INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 24 through 25, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Nuestra Clinica Rehabilitacion 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 March 24, 2011.
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Plan of Correction
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709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of the policy and procedure manual, personnel files, and an interview with the associate director, the facility failed to document an annual individual staff evaluation.
The findings include:
On January 24, 2011, the policy and procedure manual and seven personnel records were reviewed. The facility's policy states:
Each employee will have an evaluation after 90 days of hire and annually thereafter.
Three employee records did not include documentation of annual performance evaluation, specifically employee records #'s 4, 5, and 7.
Employee #4 was hired on October 25, 2008, documentation of an annual review would have been due by January 25, 2010. As of the date of inspection there was no documentation of an annual performance review.
Employee #7 was hired on October 8, 2008, documentation of an annual review would have been due by January 8, 2010. As of the date of inspection there was no documentation of an annual performance review.
Employee #5 was hired on June 12, 2006, documentation of an annual review would have been due by September 12, 2010. The employee record did have documentation of an employee performance review, however it was not dated either by the employee or the employee's supervisor.
The associate director was advised of the missing annual performance review on January 24, 2011 but could not materialize documentation of an annual review for the above mentioned employees.
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Plan of Correction
Annual reviews have been completed on employees's #4, 5, and 7 as of todays date. Future reviews will be completed by due date and this procedure will be overseen by the human resource department. In additon to supervising compliance the human resource department will send a reminder email to supervisors to ensure timely completion of future reviews. In additino the Associate Director will be the initial reviewer of employee files and will advise supervisors of annual review due date via, email to ensure reviews completion in a timely fashion. The review will be signed and dated by by both the supervisor and employee. This will be monitored by Associate Director and disciplinary measures will be taken to ensure that proper procedure will be followed. |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
Based upon a review of the facility's policy of procedures manual, a review of the facility's Monthly Medication Inventory and Quality Assurance Form Book and an interview with the Associate Director, the facility failed to follow the facility's policy.
The findings include:
The Medication Inventory and Quality Assurance Forms were reviewed on January 24, 2011. Facility policy titled, Medication Policies, Inspection of Drug Storage Areas states:
The Nurse or designee will record the results of the inspection on the Monthly Medication Inventory and Quality Assurance Form. This report is given to the nurse for signature and filing.
During a review of the Monthly Medication Inventory and Quality Assurance Form Book it was found that there were no completed Monthly Medication Inventory and Quality Assurance Forms for the months of January 2010, February 2010, March 2010, April 2010, May 2010, June 2010, and July 2010. Therefore the inspector was unable to determine if an inspection of the drug storage area had been conducted during the months of January 2010 through July 2010. An interview was conducted with the Associate Director and she confirmed it was not done.
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Plan of Correction
The nurse has assumed full responsibility for medication inventory and quality assurance forms as of February 1, 2011. The inventory and assessment will be completed monthly and this documentation will be forwarded to the Associate Director for signature and review. The forms will also be sent to the fiscal office to be filed and stored as a permanent record.This procedure will be overseen by the Associate Director and the Program Director. |
709.32(c)(4) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
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Observations
Based on a review of the facility's policy and procedures manual, medication administration records, and an interview with the nurse on January 26, 2011 the facility failed to document medication records in accordance with facility policy.
Findings:
Facility policy titled Nuestra Clinica Residential Medication Policies Section 709.32c Page 4 states:
"In the event that a client refuses a prescribed medication, staff will document the client's refusal in the Medication Administration Log and contact the on call medical staff to review the situation if the client's refusal could be considered an immediate health risk.
Facility policy titled Nuestra Clinica Residential Medication Policies Section 709.32c Page 7 states:
When a client discontinues taking a particular type of prescribed medication, the disposal of that medication will be documented on his medication log if appropriate, by the staff member who disposed of medication.
The facility failed to follow their policy and document whether or not a client received their medication, if a client refused their medication or whether the medication was discontinued or their medication was being taken as prescribed in five medication records reviewed.
Client # 1
Drug: CheraTussinac Sirup (sic) 5-10 ML
Prescribed on: 1/10/11
Frequency: take 1 or 2 tsp every 4-6 hours
Dates not taken: 1/13/11 morning (M), dinner (D)
1/14/11(M) and (D), 1/15/11 (D), 1/16/11 (M)(D), during the following dates the medication was not taken at all: 1/17/11, 1/18/11, 1/19/11, 1/20/11, 1/21/11, 1/22/11, 1/23/11, 1/24/11, None of the dates specified a reason why the clients skipped or missed a dosage. Also 1/16/11 was the last day the client took his meds.
