Observations
Based on a review of the facility's Staffing Requirements Facility Summary Report (SRFSR), the facility failed to ensure that all personnel received at least 6 hours of HIV/AIDS training, using a Department approved curriculum, within the regulatory time frames.
The findings include:
The facility's SRFSR form, completed by the Project, was reviewed prior to July 10, 2014. The facility's SRFSR form listed two employees, # 6 and 7, as not having completed one of the mandatory trainings within the regulatory time frames. The facility failed to ensure that employees # 6 and 7 completed one of the mandatory trainings within the regulatory time frames.
Employee # 6 was hired as an Addiction Recovery Assistant on September 13, 2010. HIV/AIDS training was due to be completed no later than September 13, 2012. Employee # 6 was not listed on the SRFSR form as having completed HIV/AIDS training.
Employee # 7 was hired as a LPN on September 15, 2009. HIV/AIDS training was due to be completed no later than September 15, 2011. Employee # 7 was not listed on the SRFSR form as having completed HIV/AIDS training.
The findings were confirmed during an interview with the facility director on July 23, 2014.
|
Plan of Correction
All current employees including employee #6 & #7 will complete mandatory trainings on or before November 30, 2014, the nursing supervisor will insure that the training is completed. All LPN's will be scheduled for mandatory training durning new employee orientation. The Program Directors and the Nursing supervisor will monitor all new hires on a monthly basis to ensure that new hires complete mandatory training during new employee orientation. |
Observations
Based on a review of client records, the facility failed to document a complete client record that included a record of services provided, record of services provided with the duration of session, and/or record of services provided with the service provider information in six of ten client records reviewed. The facility also failed to document group progress notes that included a summary of client's participation in four of ten client records reviewed.
The findings include:
Ten client records requiring documentation of a complete client record were reviewed on July 23, 2014. The facility failed to document a record of services provided, a record of services provided with the duration of session, and/or a record of services provided with the service provider information in client records # 1, 2, 3, 4, 5 and 10. The facility failed to document group progress notes that included a summary of client's participation in client records # 2, 3, 7 and 10.
Client # 1 was admitted May 29, 2014 and was still an active client as of 7/23/14. The duration of session was missing for the record of services documented from 5/29/14 to 7/22/14.
Client # 2 was admitted May 7, 2014 and was still an active client as of 7/23/14. Client record # 2 did not include documentation of record of services from May 2014 to June 2014. The service provider information was missing for the record of services documented from 7/8/14 to 7/15/14. Also, the summary of client's participation in group counseling sessions was missing in group progress notes dated from 6/2/14 to 7/18/14.
Client # 3 was admitted June 13, 2014 and was still an active client as of 7/23/14. The service provider information was missing for the record of services documented from 6/13/14 to 7/17/14. Also, the summary of client's participation in group counseling sessions was missing in group progress notes dated 7/8/14 to 7/18/14.
Client # 4 was admitted June 16, 2014 and was still an active client as of 7/23/14. The duration of session was missing for the record of services documented from 6/17/14 to 7/22/14.
Client # 5 was admitted September 3, 2013 and discharged November 12, 2013. The service provider information was missing for the record of services documented from September 2013 to October 2013.
Client # 7 was admitted October 25, 2013 and discharged December 26, 2013. The summary of client's participation in group counseling sessions was missing in group progress notes dated 11/1/13, 11/11/13, and 11/15/13.
Client # 10 was admitted February 10, 2014 and was discharged May 15, 2014. Client record # 10 did not include documentation of a record of services from February 2014 to May 2014. The summary of client's participation in group counseling sessions was missing in group progress notes dated 2/13/14, 2/14/14, 2/18/14, 2/21/14, 2/24/14, 3/7/14, 4/9/14, 4/22/14, and 5/13/14.
The findings were confirmed during an interview with facility director on July 23, 2014 at approximately 3:30 P.M.
|
Plan of Correction
Record of services will be documented on a daily basis by the clinical staff begining immediately. The overnight Addiction Recovery Assistant will monitor the charts on a daily basis to ensure compliance. Full compliance will be acheive immediately, Logs will be reviewed on a monthly basis by the clinical supervisor to insure that they are compelted as require. Client records #1, 2, 3, & 4 will be reviewed and updated by the clinical staff to the extend permitted by law and policy any missing information in the record will be corrected by the priamry couselor or addiction recovery assistant based on who provided the service by 10/30/2014. The clinical supervisor will review the policy regarding group note documemtation with clinical staff in the staff meetings of August and September 2014. The supervisor will conduct a focus monitor over the next 90 days to insure that group notes include a summary of the clients participation. Full compliance is expected within 30 days. The clinincal supervisor will be responsible for ongoing compliande of group progress notes.
|