Observations
Based on a review of personnel records, the staffing requirements facility summary report and an interview with the facility director the project failed to obtain FBI finger print clearance documentation.
Findings:
Seven personnel records were reviewed on October 26, 2009. Two of the seven were required to have an FBI finger print clearance documentation since both provide activities for the adolescent population. Two of the two staff providing services to the adolescent population did not have the FBI finger print clearance documentation in the personnel records.
Staff record # 2 - Hired February 28, 2009 and providing adolescent activities did not have verification of an FBI finger print clearance in the personnel record on October 26, 2009.
Staff record # 5 - Hired September 12, 2009 and providing adolescent activities did not have verification of an FBI finger print clearance in the personnel record on October 26, 2009.
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Plan of Correction
Project Director will have all employees who work in direct contact with adolescents complete FBI finger print clearance in addition to completing the current state level background checks and Child Abuse Clearances. Current employees will complete FBI finger pring clearance documentation by 2/28/10. Copies of received clearance documentation willbe filed in the personnell records. |
Observations
Based on a review of client records and an interview with the facility director the project failed to document client medical histories as required by facility procedure in seven of seven client records.
Findings:
Based on a review of seven client records on October 26, 2009 the project failed to document a medical history in one of seven records. Six of six records did not include a date of medical history completion. An interview with the facility director on October 26, 2009 indicated the medical history is to be completed and documented in the client record between the first and third individual counseling session.
Client record # 1 - Client admitted April 7, 2009. A review of the record on October 26, 2009 revealed that the record failed to provide documentation of a medical history.
Client record #2 - Admitted August 12, 2009. A review of the record on October 26, 2009, revealed that the record failed to document the date the medical history was completed or documented.
Client record #3 - Admitted September 2, 2009. A review of the record on October 26, 2009, revealed that the record failed to document the date the medical history was completed or documented.
Client record #4 - Admitted September 15, 2009. A review of the record on October 26, 2009, revealed that the record failed to document a date the medical history was completed or documented.
Client record # 5- Admitted September 2, 2009 and discharged October 9, 2009. A review of the record on October 26, 2009, revealed that the record failed to document the date the medical history was completed or documented.
Client record # 6 - Admitted November 11, 2008 and discharged February 4, 2009. A review of the record on October 26, 2009, revealed that the record failed to document the date the medical history was completed or documented.
Client record # 7 - Admitted June 17, 2009 and discharged September 18, 2009. A review of the record on October 26, 2009, the record failed to document a date the medical history was completed or documented
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Plan of Correction
Project Director will conduct an in-service and provide supervision sessions with staff who can not attend the scheduled in-service to review the policies and procedures related to completion of pg. 17 (Medical History) of the biopsychosocialspiritual assessment. The inservice will be scheduled and conducted by 2/28/10. The medical history pg. 17 will be modified to include a date completed space ont he form. The form will be modified by 2/28/10. |