Drug: Omeprazole 40 MG
Prescribed on: No date listed
Frequency: No frequency listed
Dates taken: Client took the medication daily from 1/20/11 to 1/24/11 but the inspector is unable to determine how often the prescription was to be taken or when it started.
Drug: Mucinex ER 1,200 MG
Prescribed on: 12/13/10
Frequency: take tab 3x/day
Dates not taken: 12/13/10 morning (M), 12/14/10 day (D), 12/15/10 (D), 12/16/10 (D), 12/17/10 (D), 12/18/10 (D)(B), 12/19/10 (D), 12/20/10 (B)(D).
Additionally there is a note that says the medication was finished, however it is undated. None of the dates specified a reason why the clients skipped or missed a dosage.
Drug: Diclofenac 75 MG
Prescribed on: 11/30/10
Client agreed to take meds on: 12/15/10
Frequency: take tab twice/day
Dates not taken: 12/17/10 (B), 12/18/10, 12/19/10 through 12/25/10, 12/27/10 through 12/31/10, 1/11/10 (M), 1/13/11 (M), 1/14/11 (M), 1/15/11, 1/16/11, 1/17/11(M), 1/18/11(M), 1/19/11(M), 1/20/11(M), 1/21/11(M), 1/22/11(M)
None of the dates specified a reason why the clients skipped or missed a dosage.
Client #2
Drug: Celexa 20 MG
Prescribed on 12/2/10
Frequency: 1 tablet by mouth once/daily
Date not taken: 12/15/10, 12/17/10, 12/18/10, 12/19/10, 12/22/10, 12/24/10, 12/25/10, 12/27/10, 12/29/10, 1/2/11, 1/4/11, 1/6/11, 1/8/11, 1/9/11 1/12/11, 1/14/11, 1/15/11, 1/16/11, 1/19/11, 1/20/11, 1/21/11, 1/22/11, 1/23/11, 1/25/11
None of the dates specified a reason why the clients skipped or missed a dosage.
Client #7
Drug: Nifedipine ER 60 MG
Prescribed on 12/20/10
Frequency: 1 tablet by mouth once/daily
Date not taken: 12/21/10, 12/22/10, 12/28/10, 12/29/10, 1/7/11, 1/9/11, 1/10/11, 1/11/11, 1/16/11, 1/19/11
None of the dates specified a reason why the clients skipped or missed a dosage.
Drug: Seroquel 50 MG
Prescribed on: 12/21/10
Frequency: take one tablet by mouth daily
Dates not taken: 12/24/10, 1/7/11
None of the dates specified a reason why the clients skipped or missed a dosage.
Client #9
Drug: Amitriptiline 100 MG
Prescribed on 12/17/10
Frequency: 1 tablet at bedtime
Date not taken: 12/18/10, 1/10/11, 1/21/11
None of the dates specified a reason why the clients skipped or missed a dosage.
Client #10
Drug: Sertraline 50 MG
Prescribed on 11/22/10
Frequency: 1 tablet daily
Date not taken: 11/28/10, 11/29/10, 11/30/10, 12/1/10, 12/2/10, 12/3/10, 12/4/10, 12/5/10, 12/7/10, 12/8/10, 12/9/10, 12/10/10, 12/11/10, 12/12/10, 12/13/10, 12/14/10, 12/15/10, 12/16/10, 12/17/10, 12/18/10, 12/19/10, 12/20/10, 12/22/10, 12/25/10, 12/26/10, 12/27/10, 12/28/10, 12/29/10, 12/30/10, 12/31/10, 1/1/11, 1/2/11,1/3/11, 1/4/11, 1/5/11, 1/7/11, 1/9/11 1/10/11, 1/14/11, 1/15/11, 1/16/11, 1/18/11, 1/19/11, 1/20/11, 1/22/11, 1/23/11
None of the dates specified a reason why the clients skipped or missed a dosage.
