.
Employee # 17, a counselor was hired September 24, 2012. The facility failed to develop an annual written individual training plan for employee # 17. The last documented training plan for employee # 17 was 7/20/2014.
In addition, based on a review of the Staffing Requirements Facility Summary Report form which was finalized by the facility on October 27, 2015, the facility failed to document an individual training plan for each employee. There were 80 support staff that did not have documentation of an annual written individual training plan.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The staff training plan process has been revised. Moving forward, as of December 8, 2015 under the direction of a newly hired HR Director, each staff training plan will be linked to staff?s annual performance evaluation and both will be due based on date of hire. The specific training plans that were identified for employees #10-17 will be updated and completed by the appropriate Clinical Manager, Director or Supervisor before end of the current training year, 12/31/15. To ensure compliance, the HR Director will utilize electronic record keeping software inherent in our Automatic Data Processing system to ensure that all required documentation due for all members of staff is tracked, completed, and reported monthly to the appropriate department heads for follow-up with their personnel. Compliance to be reported monthly to the Executive Director in the HR Dashboard meeting on an ongoing basis. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and a review of the Staffing Requirements Facility Summary Report form, the facility failed to ensure that staff persons receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year. All other staff shall complete the training within the first 2 years of employment.
The findings include:
One personnel record requiring documentation of 6 hours HIV/AIDS training and at least 4 hours of TB/STD training were reviewed on October 27, 2015; in addition to a review of the Staffing Requirements Facility Summary Report form. The facility failed to ensure all staff persons received a minimum of 6 hours HIV/AIDS training and at least 4 hours of TB/STD training.
Employee # 7, a counselor was hired June 22, 2014. HIV/AIDS training was to be completed within the first year of employment or by June 22, 2015. The facility failed to ensure and document that employee # 7 completed HIV/AIDS as of the time of inspection.
A van driver was hired June 20, 2010. HIV/AIDS and TB/STD training was to be completed within the first 2 years of employment. Based on the staffing form, the facility failed to document or verify that the van driver completed HIV/AIDS & TB/STD training.
The admissions manger was hired October 28, 2013. HIV/AIDS and TB/STD training was to be completed within the first 2 years of employment. Based on the staffing form, the facility failed to document or verify that the admissions manager completed HIV/AIDS & TB/STD training.
Admissions coordinator 1 was hired May 15, 2007. HIV/AIDS and TB/STD training was to be completed within the first 2 years of employment. Based on the staffing form, the facility failed to document or verify that the admissions coordinator 1 completed HIV/AIDS & TB/STD training.
Admissions coordinator 2 was hired October 27, 2008. HIV/AIDS and TB/STD training was to be completed within the first 2 years of employment. Based on the staffing form, the facility failed to document or verify that the admissions coordinator 2 completed HIV/AIDS & TB/STD training.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of December 8, 2015, under the direction of a newly hired HR Director, all required staff trainings will be monitored and tracked utilizing the electronic record keeping software inherent in our Automatic Data Processing system to ensure that all required trainings due for each member of staff are completed and reported monthly to the appropriate department heads for follow-up with their personnel. All 5 individuals identified for HIV/AIDS and/or TB/STD training are scheduled for the required trainings which will be completed by 1/18/16. Compliance to be reported monthly to the Executive Director in the HR Dashboard meeting on an ongoing basis. |
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.
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Observations
Based on a review of CPR and first aid certificates and administrative documentation, the facility failed to ensure that general training requirements were met.
The findings include:
The facility failed to ensure van drivers received general training, specifically CPR certification and first aid training. The facility has designated drivers that provide transportation for Kirkbride clients utilizing the facilities vehicles; however these van drivers were not certified in CPR or first aid training as of the time of inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The van drivers have completed the required CPR training on 11/11/15. Additionally, CPR training has been added as a requirement to the job description of ?Van Driver? to ensure that any future hires for this position will receive CPR training. Starting December 8, 2015 under the direction of a newly hired HR Director, all required staff trainings will be monitored and tracked utilizing the electronic record keeping software inherent in our Automatic Data Processing system to ensure that all required trainings due for each member of staff are tracked, completed, and reported monthly to the appropriate department heads for follow-up with their personnel. Compliance to be reported monthly to the Executive Director in the HR Dashboard meeting on an ongoing basis. |
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 on a review of personnel records and a review of the Staffing Requirements Facility Summary Report form, the facility failed to ensure that each counselor completed at least 25 clock hours of annual training.
