INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 7, 2013 to October 11, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Habit OPCO, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
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Plan of Correction
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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.
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Observations
Based on a review of personnel and training records, the facility failed to provide documentation that the clinical director received supervision in one of one record.
The findings included:
Six staff training records were reviewed on October 8, 2013. One personnel record reviewed was that of the clinical director. This personnel record required the documentation of monthly meetings between the clinical director and the facility director for the first six months of employment in that position. The facility failed to document monthly supervision meetings in personnel record # 2.
Employee # 2 was hired by the project on January 3, 2012, and was moved to the position of clinical director at this facility on April 8, 2013. Monthly supervision meetings were required to take place in April, May, June, July, August and September 2013. There was no documentation of monthly supervision meetings in the personnel record of employee # 2.
The findings were reviewed and confirmed with the facility director.
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Plan of Correction
The Facility Director will ensure that all supervisory notations generated whether the session is completed via electronic messages, phone conversations, or in person, during the transitional six month period for new management personnel.
Ongoing review and compliance to this regulation will be enforced and reviewed by the Project Director or designee.
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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 and training records, the facility failed to provide documentation of an individual training plan developed with input from employee and supervisor in two of six staff training records reviewed.
The findings included:
Six staff training records were reviewed on October 8, 2013. According to the Staffing Requirements Facility Summary Report the facility training year is from January 1, 2013 to December 31, 2013.
Personnel training record # 4 documented a training plan signed by the supervisor on January 31, 2013. The individual training plan was not signed by the employee.
Personnel training record # 5 documented a training plan signed by the employee upon hire of February 19, 2013. The individual training plan was not signed by the supervisor.
The findings were reviewed and confirmed with the clinical director.
This is a repeat deficiency from the 10/12/2012 onsite review.
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Plan of Correction
The Facility Director, or their designee, will ensure that Individual Training Plan(s) be developed with each staff and signed by the respective staff member and their supervisor to ensure compliance to this regulation. The onsite HR representative will maintain a tracking mechanism for all employees to ensure compliance to this regulation.
The presentation of this deficiency and the measures to correct the same will be reviewed during the November Staff meeting on Tuesday, November 19, 2013.
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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 and training records, the facility failed to provide documentation of HIV/AIDS and TB/STD training in one of four records reviewed.
The findings included:
Six staff training records were reviewed on October 8, 2013. Four training records were reviewed for the mandatory training requirements.
Personnel training record # 4 documented a hire date of October 1, 2012, as a counselor. The employee was required to obtain six hours of HIV/AIDS and 4 hours of TB/STD by October 1, 2013. The facility failed to ensure the training occurred as of the date of the inspection.
The findings were reviewed and confirmed with the clinical director.
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Plan of Correction
The Clinical Director will ensure that the specific staff member identified, along with any and all new hires, complete the required six (6) hours of HIV/AIDS training along with four (4) hours of TB, STD & other Health related trainings. Any and all staff members will be required to complete this training within the required time frame as noted in 704.11(c)(1); and acquire documented evidence to the same which will be recorded in their personnel files. The onsite HR representative will maintain a tracking mechanism for all employees to ensure compliance to this regulation.
The presentation of this deficiency and the measures to correct the same will be reviewed during the November Staff meeting on Tuesday, November 19, 2013.
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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on the physical plant inspection, the facility failed to ensure that the hot water temperature did not exceed 120 F.
The findings included:
The physical plant inspection took place on October 9, 2013. At 10:30 a.m., the water temperature was tested in the staff bathroom and it tested at 130 F; the clinical and facility directors were informed of the findings. At 3:30 p.m. the water temperature was tested in the men's restroom in the clinical hallway. The water temperature tested at 130 F with the clinical and facility director present.
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Plan of Correction
The Program Director will notify the Landlord to adjust water temperature accordingly. (This notification has been made as of the time of the draft).
Water temperature checks will be added and accessed, documented accordingly, via monthly security checks by the security associate. The admin manager will audit the security checks quarterly to ensure these were completed.
