INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 10, 2009 through June 11, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHD Womanspace 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 and a plan of correction is due on July 10, 2009.
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Plan of Correction
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709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on the review of the facility's policy and procedure manual on June 10, 2009, the facility failed to make available to the public an annual report by the end of the facility's fiscal year which is June 30, 2008.Findings:During the review of the facility's policy and procedure manual the annual report was not made available to the public until January 14, 2009 when it appeared in the Philadelphia Daily News. The documentation was required to be made public prior to the end of their 2008 fiscal year which ended June 30, 2008.
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Plan of Correction
Program Director will ensure that the annual report be made available for public viewing prior to the end of the fiscal year, which ends on June 30, 2009 by submitting proof of publication by September 30, 2009.
Program Director will submit proof of publication by September 30th during each subsequent year to ensure that deficiency #0135 does not recur. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records on June 11, 2009, the facility failed to document complete case consultations notes in one of two client records.Findings:Six client records were reviewed. Case consultations were required in two client records. Case consultation note in record #2 was documented late. In accordance with the facility's policy and procedure case consultation notes will be documented every 90 days after admission. Client record #2 was admitted on 10/1/08 and case consultation note for second case consultation was not documented. The first case consultation documentation was completed on 12/3/08 and the next one should have been completed by 3/3/09. As of to date none have been completed. The next case consultation note should have also been completed by 6/3/09.
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Plan of Correction
Program Director will implement a Clinical Documentation Tracking Board, to be located in the Administration Office and updated weekly by Clinician. New admissions will be added within 24 hours of admission by Community Care Specialist Staff member who completed the Intake Packet with the client. The Clinical Documentation Tracking Board, will post due dates for all clinical documentation, inlcuding quarterly Case Consultations and will be visible at all times in the Administration Office.
Clinician will schedule Case Consultations within 14 days prior to due date.
Program Director will perform monthly clinical chart audits to ensure timely completion of Case Consultations. |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in three of six client records.Findings:Six client records were reviewed on June 11, 2009. Follow-up information was required in three client records. In accordance with the facility's policy, follow-ups are to be completed 30 days after discharged if not being referred. Follow-up information was not documented in records #3, 5 and 6. Client #3 was discharged on 12/29/08 and no follow-up was documented. Client # 5 was discharged on 9/30/08 and there was no follow-up documented. Client #6 was discharged on 10/20/08 and there was no follow-up documented.
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Plan of Correction
In order to ensure that Womanspace Philadelphia does not fail to follow up with future AWOL status clients, Program Director will create a Discharge Follow Up Contact Progress Note template, which will require follow up phone calls to the documented Emergency Contact person and will have space to include an additional contact attempt i.e. ICM, Outreach worker, or additional family member.
Primary Therapist will complete and document contact attempt via Discharge Follow up Contact Progress Note within three weeks of the client discharge date.
Program Director will implement a Clinical Documentation Tracking Board, which will be updated daily with regards to discharge clients and will include discharge tracking through to completion. Program Director will follow up with Discharge Tracking on a weekly basis, to ensure that contact calls are completed and documented in accordance with #1813 and to ensure that this deficiency does not recur.
To ensure that follow up contact occurs with Planned Discharges, Program Director will update the current Aftercare for Planned Discharge to add a 30 day client contact section to the end of the document.
Program Director will present Discharge Contact template and updated Aftercare Plan for Planned Discharge to clinical team, review the importance of discharge documentation and reiterate the due dates for discharge documentation, which will also be visible at all times via the Clinical Documentation Tracking Board.
Program Director will complete monthly audits of client records for clients that have been discharged within the last 60 days, to ensure that Clinicians are completing discharge documentation in a timely matter and deficiency #1813 does not recur. Additional training will be provided as needed.
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