Drug: Atripia (no dosage indicated)
Prescribed on 1/7/11
Frequency: 1 tablet at bedtime
Date not taken: 1/9/11, 1/21/11
Neither date specified a reason why the clients skipped or missed a dosage
Drug: Amoxicillin 500 MG
Prescribed on 11/21/10
Frequency: 1 tablet 3 times daily
Date not taken: 11/28/10, 11/30/10, 12/5/10, 12/6/10, 12/7/10, 12/9/10, 12/11/10, 12/12/10, 12/13/10, 12/14/10, 12/15/10, 12/16/10, 12/17/10, 12/18/10, 12/19/10, 12/20/10, 12/21/10, 12/22/10, 12/24/10, 12/25/10, 12/26/10, 12/27/10, 12/28/10, 12/29/10, 12/30/10, 12/31/10, 1/1/11, 1/2/11,1/3/11, 1/4/11, 1/5/11, 1/6/11, 1/7/11, 1/8/11, 1/9/11 1/10/11, 1/11/11, 1/12/11, 1/13/11, 1/14/11, 1/15/11, 1/16/11, 1/17/11, 1/18/11, 1/19/11, 1/20/11, 1/21/11, 1/22/11, 1/23/11, 1/24/11
None of the dates specified a reason why the clients skipped or missed a dosage
Drug: Mirtazapine (no dosage indicated)
Prescribed on 11/21/10
Frequency: 1 tablet 3 times daily
Date not taken: 11/25/10, 11/28/10, 11/29/10, 11/30/10, 12/5/10, 12/7/10, 12/12/10, 12/13/10, 12/15/10, 12/16/10, 12/19/10, 12/20/10, 12/22/10, 12/24/10, 12/25/10, 12/26/10, 12/29/10, 12/31/10, 1/2/11, 1/5/11, 1/6/11, 1/9/11, 1/21/11
None of the dates specified a reason why the clients skipped or missed a dosage
After reviewing the records, an interview was conducted with a nurse who advised the inspectors, that the missing dates were times when the clients refused to take their medication. However, the staff neglected to document it in the clients' records
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Plan of Correction
On February 16, 2011 a staff meeting was held and all staff were eduated on the medication policy and asked to sign a form acknowledging attendance at the training.Staff were informed that in the event of a client refusing medication, the staff person must document the refusal in the medication book, date the book, and initial the medication log as to whether client failed to come in the office for mediation or tht the client refused the medication. The on duty staff will then call the nurse and advise of the refuasl. If the situation is not life threatening, the nurse,upon her return to the facility, will educate the client on the risks involved in medication non compliance. In addition, the nurse will advise the client's primary counselor of the non compliance issue and the counselor will add this problem to the treatment plan and future goals for the client. If the client remains non compliant they will be referred for a mental health assessment by psychaitrist. If the evaluation concludes the client should remain on medication then the client must adhere of face progressive disciplanry actions including loss of privledges up to possible discharge.If medication is discontinued by physician/psychiatrist it will be documented on the medication log, medication will be properly disposed of,and documentation of when and who disposed of the medication will be kept.Staff will also be held accountable for the documentation of medication and refusals. This will be overseen by the nurse,associate director and the project director. Failure to comply will result in disciplinary measures stated in the employee handbook, which includes possible termination.***
**The nurse will review the medication sheets daily for compliance. Any discrepancies will be reported to the associate director and the employee will be retrained by the nurse. If any employee has further problems with documentation after the initial training they will be placed on a probationary period to allow direct supervision of procedure. Failure to comply with policy during the probation period may result in discipinary action up to and including termination** |
709.32(c)(6) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(6) Inventories.
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Observations
Based upon a review of the facility's policy of procedures manual, a review of the facility's Medication Inventory and Quality Assurance Form Book and an interview with the Associate Director, the facility failed to follow the facility's policy.
The findings include:
The Medication Inventory and Quality Assurance Forms were reviewed on January 24, 2011. Facility policy titled, Medication Policies, Inventories:
All inventories are documented on the Monthly Medication Inventory and Quality Assurance Form and will be coducted one time per month by a staff member. The form is then given to the nurse for review and signature. Upon completion of the inventory the nurse reports results to the facility director.
During a review of the Monthly Medication Inventory and Quality Assurance Form Book it was found that there were no completed Monthly Medication Inventory and Quality Assurance Forms for the months of January 2010, February 2010, March 2010, April 2010, May 2010, June 2010, and July 2010. Therefore the inspector was unable to determine if invtory had been done during the months of January 2010 through July 2010. An interview was conducted with the Associate Director and she confirmed it was not done.