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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 personnel and training records, the facility failed to document that each employee received fire extinguisher training upon hire in one of three records reviewed.
The findings included:
Eight personnel records were reviewed on October 8, 2013. Three personnel records were reviewed for documentation of fire extinguisher training upon hire.
Employee # 5 was hired on February 19, 2013, as a counselor. Fire extinguisher training was documented on May 1, 2013. The fire extinguisher training did not happen upon hire.
The findings were reviewed and confirmed by the clinical director.
This is a repeat deficiency from the 10/12/2012 onsite review.
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Plan of Correction
The Program Director, or their designee, will ensure that all staff fire extinguisher training is provided to all new employee's upon their hire.
A review of personnel files will be conducted by the Program Director, or their designee, during a new employee's first week of employment to ensure compliance to this regulation.
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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 personnel and training records, the facility failed to document that each employee received training on assigned tasks during emergencies upon hire in one of three records reviewed.
The findings included:
Eight personnel records were reviewed on October 8, 2013. Three personnel records were reviewed for documentation of emergency training upon hire.
Employee # 8, the contracted employee, has worked for multiple months at this site. There was no documentation of training for emergencies at the time of the review.
The findings were reviewed and confirmed by the clinical director.
This is a repeat deficiency from the 10/12/2012 onsite review.
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Plan of Correction
The Program Director, or their designee, will ensure that all staff has a documented record of emergency training, per site location, filed within their personnel file.
A review of personnel files will be conducted by the Program Director or their designee within the first week of any new employee or contract hire start date to ensure compliance to this regulation.
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709.26(d)(1) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(1) The application for employment.
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Observations
Based on a review of personnel records, the facility failed to document staff work performance evaluations in four of six personnel records.
The findings included:
Six personnel records were reviewed on October 8, 2013. Work performance evaluations were required in six personnel records. The facility did not document staff work performance evaluations in personnel records # 3, 4, 5 and 6.
Employee # 3 was hired on April 16, 2012. A work performance evaluation was documented on July 3, 2012. A work performance evaluation was due by April 16, 2013. The work performance evaluation was not documented as of the date of the inspection.
Employee # 4 was hired on October 1, 2012. A work performance evaluation was due by October 1, 2013. The work performance evaluation was not documented as of the date of the inspection.
Employee # 5 was hired on February 19, 2013. Per facility policy, a work performance evaluation was due by May 19, 2013. The work performance evaluation was not documented as of the date of the inspection.
Employee # 6 was hired on April 29, 2013. Per facility policy, a work performance evaluation was due by July 29, 2013. The work performance evaluation was not documented as of the date of the inspection.
The findings were reviewed and confirmed with the clinical director.
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Plan of Correction
The Facility Director, or their designee, will commence a routine review during Monthly Staff meetings of any upcoming/pending annual audits and/or new hire reviews that are due; thereby creating a more efficient system by which full compliance to this regulation and the facility policy is met. The onsite HR representative will maintain a tracking mechanism for all employees to ensure compliance to this regulation.
The annual reviews noted as deficient in this audit have since been completed, presented to staff, and filed accordingly in the respective staff personnel files. The new hire 90 day reviews, as per facility policy, are being completed at the time of this draft and will be presented and filed in the respective personnel files no later than the end of November 2013.
The presentation of this deficiency and the measures to correct the same will be reviewed during the November Staff meeting on Tuesday, November 19, 2013.
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709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based on a review of personnel records, the facility failed to document written job descriptions which contained the employee's and supervisor's dated signatures in five of five personnel records.
The findings included:
Six personnel records were reviewed on October 8, 2013. Five personnel records were reviewed for job descriptions. The facility failed to obtain the required documentation of a signed job description in personnel records # 2, 3, 4, 5, and 6.
Employee # 2 was hired on January 3, 2012, as a facility director. The employee was moved to a clinical director in December 2012. The job description for the clinical director was missing the supervisor's dated signature at the time of the review.
