INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on January 12-13, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Discovery House, 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records, the facility failed to document at least 25 hours of annual training for counselors. The training year reviewed was from January 1, 2021 through December 31, 2021.
Employee #4 was hired on October 21, 2013 and promoted to counselor on September 15, 2019. Documentation showed only 16 training hours during 2021.
Employee #5 was hired on March 30, 2014 and promoted to counselor on February 10, 2020. Documentation showed only 16.3 training hours during 2021.
Employee #6 was hired on October 7, 2019 as a counselor and was still in that position at the time of the inspection. Documentation showed only 15.35 training hours during 2021.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
A training plan has been created for all employees as of 02/01/2022. Training plans will be developed by Clinic Director and/or Clinical Supervisor upon hire and annually thereafter.
A review of the staff members adherence to the appropriate amount of trainings each year was presented and reviewed by Clinic Director during the full staff meeting held on 01/25/2022. Also discussed was that the staff ensure that certificates of completion of trainings are provided to the Clinical Supervisor so that it may be accurately represented in the training binder/ personnel files.
The CTC Management team will complete a quarterly review of trainings to ensure compliance with training plans for all staff. This effort will remain ongoing to ensure this is not a repeat deficiency. Licensing and Credentialing department will also be looped in to ensure compliance.
|
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, 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.
|
Observations
Based on review of fire drill logs, the facility failed to document whether the fire alarm or smoke detector was operative during the January through December 2021 fire drills.
This is a repeat citation from the January 14, 2021 licensing inspection.
The finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
On 01/13/2022 the Health and Safety Liason reviewed the Health and Safety documentation requirements including the ""Emergency Drill form"". The form will be completed for all emergency drills and for all fire drills it will document whether the fire alarm or smoke detector was operative during the drills. Clinic Director will review form following all drills to ensure that the proper form is being utilized.
The Health and Safety manager will review the Health and Safety binder, on a monthly basis, to note and ensure all Fire Drills are conducted and documented accordingly. Clinic director will monitor on a quarterly basis. Clinic Director updated Form to reflect the change needed on 01/13/2022. New form to be implemented at next fire drill.
|
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
|
Observations
Based on the review of personnel files, the facility failed to document an annual performance evaluation for employee #6 in 2021.
Employee #6 was hired as a counselor on October 7, 2019 and was still in that position at the time of the inspection.
The finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The annual written staff evaluation for Employee #6 has been brought up to date as of 01/18/2022.
The annual Performance Evaluations for all staff will be conducted on a ""common review date"" schedule. Staff's immediate supervisor will be in charge of compliance to the review date schedule with the Clinic Director overseeing. All employees are scheduled for review in Quarter 4 of each year. The CTC Director will complete a year end evaluation Audit to ensure compliance.
|
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.
|
Observations
Based on a review of patient records, the facility failed to keep disclosure of client identifying information within the limited established by 4 Pa. Code 255.5(b) for releases of information in one out of ten records reviewed. The releases of information forms permitted the release of current dose level, drug test results, medical history, lab work results, discharge summary, treatment plan and intake summary.
Patient #4 was admitted on March 10, 2021 and was still active at the time of the inspection. The four releases dated March 10, 201 were to two funding sources and two government agencies.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Clinic Director will provide a training on completing a release of information correctly to make sure the program is in compliance with this regulation. The training to be conducted on 3/1/2022.
The Clinical Supervisor will review releases of information for accuracy and ensure that these releases of information are completed in its entirety during the quality records review process to ensure continued compliance in this area. Regional director will provide a review of §255.5 and 42 CFR. To be scheduled in March 2022 according to RD availability. Compliance team will also be providing a training surrounding ROI's and will schedule at the request of Clinic Director or Regional Director.
|
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on the review of patient records, the facility failed to notify the patient, in writing, of a decision to involuntarily terminate the client's treatment in one out of one applicable record.
Patient #3 was admitted on September 14, 2020 and discharged on February 17, 2021.
The finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Clinic Director, as per Operational protocol, will review any and all recommendations for involuntary transitions from program services with the RD and will ensure final outcomes of such are provided to the patient in written format. The Clinical Supervisor will oversee and monitor same as will the Clinic Director and such will be discussed in supervision and regular monthly staff meetings.