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Plan of Correction
The nurse has assumed full responsibility for medication inventory and quality assurance forms as of February 1, 2011. The inventory and assessment will be completed monthly and this documentation will be forwarded to the Associate Director for signature and review. The forms will also be sent to the fiscal office to be filed and stored as a permanent record.This procedure will be overseen by the Associate Director and the Program Director. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on an inspection of the facility's physical plant and an interview with the associate director, the facility failed to ensure the facility was in good repair at all times.
The findings include:
A physical inspection was conducted on January 25, 2011 between 2:05 pm and 2:45 pm. During the tour at 2:20 pm it was found that the ceiling above the shower in the main client bathroom on the third floor was peeling and in need of repair. During an interview with the associate director, the licensing inspector was advised the ceiling had been damaged due to a recent snow storm and it was currently under repair.
Additionally it was found that the ceiling directly above the shower in the main client bathroom on the second floor was peeling and in need of repair.
Both instances were confirmed by the associate director.
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Plan of Correction
The ceilings on the second and third floors were repaired and repainted on February 1,2011.
In addition a safety walk through will be conducted on a monthly basis to identify maintenance needs in a timely manner. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on an inspection of the facility's physical plant and a conversation with the associate director, the facility failed to ensure that all bathtubs and showers had slip-resistant surfaces.
The findings include:
A physical plant inspection was conducted on January 25, 2011 between 2:05 pm and 2:45 pm. At 2:20pm it was found that the bathtub/shower in the main client bathroom on the third floor did not have a rubberized mat or any mechanism to prevent slipping.
Additionally it was found that the the bathtub/shower in the main client bathroom on the second floor also did not have a rubberized mat or any mechanism to prevent slipping.
Both instances were confirmed by the associate director.
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Plan of Correction
On January 27, 2011, the associate director purchased rubber mats for the all bathtubs/showers in the faciltiy and they have been placed in the bathtubs/showers to prevent slipping. These mats will be checked during monthly safety walk through to make sure they remain in good condition or are replaced if found to be defective or deteriorated. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on an inspection of the physical plant and an interview with the CEO, the facility failed to ensure that exits from the residential facility are unobstructed.
The findings include:
A physical plant inspection was conducted on January 11, 2011 between 2:05 pm and 2:45 pm. At approximately 2:40pm it was found that the second exit from the basement had a wooden plank blocking the exit. The bar was used as a lock however the door has additional locks on the top and bottom of the door.
The associate director confirmed this.
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Plan of Correction
On the date of inspection the board was removed from the door. Locks on the top and bottom of the door were removed, and a slide lock that can be opened with one slide of the hand was placed in the middle of the doors.
Safety committee officer will do a security walk through monthly, along with house manager supervisor weekly walk throughs to ensure that deficiency does not reoccur. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on observation and a conversation with the associate director, the facility failed to ensure fire extinguishers are inspected and approved annually.
The findings include:
While reviewing documentation in the work area provided in the rear building, it was observed on January 24, 2011 at approximately 12:30 PM, that the fire extinguisher in the rear building had not been inspected since December 2007.
A conversation with the associate director confirmed that the fire extinguisher was expired.
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Plan of Correction
On the date of the inspection the fire extinguisher from the rear building was removed and taken out for inspection. The extinguisher was passed inspection and was tagged to acknowledge the inspection date.
Going forward extinguishers will be checked during the monthyly safety walk through of the facility and those in need will be taken out for inspection and tagged to show completion of inspection. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records it was determined that the facility failed to ensure that all staff were instructed in the use of fire extinguishers upon employment.
The findings were:
On January 24, 2011 seven personnel records were reviewed. It was found that one employee was not instructed in the use of a fire extinguisher upon hire, specifically employee # 4.
Employee #4 was hired on October 25, 2008 and as of the date of inspection, there was no documentation of fire extinguisher training in employee #4's personnel file.
A discussion with the associate director on January 24, 2011 confirmed there was no documentation that the identified employee received instruction in the use of a fire extinguisher.
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Plan of Correction
Employee #4 was instructed on the use of fire extinguishers on February 1, 2011. In addition, the Associate Director will supervise all future instruction off new employees on the use of fire extinguishers. This instruction will be dated, signed, and placed in the employees file. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 records it was determined that the facility failed to ensure that personnel on all shifts were trained to perform assigned tasks during emergencies.
The findings were:
A review of seven personnel records revealed that three employees were not trained to perform assigned tasks during emergencies, specifically employees #s 4, 6, and 7.