Employee # 3 was hired on April 16, 2012, as a counselor. The employee was moved to a lead counselor on August 27, 2012. The job description for the lead counselor was dated for "date of hire." There was no documentation of a signed job description for the lead counselor position in the personnel record at the time of the review.
Employee # 4 was hired on October 1, 2012, as a counselor. The job description for the counselor position was missing the supervisor's dated signature at the time of the review.
Employee # 5 was hired on February 19, 2013, as a counselor. There was no documentation of a signed job description in the personnel record at the time of the review.
Employee # 6 was hired on April 29, 2013, as a counselor. There was no documentation of a signed job description in the personnel record at the time of the review.
The findings were reviewed and confirmed with the clinical director.
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Plan of Correction
The Facility Director, or their designee, will ensure that all written job descriptions are presented to and signed off by both, the employee at the point of hire and/or promotion and their immediate supervisor. Existing onsite HR policies will be reviewed for compliance and to ensure that these regulatory standards are maintained ongoing. The onsite HR representative will maintain a tracking mechanism for all employees to ensure compliance to this regulation.
Corrections to all cited personnel files have been executed at the time of this draft, dated and filed accordingly.
The presentation of this deficiency and the measures to correct the same will be reviewed during the November Staff meeting on Tuesday, November 19, 2013.
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of patient records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in five of five patient records reviewed. The facility exceeded 4 Pa. Code, Subsection 255.5(b) in one of five records reviewed.
The findings included:
Eleven patient records were reviewed October 9, 2013 through October 11, 2013. Five records were reviewed regarding release of information documentation. The facility failed to ensure that an informed and voluntary consent to release information was obtained in four patient records reviewed, # 1, 2, 6, 7 and 8.
A review of patient record # 1 revealed a letter was written "To Whom it May Concern" and faxed to a medical facility. A consent to release could not be verified for this letter at the time of the record review. A release for an emergency contact dated 6/3/2013 did not include the purpose or the witness dated signature. A release for a medical facility dated 8/1/2013 did not include the purpose or the date of the patient signature. Additionally, two consents to release information dated 6/6/2013 and 6/20/2013 did not include a witness dated signature.
A review of patient record # 2 revealed a consent to release information to a medical facility dated 5/23/2013 with a purpose to coordinate care that stated "communicate with and disclose to one another." A release for a medical facility dated 3/26/2013 noted the release could only be revoked in writing and contained no witness dated signature. A release for a medical facility dated 1/8/2013 failed to include a witness dated signature.
A review of patient record # 6 revealed a consent to release information was not documented for a referral facility to whom the patient had been transferred. A release for an emergency contact dated 7/30/2013 did not include the purpose or the witness dated signature. Two consents to release information to funding sources were signed when the patient was at a prior facility and the record did not contain updated releases following the transfer to the current facility.
A review of patient record #7 revealed a release for an emergency contact dated 9/26/2013 did not the witness dated signature. There were no other consents to release documented in the record; however, there was a copy of the patient's insurance card in the record.
A review of patient record # 8 revealed a release for an emergency contact dated 9/4/2013 did not include the purpose or the witness dated signature. On 9/4/2013, there was a release that had been faxed to a hospital that failed to contain the witness dated signature; however, the release documented in the record did contain the witness dated signature. A release for an insurance company dated 9/4/2013 contained the approved content based on 4 Pa. Code, Subsection 255.5(b); however, "additional description" included "Psychosocial Evaluation, Utilization Review" for the purpose of eligibility/verification. The additional information exceeded 4 Pa. Code, Subsection 255.5(b) by releasing the psychosocial evaluation. A release for an insurance company dated 9/4/2013 contained the approved content based on 4 Pa. Code, Subsection 255.5(b); however, "additional description" included "summary of treatment, Psychosocial Evaluation, length of Rx data, Rx modality, last methadone/suboxone dose, prescription verification, discharge summary" for the purpose to request authorization. The additional information exceeded 4 Pa. Code, Subsection 255.5(b) by releasing the summary of treatment, Psychosocial Evaluation, length of Rx data, Rx modality, last methadone/suboxone dose, prescription verification, discharge summary.