The findings include:
The facility's training year was from July 1, 2014 through June 30, 2015.
Nine personnel records were reviewed on October 27, 2015, for documentation of at least 25 clock hours of annual training. The facility failed to ensure six out of nine employees # 11, 12, 13, 16, 17 and 18 completed at least 25 clock hours of annual training.
Employee # 11 was hired September 9, 2013, and was required to complete 25 hours of annual training. Employee # 11's training file included documentation of 11 training hours.
Employee # 12 was hired May 31, 2013, and was required to complete 25 hours of annual training. Employee # 12's training file included documentation of 23 training hours.
Employee # 13 was hired March 29, 2012, and was required to complete 25 hours of annual training. Employee # 13's training file included documentation of 24 training hours.
Employee # 16 was hired January 19, 2011, and was required to complete 25 hours of annual training. Employee # 16's training file included documentation of 9 training hours.
Employee # 17 was hired September 24, 2012, and was required to completed 25 hours of annual training. Employee # 17's training file included documentation of 20 training hours.
Based on a review of the staffing form, employee # 18 was hired April 2, 2013 and was required to complete 25 hours of annual training. The staffing form only documented 4 training hours for employee # 18.
In addition, the Staffing Requirements Facility Summary Report form which was finalized by the facility on October 27, 2015 documented less than 25 clock hours of training for employee # 11, 12, 13, 16, 17 and 18.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Starting December 8, 2015, under the direction of a newly hired HR Director, all required staff trainings will be monitored and tracked utilizing the electronic record keeping software inherent in our Automatic Data Processing system to ensure that the required training hours due for counselors are tracked, completed, and reported monthly to the appropriate department heads for follow-up with their personnel. Compliance to be reported monthly to the Executive Director in the HR Dashboard meeting on an ongoing basis. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to keep the grounds clean, safe, and sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
The findings include:
A physical plant inspection was conducted on October 29, 2015. The facility failed to keep the grounds safe, and sanitary and in good repair at all times.
1. 2nd floor West Wing - Broken dresser drawers were observed in rooms 201 and 309.
2. 2nd floor West Wing - The towel racks were broken, specifically in rooms 209 and 211
3. 2nd floor West Wing - The refrigerator was broken and not clean.
4. Detox Unit - The shower knobs where broken in bedroom 111.
5. 2nd floor East Wing - The refrigerator was broken and not clean or sanitary as it had mold inside. The refrigerator had food inside and was being used by staff at the time of inspection.
6. 2nd floor East Wing - The furniture was not in good repair as tape was observed on some of the couches and chairs throughout the residential floors.
7. East Wing - Large dead bugs were observed near the emergency exit inside the female unit.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All 7 items identified during the inspection have been addressed. Drawers were either fixed or replaced, along with towel racks and shower knobs where indicated at the time of inspection. Refrigerators cited were replaced later upon delivery, and purchase orders submitted for replacement of furniture. The emergency exit in the stairwell tower referenced in Item #7 has been cleaned and added to the rounds for housecleaning staff.
Problems identified in the course of normal day to day activities are to be reported immediately to our Engineering Line. Once a work or purchase order is submitted this is documented as to the date/time of the submission. Replacement and/or repair of broken items are an ongoing process and Environment of Care (EOC) rounds are conducted on a monthly basis. Whenever possible, repairs or replacement of broken items will be conducted ASAP, and no later than 72 hours after notification to Engineering or Housekeeping staff.
When fixes or replacement of items cannot be corrected or obtained within the aforementioned time-frame (for example, due to repairs or replacements that require the ordering of new hardware, furniture, parts, etc?) and if items are broken and pose a hazard they will be immediately removed from the area until they can be repaired or replaced so as to ensure the safety or well-being of residents, employees or visitors.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to provide documentation of fire extinguisher training upon staff employment.