Clinic Director will provide, upon the decision of involuntarily termination, all patients with written notification of such decision with the reason identified. The notification of termination will be documented in the EMR.
Ongoing compliance with this regulation will be monitored utilizing the quality record review process which will be analyzed monthly at the program level by the clinical supervisor and CTC Director.
|
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
|
Observations
Based on a review of physician timesheets, the facility failed to provide at least one hour of physician time a week, on site for every ten patients.
During the week of October 3-9, 2021, the patient census was 371. The facility was required to provide at least 37.1 physician hours. There were 28 physician hours documented.
During the week of November 21-27, 2021, the patient census was 376. The facility was required to provide at least 37.6 physician hours. There were 31 physician hours documented.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The CTC Director, in concert with the Regional Director, will ensure that the sufficient coverage is provided by the Program Physician, providing at least 1 hour per week onsite for every ten patients, along with the use of the mid-level practitioner adhering to the accepted ratio breakdown. CD will submit request for Physician Exception to provide a 80/20 split. In addition CD will monitor MD schedules accordingly to ensure ample coverage is on site as per regulation and will make timely requests with RD during weekly supervision of added Medical coverage if needed or foreseen in order to identify and on-board additional medical coverage.
|
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
|
Observations
Based on a review of patient records, the facility failed to document an emergency contact in one out of ten records reviewed.
Patient #3 was admitted on September 14, 2020 and discharged on February 17, 2021.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Clinic Director, Clinical Supervisor and Charge Nurse will complete a thorough DEA, pt verification and updated contact information training with nursing and ALL staff in order to ensure compliance to regulation. This will ensure not only compliance but that all staff are able to educate and inform patient's to the same within all departments of the facility/program. Training and education shall occur by 3/8/22. Clinic Director and Clinical Supervisor will also retrain and educate staff about the importance of an emergency contact for each patient and how to enter such into EMR.
|
715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
|
Observations
Based on observation of medication administration, the facility failed to follow their policy and procedures manual in regard to identifying patient. Section 6.1 of the policy and procedures manual states the dispensing nurse will verify the current dose order with the patient prior to administering medication. Verification was not completed on five patients. In addition, section 6.1.1 of the facility's policy and procedures manual states patients will present at the dispensing window without hats. Eight patients were not asked to remove their hats during dispensing.
This is a repeat citation from the January 14, 2021 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Clinic Director and the Charge Nurse will complete a thorough DEA, Pt. verification and updated contact information training with nursing and ALL staff in order to ensure compliance to regulation] to ensure not only our compliance to such, yet also ensure all staff are able to educate and inform Pt's to same within all departments of the facility/program.
This training will occur by 3/8/22. Clinic Director did speak to Nursing Staff on 1/14/22 and addressed this issue. Nurses were re-trained and re-educated about verifying patient identity. This was also addressed in the 2/9/22 meeting with the nursing staff and clinic director."
|
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.
|
Observations
Based on a review of patient records, the facility failed to conduct random urinalysis at least monthly in one out of ten records reviewed.
Patient #5 was admitted on June 14, 2021 and was still active at the time of the inspection. There was no documentation of a urinalysis in October 2021.
This is a repeat citation from the January 14, 2021 licensing inspection.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
All methadone and buprenorphine patients are to provide drug screening analysis samples based on state regulations, at minimum, monthly. Huntingdon Valley CTC uses an EMR to randomly generate a monthly urinalysis screening for all patients.
The Charge Nurse and CTC Director will monitor compliance in this area using EMR reporting as well as the quality record review process. Non-compliance with Urinalysis screenings will be addressed individually during Multi-disciplinary Team Meetings. Clinic Director met with Nursing staff on 2/09/22 and discussed ensuring that patients are given their Urinalysis screenings monthly and how to prevent a patient from avoiding the screening. New procedures were put into place to address the issue. Charge nurse will monitor on a monthly basis to ensure all Pt.'s have provided their random monthly and will review same with CD. If needed, hard-holds will be utilized for NFT's or random tests in system or if Pt. attendance impacts the administration of UDS.
|
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
|
Observations
Based on the review of patient records, the facility failed to provide 2.5 hours of psychotherapy, one hour of which shall be individual therapy per month during the patient's first two years in four out of four applicable records.