Employee # 4 was hired on October 25, 2008. As of the date of this inspection there was no documentation that employee #4 had received training for emergencies.
Employee # 6 was hired on February 22, 2010. As of the date of this inspection there was no documentation that employee # 6 had received training for emergencies.
Employee # 7 was hired on October 8, 2008 and promoted to a counselor assistant on January 4, 2010. As of the date of this inspection there was no documentation that employee # 7 had received training for emergencies.
A discussion with the associate director on January 24, 2011 confirmed there was no documentation that the identified employees had received instruction in the case of an emergency.
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Plan of Correction
All employees have been instructed on what do to in case of emergency/disaster, specifically employees #4,6,and 7.
The employee files have been updated to reflect this training. In addition disaster protocol has been placed at each desk in case of emergency.
** The associate director will train the employee within first seven days of employment and the human resource department will oversee compliance to this procedure. The employee files will be reviewed on a monthly basis to assess updated training needs. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and the facility's policy and procedures manual, the facility failed to document a psychosocial evaluation that included the client's problems/needs, assets and strengths, support system, preferred defense mechanisms, negative factors that could interfere with treatment, the clients' attitude towards treatment, and the counselors' conclusions/impressions in ten of ten outpatient client records reviewed.
The findings include:
Ten client records were reviewed on January 25, 2010, and were required to document a psychosocial evaluation. Six client records did not include a clinical assessment of the client; and only included client historical information.
The facility's policy states:
The Bio/Psychosocial Evaluation gathers counselor impressions as well as important data obtained during the intake process including the bio/psychosocial history to formulate a summarization of client information and clinical conclusions drawn from the data.
Biopsychosocial evaluation should:
-Give an overview of underlying issues
-State client's preferred defense mechanisms.
-State negative factors that could interfere with the treatment process.
-Give overview of current support system with consideration of supports aside from immediate family.
-State your (the clinician's) conclusions
The facility failed to document a psychosocial evaluation that included a clinical assessment in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
Client #1 was admitted on November 23, 2010. The psychosocial evaluation was completed on November 25, 2010. The psychosocial evaluation did not include a clinical assessment of the client's assets and strengths, potential support systems, coping mechanisms, negative factors that could interfere with treatment, or the counselor's impressions; and only included client historical information.
Client #2 was admitted on December 1, 2010. The psychosocial evaluation was completed on December 3, 2010. The psychosocial evaluation did not include a clinical assessment of the client's assets and strengths, potential support systems, coping mechanisms, negative factors that could interfere with treatment, the client's attitude towards treatment, or the counselor's impressions; and only included client historical information.
Client #3 was admitted on December 10, 2010. The psychosocial evaluation was completed on December 16, 2010. The psychosocial evaluation did not include a composite picture of the client, a clinical assessment of the client's problem's/needs, assets and strengths, potential support systems, coping mechanisms, negative factors that could interfere with treatment, the client's attitude towards treatment, or the counselor's impressions; and only included client historical information. Additionally, the evaluation was illegible which made it difficult to read.
Client # 4 was admitted on April 5, 2010. The psychosocial evaluation was completed on April 5, 2010. The psychosocial evaluation did not include a clinical assessment of the client's assets and strengths, potential support systems, coping mechanisms, negative factors that could interfere with treatment, or the counselor's impressions; and only included client historical information.
Client # 5 was admitted on July 19, 2010. The psychosocial evaluation was completed on July 22, 2010. The psychosocial evaluation did not include a composite picture of the client, a clinical assessment of the client's problem's/needs, assets and strengths, potential support systems, coping mechanisms, negative factors that could interfere with treatment, the client's attitude towards treatment, or the counselor's impressions; and only included client historical information. Additionally, the evaluation was illegible which made it difficult to read.
Client #6 was admitted on August 31, 2010 and discharged on September 28, 2010. The psychosocial evaluation was completed on September 7, 2010. The psychosocial evaluation did not include a clinical assessment of the client's assets and strengths, potential support systems, coping mechanisms, negative factors that could interfere with treatment, or the counselor's impressions; and only included client historical information
Client #7 was admitted on May 17, 2010 and discharged on August 9, 2010. The psychosocial evaluation was completed on May 19, 2010. The psychosocial evaluation did not include a clinical assessment of the client's assets and strengths, potential support systems, coping mechanisms, negative factors that could interfere with treatment, or the counselor's impressions; and only included client historical information
Client #8 was admitted on December 7, 2010. The psychosocial evaluation was completed on December 13, 2010. The psychosocial evaluation did not include a clinical assessment of the client's assets and strengths, potential support systems, coping mechanisms, or negative factors that could interfere with treatment; and only included client historical information.