The findings include:
Six personnel records were reviewed on October 27, 2015, to verify that staff had been instructed in the use of a fire extinguisher upon employment. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel records, # 1, 2, 3, 4, 5 and 6.
Employee #1 was hired January 26, 2015. Fire extinguisher training was due upon hire; however the facility failed to provide documentation of this training as of the time of inspection
Employee #2 was hired December 15, 2014. Fire extinguisher training was due upon hire; however the facility failed to provide documentation of this training as of the time of inspection.
Employee #3 was hired October 15, 2014. Fire extinguisher training was due upon hire; however the facility failed to provide documentation of this training as of the time of inspection.
Employee #4 was hired May 11, 2015. Fire extinguisher training was due upon hire; however the facility failed to provide documentation of this training as of the time of inspection.
Employee #5 was hired June 10, 2015. Fire extinguisher training was due upon hire; however the facility failed to provide documentation of this training as of the time of inspection.
Employee #6 was hired April 15, 2015. Fire extinguisher training was due upon hire; however the facility failed to provide documentation of this training as of the time of inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Fire Extinguisher training is provided for all new hires during orientation. As of December 8, 2015, under the direction of a newly hired HR Director, all required staff trainings will be monitored and tracked utilizing the electronic record keeping software inherent in our Automatic Data Processing system to ensure that all required trainings due for each member of staff are completed and reported monthly to the appropriate department heads for follow-up with their personnel. Fire extinguisher training for the identified employees #1-6 will be completed by 12/18/15. The listed ?Contents? of the section within each HR file that contains this data is labeled ?Fire Safety and Prevention? under ?New Hire Orientation? for future reference. Compliance to be reported monthly to the Executive Director in the HR Dashboard meeting. |
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 on a review of the facility's fire drill log, the facility failed to document the amount of time it took for evacuation, 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. In addition, the facility failed to ensure all personnel on all shifts are trained to perform assigned tasks during emergencies.
The findings include:
The facility's fire drill log was reviewed on October 27, 2015, covering the period of November 2014 through September 2015. The facility failed to document on the fire drill logs 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.
Additionally, six personnel records were reviewed on October 27, 2015, to verify that all personnel on all shifts were trained to perform assigned tasks during emergencies. The facility failed to document the completion of emergency training in personnel records, # 1, 2, 3, 4, 5 and 6.
Employee # 1 was hired January 26, 2015. Emergency training was due upon hire; however the facility failed to provide documentation of this training as of the time of inspection
Employee # 2 was hired December 15, 2014. Emergency training was due upon hire; however the facility failed to provide documentation of this training as of the time of inspection.
Employee # 3 was hired October 15, 2014. Emergency training was due upon hire; however the facility failed to provide documentation of this training as of the time of inspection.
Employee # 4 was hired May 11, 2015. Emergency training was due upon hire; however the facility failed to provide documentation of this training as of the time of inspection.
Employee # 5 was hired June 10, 2015. Emergency training was due upon hire; however the facility failed to provide documentation of this training as of the time of inspection.
Employee # 6 was hired April 15, 2015. Emergency training was due upon hire; however the facility failed to provide documentation of this training as of the time of inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All fire drills are triggered by use of the fire alarm, thus operational ability of the alarm is always tested during a drill although this is not clearly indicated on the Fire Alarm Report. The report sheet has since been updated to include language that indicates the testing/operational ability of the fire alarm during all fire drills.
?Time of Alarm? and ?Time Evacuation Completed? is evidenced on the Fire Alarm Reports that were reviewed at the time of the audit. However, we have updated the form so that it clearly indicates the ?Total Time Taken for Evacuation?. Additionally, we have added a section to indicate the number of persons in the facility at the time of the drill/alarm. Use of the newly revised form began on 11/25/15.
We have also reviewed documentation of training regarding assigned tasks performed by staff during emergencies and moving forward orientation for new hires will clearly document knowledge of assigned tasks during emergencies which will also be filed under the ?Fire Safety and Prevention? section of each individual?s HR file. Emergency training for the identified employees #1-6 will be completed by 12/18/15.