The findings were reviewed and confirmed with the clinical director.
This is a repeat deficiency from the 10/12/2012 onsite review.
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Plan of Correction
It is noted and recorded in an internal electronic correspondence dated 08/02/2013 that some of the 'old' authorization to release forms remained in circulation as identified during chart reviews.
The Facility Director and/or their designee will ensure that only the new authorization to release information forms created and disseminated electronically to all staff following previous audit(s) remain on site. These newly edited releases developed and implemented on 2/2013 contain: Witness signature and date lines, Verbal and in Written revocation statements, along with space to provide a brief narrative as to the purpose for the release.
Management staff will ensure all existing staff are presented with hard copies of the appropriate, newly edited authorization to release information documentation during the November 19, 2013 monthly staff meeting in Dunmore. Any and all older releases will be extracted from circulation at this time as well.
During the November 19, 2013 staff meeting and subsequent group supervision sessions the Clinical Director will provide an in-service training to review 4 Pa. Code, Subsection 255.5(b) and the appropriate release of information related to the same.
All new patient packets will be reviewed by Administrative staff to ensure all contain the appropriate release(s) and that all updated medical billing releases are present for signature upon admission. This will be reviewed and authorized as done by the Facility Director and/or their designee at the time of admission for any new patients on site. Training will also occur for all staff engaged in this process at the front end.
Additionally, it will be part of the documented orientation and training for any and all new staff who will execute this document to ensure compliance to this regulation. Ongoing reviews will be conducted by the Clinical Director to ensure ongoing compliance to this end.
The presentation of this deficiency and the measures to correct the same will be reviewed during the November Staff meeting on Tuesday, November 19, 2013.
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709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on a review of patient records, the facility failed to ensure that verbal medication orders were put in writing and signed within 24 hours thereafter by the prescribing physician, in four of eleven patient records.
The findings included:
Eleven patient records were reviewed October 9, 2013 through October 11, 2013. All verbal medication orders are required to be signed within 24 hours by the prescribing physician. Patient records # 2, 4, 5, 7, 8 9 and 10 contained documentation of a verbal medication order that was not signed by the prescribing physician within 24 hours.
Patient # 2 was admitted on January 10, 2013, and discharged on July 11, 2013. A verbal order dated January 20, 2013, at 7:51 a.m. was signed by the prescribing physician on January 22, 2013, at 9:48 a.m., 48 hours later. A verbal order dated February 1, 2013, at 8:11 a.m. was signed by the prescribing physician on February 3, 2013, at 9:15 a.m., over 48 hours later.
Patient # 4 was admitted on September 22, 2012, and discharged on September 23, 2013. A verbal order dated September 17, 2013, at 8:19 a.m. was signed by the prescribing physician on September 20, 2013, at 11:22 a.m., over 72 hours later.
Patient # 5 was admitted on May 24, 2012, and discharged on May 28, 2013. A verbal order dated May 14, 2013, at 1:08 p.m. was signed by the prescribing physician on May 16, 2013, at 7:29 a.m., over 36 hours later.
Patient # 7 was admitted on October 1, 2013. A verbal order dated October 5, 2013, at 7:36 a.m. was signed by the prescribing physician on October 7, 2013 at 11:11 a.m., over 48 hours later.
Patient # 8 was admitted on September 4, 2013. A verbal order dated September 7, 2013, at 8:13 a.m. was signed by the prescribing physician on September 14, 2013, at 7:17 a.m., over a week later. A verbal order dated September 10, 2013, at 6:29 a.m. was signed by the prescribing physician on September 14, 2013, at 7:17 a.m., over 4 days later. A verbal order dated September 19, 2013, at 9:14 a.m. was signed by the prescribing physician on September 20, 2013, at 11:22 a.m., over 24 hours later.