Client #9 was admitted on December 3, 2010. The psychosocial evaluation was completed on December 6, 2010. The psychosocial evaluation did not include a clinical assessment of the client's problems/needs, assets and strengths, potential support systems, coping mechanisms, or negative factors that could interfere with treatment, or the counselor's impressions; and only included client historical information.
Client #10 was admitted on November 17, 2010. The psychosocial evaluation was completed on December 13, 2010. The psychosocial evaluation did not include a clinical assessment of the client's assets and strengths, potential support systems, coping mechanisms, or negative factors that could interfere with treatment, and attitude towards treatment; and only included client historical information.
An interview with the associate director confirmed the psychosocial evaluations were missing components.
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Plan of Correction
On February 4, 2011, the bio-psychosoical evaluations were expanded to prompt the clinician to write a clinical conclusion in narrative form at the end of the assessment. In addition, direct questions were added to the evaluation to prompt the clinician to ask probing questions.
**Associate director will conduct chart audits on a weekly basis under the supervision of the project director. Clinicians that continue to exhibit difficulty following policy and procedure will be retrained in house and be registered and BDAP trainings. Once a clinician has had the additional training they will be monitored for compliance. Any further devience from protocol will lead to disciplinary measures that include probation upto and including termination. |
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 the review of client records and an interview with the facility director, the facility failed to document case consultations which specified the individuals that were present during the consultation in ten of ten client records reviewed.
The findings include:
Ten client records were reviewed on January 25, 2011. Per agency policy, the initial case consultations shall be completed after fourteen days then, every thirty days thereafter. Case consultations were required in each of the ten client records reviewed. The facility did not document a case consultation which specified who was present. Instead there was a pre-printed list of names on the consultation form in which all employees were made to be present during every consultation, although at least one of the employees was no longer employed with the project. An interview with the facility director on January 25, 2011 confirmed that the facility did not properly document case consultations in any of the client records.
Client # 1 was admitted on November 23, 2010. A case consultation was completed using a form with preprinted names including that of an employee who was no longer employed with the project. This case consultation was signed by the counselor on December 10, 2010 and signed by the Project/Facility Director on December 14, 2010. Another case consultation was completed and signed by the counselor on January 11, 2011 and signed by the Project/Facility Director on January 20, 2011.
Client # 2 was admitted on December 1, 2010. A case consultation was completed on January 25, 2011 using a form with preprinted names including that of an employee who was no longer employed with the project.
Client # 3 was admitted on December 10, 2010. A case consultation was completed on December 21, 2010 using a form with preprinted names including that of an employee who was no longer employed with the project; additionally the case consultation was illegible and difficult to read.
Client # 4 was admitted on April 5, 2010 and discharged on June 2, 2010. A case consultation was completed on June 13, 2010 using a form with preprinted names and was unsigned.
Client #5 was admitted on July 19, 2010 and discharged on September 9, 2010. A case consultation was completed on July 27, 2010 using a form with preprinted names including that of an employee who was no longer employed with the project; additionally the case consultation was illegible and difficult to read.
Client #6 was admitted on August 31, 2010 and discharged on September 28, 2010. A case consultation was completed on September 7, 2010 using a form with preprinted names including that of an employee who was no longer employed with the project.
Client #7 was admitted on May 5, 2010 and discharged on August 9, 2010. Case consultations were completed on May 25, 2010; June 4, 2010; June 18, 2010; and July 18, 2010 each using a form with preprinted names. Furthermore the dispositions were identical for the June 4, 2010; June 18, 2010; and July 18, 2010 case consultations, each read:
Client will be working on D&A education coping skills, triggers to relapse and relapse prevention. Begin to work on finding reliable housing per discharge planning.
Client #8 was admitted on December 7, 2010. A case consultation was completed on December 21, 2010 using a form with preprinted names including that of an employee who was no longer employed with the project.
Client #9 was admitted on December 3, 2010. Case consultations were completed on December 7, 2010 and January 8, 2011 both using a form with preprinted names including that of an employee who was no longer employed with the project.