Again, all required staff trainings will be monitored and tracked by the HR Director utilizing the electronic record keeping software inherent in our Automatic Data Processing system to ensure that all required trainings due for each member of staff are completed. Compliance to be reported monthly to the Executive Director in the HR Dashboard meeting.
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709.26(b) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
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Observations
Based on a review of personnel records, the facility failed to include an annual work performance evaluation in six out of eight personnel records reviewed.
The findings include:
Eight personnel records were reviewed on October 27, 2015, for documentation of an annual work performance evaluation. The facility failed to document an annual work performance evaluation in personnel records, # 10, 12, 13, 14, 15 and 17.
Employee # 10, a counselor was hired June 11, 2013. The facility failed to document an annual work performance evaluation for employee # 10 as of the time of review.
Employee # 12, a counselor was hired May 31, 2013. The facility documented an annual work performance evaluation; however the facility failed to verify it was an annual evaluation, as the plan was not dated at the time of review.
Employee # 13, a counselor was hired March 29, 2012. The facility failed to document an annual work performance evaluation for employee # 13. The last documented performance evaluation for employee # 13 was July 30, 2013.
Employee # 14, a counselor was hired January 20, 2013. The facility failed to document an annual work performance evaluation for employee # 14. The last documented performance evaluation for employee # 14 was August 26, 2014.
Employee # 15, a counselor was hired February 10, 2014. The facility failed to document an annual work performance evaluation for employee # 15. The last documented performance evaluation for employee # 15 was July 7, 2014.
Employee # 17, a counselor was hired September 24, 2012. The facility failed to document an annual work performance evaluation for employee # 17. The last documented performance evaluation for employee # 17 was July 23, 2013.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The staff performance evaluation process has been revised. Moving forward as of December 8, 2015, under the direction of a newly hired HR Director, each staff member?s performance evaluation will be linked to their annual training plan and both will be due based on date of hire. To ensure compliance, the HR Director will utilize electronic record keeping software inherent in our Automatic Data Processing system to ensure that all required documentation due for all members of staff is tracked, completed, and reported monthly to the appropriate department heads for follow-up with their personnel. Compliance to be reported monthly to the Executive Director in the HR Dashboard meeting. |
709.63(a) LICENSURE Client record
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
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Observations
Based on a review of client records, the facility failed to document a complete client record which included a record of services provided.
The findings include:
Four detox client records were reviewed on October 27, 2015, to ensure the facility documented a complete client record which included a record of services provided for each client. The facility failed to document a record of services provided in two of four records reviewed, # 6 and 13.
Client # 6 was admitted to the facility on October 22, 2015. The facility failed to document a complete client record which included a record of services provided for client #6, as of the date of the licensing inspection.
Client # 13 was admitted to the facility on October 22, 2015. The facility failed to document a complete client record which included a record of services provided for client #13, as of the date of the licensing inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Re-training has occurred with all detox counselors on 11/26/15 to address the required completion of the record of service. Monitoring of ongoing compliance is to occur through documented monthly supervision with the Program Director for a 3 month period. Any variances to be reported in the monthly Chemical Dependency Dashboard meeting. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the facility failed to complete random drug-screening urinalysis at least monthly for each patient.
The findings include:
Twelve narcotic treatment patient records were reviewed on October 27, 2015. The facility failed to provide monthly drug-screening urinalysis for patient, # 16 and 23.
Patient # 16 was admitted to the program on May 2, 2015 and discharged on July 23, 2015. The facility failed to provide and document a monthly drug-screening urinalysis for patient # 16 for the month of June and July.
Patient # 23 was admitted to the program on August 18, 2015 and discharged on October 12, 2015. The facility failed to provide and document a monthly drug-screening urinalysis for patient # 23 for the month of September and October.
The findings were reviewed with facility staff during the monitoring inspection.