Patient #4 was admitted on March 10, 2021 and was still active at the time of the inspection. The patient did not receive any individual therapy during October and December 2021.
Patient # 5 was admitted on June 14, 2021 and was still active at the time of the inspection. In October 2021, the patient only received 30 minutes of individual therapy. In November and December 2021, the patient received one hour of group therapy and zero individual therapy sessions for each month.
Patient #6 was admitted on August 2, 2021 and was still active at the time of the inspection. The patient did not receive any individual therapy in November 2021.
Patient #10 was admitted on September 14, 2020 and was still active at the time of the inspection. In December 2021, the patient received 30 minutes of individual therapy, one no show for an individual session and no group therapy sessions.
This is a repeat citation from the January 14, 2021 licensing inspection.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
CTC Clinic Director and Clinical Supervisor are responsible for ensuring compliance with psychotherapy services for all patients within this narcotic treatment program. The Clinical Supervisor reviewed the requirements for counseling services with all counselors on 01/25/2022.
As of 02/01/2022, each counselor will run their Direct Services Analysis reports in the EMR and turn into the Clinical Supervisor for verification of patient compliance to psychotherapy. The Clinical Supervisor will review the reports in individual and group supervision. Weekly supervision of all counselors with clinical supervisor will occur. Daily completion of the Counselor Daily Checklist will be monitored by both CS and CD.
Patients that missed counseling will be held to meet with a member of the clinical team prior to medicating to address issues of counseling non-compliance. Continued issues of counseling non-compliance after multiple intervention attempts will be brought to the team for consideration of an administrative discharge.
|
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
|
Observations
Based on the review of patient records, the facility failed to send patient files to the patient's new facility for a transfer of services in one out of one applicable record reviewed.
Patient #7 was admitted on October 4, 2017 and discharged on November 4, 2021.
The finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Clinic Director and Clinical Supervisor will provide a training by 3/8/22 for transfer processes between OTP's for continued maintenance, detoxification or another treatment activity. The training will review the requirement that the transfer occur within 7 days of the request of the patient and that a transfer acknowledgement form has been documented in the EMR.
Monthly reviews of any/all transfer patients either ""IN"" or ""OUT' of Huntingdon Valley CTC will be completed to ensure documented compliance to regulation.
Ongoing compliance with this regulation will be monitored utilizing the quality record review process which will be analyzed monthly at the program level by the clinical supervisor and CTC Director. The Clinical Supervisor will address non-compliance in this area during individual supervision
|
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
|
Observations
Based on the review of patient records, the facility failed to document an annual physical examination in one out of four applicable records reviewed.
Patient #9 was admitted on December 9, 2015 and was still active at the time of the inspection. There was no physical examination in 2021.
The finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Annual medical exam for patient #9 was completed and documented in the EMR on 01/22/2022.
A mandatory training for all staff was provided by the Director on 01/25/2022 which reviewed Annual documentation requirements including that all Annual Medical Assessments are to be scheduled a minimum of two weeks prior to the scheduled due date in the EMR to ensure that completion of the required documentation is timely.
The Clinic Director will review the services due report in the EMR a minimum of once per week with CTC leadership to ensure patients are scheduled for and complete their annual physicals timely. Charge nurse will monitor, weekly, for the completion of annual physical examinations, along with Medical Director .
|
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
|
Observations
Based on the review of patient records, the facility failed to document an annual clinical evaluation in five out of six applicable records reviewed.
Patient #1 was admitted on September 14, 2012 and was still active at the time of the inspection. There was no documentation of a clinical evaluation in 2021.
Patient #2 was admitted on January 4, 2017 and was still active at the time of the inspection. An annual clinical evaluation was due on January 4, 2022; however, there was no documentation of one in the patient's records.
Patient #7 was admitted on October 4, 2017 and discharged on November 4, 2021. An annual clinical evaluation was due on October 4, 2021; however, there was no documentation of one in the patient's record.