Client #10 was admitted on November 17, 2010. A case consultation was completed on December 23, 2010, using a form with preprinted names including that of an employee who was no longer employed with the project.
Based on the review of client records and an interview with the facility director, the facility failed to document discharge summaries in five of five discharge records reviewed.
The findings include:
Eleven client records were reviewed on January 26, 2011. Discharge summaries where required in five discharge records reviewed, #5, 6, 7, 8 and 11. Discharge summaries are to have documentation of the client's reason for treatment, services offered, response to treatment and the client's status at the time of discharge. Client records #5, 6, 7 and 8 did not have documentation of client's reason for treatment and the client's response to treatment. An interview with the facility director on January 26, 2011 confirmed that the client's reason for treatment and the client's response to treatment was not documented in client records #5, 6, 7 and 8.
Based on a review of client records and an interview with the facility director, the facility failed to document follow-up information in three of five discharge records reviewed.
The findings include:
Eleven client records reviewed on January 26, 2011. Follow-up information were required in three of the five discharge records, #5, 6 and 8. Per the facility's policy and procedure, all clients will either be contacted within 7 days if being referred or 30 days following their discharge date. An interview was conducted with the facility director on January 26, 2011 and it was confirmed that follow-up contact was not documented in client records #5 and 8. Also, the follow-up information for client record #6 was documented late.
Client #5 was admitted on March 26, 2010 and discharged on August 3, 2010. As of the date of the inspection there was no documentation of the client's follow-up information in the record reviewed. The follow-up should have taken place by September 3, 2010.
Client #6 was admitted on May 26, 2010 and discharged on July 6, 2010. The follow-up took place on August 9, 2010. The follow-up should have been documented by August 6, 2010.
Client #8 was admitted on July 16, 2010 and discharged on September 14, 2010. As of the date of the inspection there was no documentation of the client's follow-up information in the record reviewed. Their follow-up should have taken place by October 14, 2010.
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Plan of Correction
The case consultation form was updated on February 4, 2011 and the emolyee list was corrected to reflect current clinicians.An area was added for the clinician to inital and verify their prescence. The project director explained the correct process of documenting the case consultation reccomendations while in the cousultation, and staff acknowledged the correct method of documentation. The clinical supervisor and project director will superivse these sessions and their documentation. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to document discharge summaries to include the reason for treatment in four of four discharge records reviewed.
The findings include:
On January 25, 2011, four client records were reviewed for discharge summaries. Four out of four client records reviewed, specifically records # 4, 5, 6 and 7, lacked documentation of the client's reason for treatment, services offered, response to treatment and/or the client's status at the time of discharge.
Client # 4 was admitted on April 5, 2010 and discharged on June 2, 2010. A discharge summary was completed on June 3, 2010 and did not have documentation of client's reason for treatment.
Client #5 was admitted on July 19, 2010 and discharged on September 9, 2010. A discharge summary was completed on September 8, 2010, before the client was discharged and did not have documentation of client's reason for treatment and the client's response to treatment.
Client #6 was admitted on August 31, 2010 and discharged on September 28, 2010. A discharge summary was completed on, September 23, 2010 before the client was discharged and did not have documentation of client's reason for treatment.
Client #7 was admitted on May 5, 2010 and discharged on August 9, 2010. A discharge summary was completed on August 9, 2010 and did not have documentation of client's reason for treatment.
An interview with the facility director confirmed that the discharge summaries were lacking the reasons for treatment, response to treatment, and/or was completed prior to the clients ' discharge.
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Plan of Correction
The discharge summaries were updated on February 4, 2011, and now specifically ask," what was the reason for treatment", and "response to treatment." In addition the staff was instructed by the project director to complete discharge summaries on day of discharge of withing 7 days of dicahrge. Clinicians acknowledged that they understood discharge summaries could not be completed prior to discharge date. Clinical supervisor will monitor these summaries under direction of the project director. |
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 and an interview with the facility director, the facility failed to document follow-up information in four of four discharge records reviewed.
The findings include:
On January 25, 2011, four client records were reviewed for follow-ups. Four out of four client records reviewed, specifically records # 4, 5, 6 and 7, lacked documentation of a follow-up contact.
Ten client records reviewed on January 25, 2011. Follow-up information was required in four of the ten records, specifically records # 4, 5, 6 and 7. Per the facility's policy and procedure, all clients will either be contacted within 7 days if being referred or 30 days following their discharge date. An interview was conducted with the facility director on January 25, 2011 and it was confirmed that follow-up contact was not documented in client records #4, 5, 6 and 7. Also, the follow-up information for client record #5 was documented late.