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Plan of Correction
To ensure compliance with random urinalysis, as of December 1, 2015 the DON is scheduling random drug-screening urinalysis (UDS) for patients on the appropriate units once a month by notifying the Charge Nurse for that unit. The Charge Nurse will ensure that all UDS?s for patients on their floor are obtained and submitted to the lab and will report back to the DON on completion for their unit, as well as any outstanding UDS?s that may not have been able to be obtained, and the requisite follow-up for those individuals. Any + results for illicit substances will also be reported to the DON for follow up with treatment team in daily morning meetings. Any variances to be reported for a period of 3 months to the Chemical Dependency Dashboard. |
715.17(c)(2) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(2) Drug storage areas. A narcotic treatment program shall develop and implement written policies and procedures regarding storage of medications and access to the medication storage area. Agents shall be stored in a locked safe that has been approved by the DEA under 21 CFR 1301.72 and 1301.74 (relating to physical security controls; and other security controls).
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Observations
Based on a physical plant inspection, the facility failed to store narcotic treatment agents in a locked safe.
The findings include:
A physical plant inspection was conducted on October 29, 2015. The facility failed to maintain narcotics in a separate double-lock box.
East Wing 2nd floor - It was observed that the narcotics were not stored in a double-lock box at the time of inspection.
The findings were reviewed with facility staff during the monitoring inspection.
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Plan of Correction
The nurse on the unit in question who was responsible for maintaining the security of the lock box was disciplined and re-trained immediately on 10/29/2015 at the time of inspection for not following existing procedure. To ensure continuing compliance the DON will conduct random checks on all units for a period of 3 months to ensure ongoing compliance with existing protocol for the safety and security of the lock boxes. Any variances to be immediately addressed with the staff responsible, and reported in monthly Chemical Dependency Dashboard meetings. |
715.23(b)(8) LICENSURE Patient records
(b) Each patient file shall include the following information:
(8) The patient 's current and past narcotic dosage level.
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Observations
Based on a review of patient records, the facility failed to document patient #15's current and past narcotic dosage level.
The findings include:
Patient # 15's record was reviewed on October 27, 2015, for documentation of current and past narcotic dosage level. The facility failed to document patient # 15's current and past narcotic dosage level.
Patient # 15 was admitted into the facility on April 24, 2015. Based on a note written by the NTP doctor it appeared patient # 15 was admitted into the narcotic treatment program on May 2, 2015 and stopped receiving medication on May 19, 2015; however, there was no definitive documentation such as doctor's order or medication administration sheet to indicate or verify that patient # 15 started or received a narcotic nor was there documentation of the patient's current and past narcotic dosage level.
The findings were reviewed with facility staff during the monitoring inspection.
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Plan of Correction
The Medication Administration Record (MAR) was not filed appropriately in the record. Upon discharge of a patient from the facility, the Charge Nurse will remove the MAR from the binder in the medication dispensing room and make sure that it is filed in the patient?s chart prior to staff from the Medical Record department picking up the record. Medical Record clerks will additionally make sure that they do not remove a patient?s record from the unit until all required documentation from that unit (including the MAR) has been integrated. Any variances will be immediately reported to the DON and/or Shift Director for a period of 3 months for immediate follow-up with appropriate staff. |
709.17(a)(1) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
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Observations
Based on a review of administrative documentation, the facility failed to implement policies and procedures for the reporting of unusual incidents.
The findings include:
As per the directive within Chapter 709 Subchapter C enacted on 10/18/2014, the facility was required to develop and implement policies and procedures for the reporting of unusual incidents.
Based on a review of internal incident reports, the facility failed to report incidents within 3 days per regulation from the time period of November 2014 until October 2015 for incidents involving:
1.Physical or sexual assault by staff or a client.
2.Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
3.Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day.
4.Event at the facility requiring the presence of police, fire or ambulance personnel.
5.Outbreak of a contagious disease requiring CDC notification.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Per regulation, all Unusual Incidents involving:
1. Physical or sexual assault by staff or a client.
2. Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
3. Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day.
4. Event at the facility requiring the presence of police, fire or ambulance personnel.
5. Outbreak of a contagious disease requiring CDC notification.
are being reported on an ongoing basis to the state within 3 business days by the Compliance Director (or his designee) who is maintaining a record of these reports, as well as documentation evidencing submission was completed. This is an ongoing process and a review of incidents in the facility is reported by the Compliance Director on an ongoing, monthly basis to the Safety and Patient Safety meetings to ensure compliance with the directive.
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