Patient #9 was admitted on December 9, 2015 and was still active at the time of the inspection. An annual clinical evaluation was due on December 9, 2021; however, it was not completed until January 12, 2022.
Patient #10 was admitted on September 14, 2020 and was still active at the time of the inspection. There was no documentation of a clinical evaluation in 2021.
This is a repeat citation from the January 14, 2021 licensing inspection.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Annual clinical evaluations for patients #1, #2, #7, #9, and #10 will all be completed and documented in the EMR as of 03/20/2022.
A mandatory training for all staff was provided by the Director on 01/25/2022 which reviewed Annual documentation requirements including that all Annual Clinical Evaluations are to be scheduled a minimum of two weeks prior to the scheduled due date in the EMR to ensure that completion of the required documentation is timely.
The Clinic Director will review the services due report in the EMR a minimum of once per week with CTC leadership to ensure annual clinical evaluations are completed timely. Charge nurse will monitor, weekly, along with Medical Director to ensure that annual evaluations are completed.
|
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of patient records, the facility failed to complete a biopsychosocial within the seven day timeframe outlined in the Section 7.1.3 of the facility's policy and procedures manual in one out of two applicable records reviewed.
Patient #4 was admitted on March 10, 2021 and was still active at the time of the inspection. The biopsychosocial was completed on September 16, 2021.
This is a repeat citation from the January 14, 2021 licensing inspection.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
A mandatory training for all staff was provided by the Director on 01/25/2022 which reviewed Admission documentation requirements including the timely completion of biopsychosocials (within the seven days of admission).
The Clinic Director and clinical supervisor will review the services due report in the EMR once per week to ensure biopsychosocial assessments are being completed timely. All new staff will be trained to complete paperwork with in the timelines that are in the policy and procedures manual.
|
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on a review of patient records, the facility failed to update treatment plans at least every 60 days in five out of ten records reviewed.
Patient #2 was admitted on January 4, 2017 and was still active at the time of the inspection. A treatment plan was dated on July 26, 2021 with the next update due no later than September 26, 2021; however, the update was not completed until September 30, 2021.
Patient #3 was admitted on September 14, 2020 and discharged on February 17, 2021. A treatment plan was completed on November 25, 2020 with the next update due no later than January 25, 2020; however, it was not completed until February 3, 2021.
Patient #4 was admitted on March 10, 2021 and was still active at the time of the inspection. A treatment plan was completed on March 16, 2021 with the next update due no later than May 16, 2021; however, it was not completed until May 28, 2021.
Patient #5 was admitted on June 14, 2021 and was still active at the time of the inspection. A treatment plan was completed on August 26, 2021 with the next update due no later than October 26, 2021; however, it was not completed until October 29, 2021.
Patient #10 was admitted on September 14, 2020 and was still active at the time of the inspection. A treatment plan was completed on July 17, 2021 with the next update due no later than September 17, 2021; however, it was not completed until September 29, 2021.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The CTC Director will work with the Clinical Supervisor and team to ensure timely updates are documented to all patient individual treatment plans in accordance to §709.92(b).
During the 01/25/2022 clinical staff meeting, the clinic director and clinical supervisor reviewed this regulation and required that all counseling staff complete internal audits of patient electronic records using EMR reporting on a weekly basis to ensure services are completed timely.
The clinical supervisor will monitor and aid with oversight of compliance with this regulation during weekly supervision meetings to ensure tx plans are updated timely; utilizing reports from the CTC's EMR [SMART] to support same. Clinical supervisor will report to Clinic Director the progress of the timeliness of completion of treatment plans by all staff.
|
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on the review of patient records, the facility failed to provide counseling services according to the patient's individual treatment plan in five out of ten records reviewed.
Patient #2 was admitted on January 4, 2017 and was still active at the time of the inspection. A treatment plan dated September 30, 2021 indicated two hours of individual counseling and three hours of group counseling per month. In October 2021, the patient only received one hour of group therapy. In November and December 2021, the patient did not receive any individual therapy sessions.
Patient #4 was admitted on March 10, 2021 and was still active at the time of the inspection. A treatment plan dated September 30, 2021 indicated two hours of individual and three hours of group therapy per month. In October and December 2021, the patient did not receive any individual therapy sessions.