Patient # 9 was admitted on March 15, 2012. A verbal order dated June 13, 2013, at 8:48 a.m. was signed by the prescribing physician on June 19, 2013 at 7:27 a.m., over 5 days later. Additionally, the order was not initiated until July 20, 2013, with no documentation to support the delay.
Patient # 10 was admitted on April 3, 2012. A verbal order dated September 26,2013, at 6:20 a.m. was signed by the prescribing physician on September 29, 2013, , at 9:30 a.m., over 72 hours later.
The findings were reviewed and confirmed with the nursing supervisor.
This is a repeat deficiency from the 10/12/2012 onsite review.
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Plan of Correction
The Facility Director and/or their designee will review with the Corporate Chief Medical Officer, Dr. Christopher Lukonis a training curriculum for presentation to on-site physician(s) to ensure a greater scope of compliance to this regulatory standard.
Measures previously taken to this end were the assignments of laptop computers configured via the MIS department of HOI to allow Physician access to execute their signature within the required time frames.
Additional measures will be reviewed up to and including a review of on-site physician scheduled coverage that may place a physician on site as frequently as possible in a 48 our period. Additionally, time will be placed onto the physicians schedule to ensure the timely execution of this task.
This regulation will also be documented within the training plans of new physician(s) as reviewed and authorized by the Chief Medical Officer.
A documented meeting covering this deficiency along with the identified and agreed upon measures to address the same will be placed into the appropriate personnel record(s) on site by December 15, 2013.
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709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of patient records, the facility failed to document a detailed history that included medical, drug or alcohol history, and personal history in four of five records reviewed.
The findings included:
Eleven patient records were reviewed October 9, 2013 through October 11, 2013. Five records were were reviewed for patient histories. The facility failed to document a detailed drug and alcohol history that included the patient's length and patterns of use in records # 2, 7 and 8. The facility failed to document detailed personal histories in records # 2, 6, 7 and 8.
Patient record # 2 failed to include a detailed family, legal, military. recreational, and sexual history.
Patient record # 6 included a reviewed history from another facility that was documented outside of the required 30 day time frame and the reviewed documentation of history was dated 10/2012, almost a year prior.
Patient record # 7 failed to include a detailed employment, educational, and sexual history.
Patient record # 8 failed to include a detailed family, legal, employment, educational, and sexual history.
The findings were reviewed and confirmed with the clinical director.
This is a repeat deficiency from the 10/12/2012 onsite review.
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Plan of Correction
The Clinical Director will provide a training directly related to obtaining and documenting a detailed history that includes medical, drug or alcohol history, and personal history. These trainings will be provided in individual and group clinical supervision beginning 11/19/2013. The Clinical Director will complete random quarterly chart audits to ensure that these are being completed ongoing. |
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 upon a review of patient records, the facility failed to document a psychosocial evaluation that included a clinical assessment of the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, patient's attitude toward treatment and the counselor's conclusions/impressions in four of four records.
The findings included:
Eleven patient records were reviewed October 9, 2013 through October 11, 2013. Four records were reviewed for psychosocial evaluations.
Patient # 1 was admitted on June 3, 2013, and discharged on September 24, 2013. The psychosocial evaluation failed to document a clinical assessment by the counselor that included the patient's coping mechanisms, and negative factors. The documentation did not include an evaluation by the clinician for the required components. Additionally, the documentation was also dated 7/30/2013 which is outside of the required 30 days from admission.
Patient # 2 was admitted on January 10, 2013, and discharged on July 11, 2013. The psychosocial evaluation failed to document a clinical assessment by the counselor that included the patient's problems/needs, assets/strengths, and support systems. The documentation did not include an evaluation by the clinician for the required components.
Patient # 6 was admitted on July 30, 2013, and discharged on October 7, 2013. The psychosocial evaluation failed to document a clinical assessment by the counselor that included the patient's assets/strengths, support systems, coping mechanisms and negative factors. The documentation did not include an evaluation by the clinician for the required components. Additionally, the documentation was also dated 9/4/2013 which is outside of the required 30 days from admission.