Client # 4 was admitted on April 5, 2010 and discharged on June 2, 2010. As of the date of the inspection there was no documentation of the client's follow-up information in the record reviewed. The follow-up should have taken place by July 2, 2010.
Client #5 was admitted on July 19, 2010 and discharged on September 9, 2010. The client was referred to another agency on September 9, 2010 the follow up was documented on October 4, 2010. The follow-up should have taken place by September 16, 2010.
Client #6 was admitted on August 31, 2010 and discharged on September 28, 2010. As of the date of the inspection there was no documentation of the client's follow-up information in the record reviewed. The follow-up should have taken place by October 28, 2010.
Client #7 was admitted on May 5, 2010 and discharged on August 9, 2010. As of the date of the inspection there was no documentation of the client's follow-up information in the record reviewed. Their follow-up should have taken place by September 9, 2010.
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Plan of Correction
The associate director will be responsible for reviewing charts for follow up forms compliance. At the time of discharge ,the discharge form will be semi completed with the name, date, snd location of aftercare. The administrative assistant will make the call 7 days after discharge and document the adherence or lack of adherence to aftercare plan. IF the client attended aftercare appointment a 30 day follow up form will be completed and the administrative assistant will follow up in 30 days documenteing continued participation in treatment or discountinuance of treatmet goals. All follow up will be placed in clients permanent record. This process will be overseen by the associate director. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, client records and an interview with the acting facility director, the facility failed to document direct observation for employee #7, a counselor assistant, from January 4, 2010 through April 4, 2010. In addition the facility failed to document close supervision for Employee #7 starting April 4, 2010 to current.
The findings were:
Employee #7 was hired as a house manager on October 8, 2008 and promoted to counselor assistant on January 4, 2010. Employee # 7's only qualifications for the position is the possession of a high school diploma.
A review of the personnel and staff records for employee #7 confirmed that no documentation was available to demonstrate direct observation was conducted on employee #7 from January 4, 2010 through April 4, 2010. In addition, no documentation was available to demonstrate close supervision for Employee #7 from April 4, 2010 to current. A conversation with the acting facility director on January 24, 2011 confirmed that no documentation was available to demonstrate that direct or close observation was conducted for employee #7.
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Plan of Correction
The facility director had a meeting with clinical supervisor to discuss the missing documents. The clinical supervisor was given a copy of the policy pertaining to counselor assistant training and supervision. Policy guidelines will be strictly adhered to in future training of counselor assitants. The disciplinary process was explained for non adherence to policy and procedures. This process progresses from warnings up to and including termination of employee for failure to comply with the policy. This will be supervised and monitored by facility director. |
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 the policy and procedure manual, personnel files, and an interview with the associate director, the facility failed to document individual training plans as per facility policy in four of seven employee records.
The findings include:
On January 24, 2011, the policy and procedure manual and seven personnel records were reviewed. Facility policy titled Staff Development Program, Individual Training Plan for each NCR Staff Person, stated:
An individual training plan will be developed annually by July 30 for all clinical and non clinical employees with input from both the employee and supervisor. This plan will identify subject areas, potential resources for training which meet the requirements for the employee's position, skill level and interest.
The facility's current training year runs from July 1, 2010 to June 30, 2011. Three out of seven employee records did not include documentation of a training plan completed by July 30, 2010, specifically records #1, 2, and 7 and one of seven records did not included a training plan at all, specifically record #6.
Employee #1's training plan was due by July 30, 2010 and had not been completed until August 10, 2010.
Employee #2's training plan was due by July 30, 2010 and had not been completed until August 20, 2010.
Employee #7's training plan was due by July 30, 2010 and had not been completed until August 24, 2010.
Employee #6's training plan was due by July 30, 2010 and had not been completed as of the date of inspection.
The associate director was interviewed on January 25, 2011. The associate director advised that she was unaware they were due by July 30, 2010 as per the facility's policy.
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Plan of Correction
Associate directore reviewed the policy on training plans. The facility director will supervise the completion of training plans prior to the July 30th due date. Employee training needs survey will be distributed in May of each year and each supervisor will complete the training plan and have it reviewed by associate director. Training plan will be placed in employees permanent file.
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