Patient #5 was admitted on June 14, 2021 and was still active at the time of the inspection. A treatment plan dated August 26, 2021 indicated two hours of individual and three hours of group therapy per month. In October 2021, the patient received 30 minutes of individual and two hours of group therapy. In November and December 2021, the patient received zero hours of individual and one hour of group therapy.
Patient #6 was admitted on August 2, 2021 and was still active at the time of the inspection. A treatment plan dated October 4, 2021 indicated two hours of individual and three hours of group therapy per month. In November 2021, the patient did not receive any individual sessions.
Patient #10 was admitted on September 14, 2020 and was still active at the time of the inspection. A treatment plan dated September 29, 2021 indicated two individual and three group therapy sessions per month. In October 2021, the patient's record showed no group sessions with one no show documented. The patient had no group sessions in November and December 2021. In December 2021 the patient received 30 minutes of individual therapy with one documented no show.
This is a repeat citation from the January 14, 2021 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The CTC Director and Clinical Supervisor will ensure the counseling team receive training on the necessity of correctly documenting frequency of counseling service requirements in the treatment plan and that compliance/ non-compliance is also documented in the EMR and progress notes. The training will be held on 03/01/2022.
Clinical supervisor will report to Clinic Director the progress of the completion of counseling that is documented in treatment plans by all staff.
Ongoing compliance with this regulation will be monitored utilizing the quality record review process which will be analyzed monthly at the program level by the clinical supervisor and CTC Director. The Clinical Supervisor will address non-compliance in this area during individual supervision
|
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
|
Observations
Based on a review of patient records, the facility failed to document an aftercare plan in one out of three applicable records reviewed.
Patient # 8 was admitted on June 15, 2012 and discharged on November 19, 2021.
The finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Clinic Director and Clinical Supervisor will provide staff with training on Discharge documentation requirements on 03/01/2022. The training will address the policy that discharge plans are to be completed upon admission, reviewed during treatment planning and revised a minimum of annually and upon a planned discharge.
Ongoing compliance with this regulation will be monitored utilizing the quality record review process which will be analyzed monthly at the program level by the clinical supervisor and CTC Director. The Clinical Supervisor will address non-compliance in this area during individual supervision. Clinical supervisor will report to Clinic Director the progress of the timeliness of discharge paperwork by all staff. Clinic Director will also work with Medical staff to monitor any medical discharges that may occur and ensure a timely and complete discharge.
|
709.93(a)(10) 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:
(10) Discharge summary.
|
Observations
Based on the review of patient records, the facility failed to document a discharge summary in three out of three applicable records.
Patient # 3 was admitted on September 14, 2020 and discharged on February 17, 2021.
Patient #7 was admitted on October 4, 2017 and discharged on November 4, 2021.
Patient #8 was admitted on June 15, 2012 and discharged on November 19, 2021.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
"Plan of Correction:
The Discharge summaries for patients #3, #7, and #8 will be completed as of 03/21/2022.
The Clinic Director and Clinical Supervisor will provide staff with training on Discharge documentation requirements on 03/01/2022. The training will address the discharge summary documentation requirements.
Ongoing compliance with this regulation will be monitored utilizing the quality record review process which will be analyzed monthly at the program level by the clinical supervisor and CTC Director. The Clinical Supervisor will address non-compliance in this area during individual supervision.
|
709.93(a)(11) 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:
(11) Follow-up information.
|
Observations
Based on the review of patient records, the facility failed to document follow-up information in one out of three applicable records.
Patient #8 was admitted on June 15, 2012 and discharged on November 19, 2021.
The finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Clinic Director and Clinical Supervisor will provide staff with training on Discharge documentation requirements on 03/01/2022. The training will address the discharge follow-up documentation requirements.
Ongoing compliance with this regulation will be monitored utilizing the quality record review process which will be analyzed monthly at the program level by the clinical supervisor and CTC Director. The Clinical Supervisor will address non-compliance in this area during individual supervision. Clinical supervisor will report to Clinic Director the progress of the timeliness of discharge follow-up by all staff, including medical staff if necessary.
|