Patient # 8 was admitted on September 4, 2013. The psychosocial evaluation failed to document a clinical assessment by the counselor that included the patient's coping mechanisms. The documentation did not include an evaluation by the clinician for the required components.
These findings were reviewed and confirmed with the clinical director.
This is a repeat deficiency from the 10/12/2012 onsite review.
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Plan of Correction
Upon completion of the intake the clinicians complete a document entitled Interpretive Summary, utilizing the data obtained via the Biopsychosocial. The interpretive summary is the medium by which the clinician provides their evaluation and clinical recommendations. The Interpretive Summary provides a holistic review of identified areas; including individual identified problems, needs, assets, strengths and support systems.
For a period of time, the same documentation was provided in a draft entitled "CCBH Assessment ". The Clinical Director will provide training to the clinical staff on October 31, 2013 during group supervision that the aforementioned clinical assessment and evaluation be present and documented in under the appropriate heading of heading of both titled documents. This will also be reviewed with staff members at a staff meeting on November 19, 2013. The clinical director will ensure compliance via random quarterly chart audits.
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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.
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Observations
Based on a review of patient records, the facility failed to document a preliminary treatment plan in two of five records.
The findings included:
Eleven patient records were reviewed October 9, 2013 through October 11, 2013. Five records were reviewed for preliminary treatment plans. The facility failed to document a preliminary treatment plan upon intake in patient records # 2 and 6.
Patient # 2 was admitted on January 10, 2013, and discharged on July 11, 2013. The preliminary treatment plan was not signed by the patient at the time of the review.
Patient # 6 was admitted on July 30, 2013, and discharged on October 7, 2013. The preliminary treatment plan was completed on September 6, 2013.
The findings were reviewed and confirmed with the clinical director.
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Plan of Correction
The Clinical Director will provide training to the clinical staff during weekly group and individual supervision, commencing on November 1, 2013, to ensure timely and thorough completion of the preliminary treatment plans. Chart reviews will be conducted randomly on new admissions one month post admission by the Clinical Director and/or their designee to ensure compliance to this regulation. |
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 patient records, the facility failed to develop individual treatment and rehabilitation plans with the patient in three of four patient records.
The findings included:
Eleven patient records were reviewed October 9, 2013 through October 11, 2013. Four patient records were reviewed for an individual treatment and rehabilitation plan developed with the patient. Patient records # 1, 2, and 6 did not contain individual treatment and rehabilitation plans that were developed with the patient.
Patient # 1 was admitted on June 3, 2013, and discharged on September 24, 2013. An individual treatment plan was not documented in the record at the time of the review.
Patient # 2 was admitted on January 10, 2013, and discharged on July 11, 2013. The individual treatment and rehabilitation plan was developed on February 12, 2013, which was outside of the 30 day requirement.
Patient # 6 was admitted on July 30, 2013, and discharged on October 7, 2013. The individual treatment and rehabilitation plan was developed on September 23, 2013 which was outside of the 30 day requirement. Additionally, the documentation did not include the patient's support system.
The findings were reviewed and confirmed with the clinical director.
This is a repeat deficiency from the 10/12/2012 onsite review.
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Plan of Correction
The Clinical Director will provide training to the clinical staff commencing on November 1, 2013 during weekly group supervision to ensure timely and thorough completion of the treatment plans.
Chart reviews will be conducted randomly on new admissions one month post admission by the Clinical Director and/or their designee to ensure compliance to this regulation.
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709.93(a) 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:
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Observations
Based on the review of patient records, the facility failed to document a complete patient record that included referral contact, case consultation notes, discharge summary and follow up information in nine of eleven records reviewed
The findings included:
Eleven patient records were reviewed October 9, 2013 through October 11, 2013. Nine patient records did not include all of the required components, # 1, 2, 3, 4, 5, 6, 9, 10 and 11.
Patient # 1 was admitted on June 3, 2013, and discharged on September 24, 2013. The record contained a discharge summary dated 10/1/2013 that did not include the reasons for treatment and the services offered.
Patient # 2 was admitted on January 10, 2013, and discharged on July 11, 2013. A case consultation is required quarterly. The record contained a case consultation dated April 16, 2013, which was due by April 10, 2013. The record contained a discharge summary dated 7/11/2013 that did not include the reasons for treatment, services offered and the response to treatment.
Patient # 3 was admitted on August 28, 2012, and discharged on April 30, 2013. A case consultation is required quarterly. The record contained a case consultation dated December 10, 2012, which was due by November 28, 2012. The record contained a discharge summary dated 6/7/2013 which did not meet the required 7 day time frame. The summary did not include the reasons for treatment, services offered, the response to treatment and patient status. A follow up was not documented for this patient at the time of the review.
Patient # 4 was admitted on September 22, 2012, and discharged on September 23, 2013. A case consultation is required quarterly. The record contained a case consultation dated April 29, 2013, which was due by March 22, 2013. The record contained a discharge summary dated 10/1/2013 which did not meet the required 7 day time frame for documentation. The summary did not include the reasons for treatment, and patient status.
Patient # 5 was admitted on May 24, 2012, and discharged on May 28, 2013. A case consultation is required quarterly. The record contained a case consultation dated March 12, 2013, which was due by February 24, 2013. The record contained a discharge summary dated 5/30/2013 that did not include the reasons for treatment and services offered.
Patient # 6 was admitted on July 30, 2013, and discharged on October 7, 2013. The record contained a discharge summary dated 10/10/2013 that did not include the services offered and patient status.
Patient # 9 was admitted on March 15, 2012. A case consultation is required quarterly and annually. The record contained a case consultation dated April 29, 2013, which was due by March 15, 2013. The case consultation did not include the staff members involved and the disposition.
Patient # 10 was admitted on April 3, 2012. A case consultation is required quarterly and annually. The record contained a case consultation dated May 1, 2013, which was due by April 3, 2013. The case consultation did not include the staff members involved and the disposition.
Patient # 11 was admitted on June 21, 2012. A case consultation is required quarterly and annually. The record contained a case consultation dated July 8, 2013, which was due by June 21, 2013.
The findings were reviewed and confirmed with the clinical director.
This is a repeat deficiency from the 10/12/2012 onsite review.
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Plan of Correction
The Clinical Director will provide ongoing training and review to the clinical staff commencing on November 1, 2013 via group supervision to ensure timely and thorough completion of all clinical paperwork. The Clinical Director will develop and provide time management tools to assist in this effort and present/review the same during group supervision sessions.
On-going chart reviews will be conducted by the Clinical Director, their designee, along with Peer Chart reviews by all clinicians during group supervision. The latter proposed to commence during the month of December 2013 and to be scheduled bi-annually in order to demonstrate and develop a team approach to assist in meeting timelines and ongoing compliance to this regulation.
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709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on the review of patient records, the facility failed to provide a physician signature on treatment plans and treatment plan updates in three of eleven records reviewed
The findings included:
Eleven patient records were reviewed October 9, 2013 through October 11, 2013. Three patient records did not include documentation of a physician's signature on treatment plans, # 2, 3 and 5.
Patient # 2 was admitted on January 10, 2013, and discharged on July 11, 2013. The patient record contained a treatment plan that did not include a physician's signature.
Patient # 3 was admitted on August 28, 2012, and discharged on April 30, 2013. The patient record contained a treatment plan that did not include a physician's signature.
Patient # 5 was admitted on May 24, 2012, and discharged on May 28, 2013. The patient record contained a treatment plan that did not include a physician's signature.
The findings were reviewed and confirmed with the clinical director.
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Plan of Correction
The Corporate Medical Director will provide on-going supervision and training to the on-site narcotics physician to ensure a thorough understanding of the regulatory expectations under this regulation. Physician scheduling along with access to electronic and remote resources will be reviewed to ensure a consistent and effective plan is executed to correct this deficiency.
On-going review(s) will be conducted by the Program and Clinical Director along with the Nurse Manager to ensure on-going compliance to this regulation.
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