INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the November 30, 2011 licensure renewal inspection. The follow-up inspection was conducted on May 7, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Gaudenzia Erie, Inc - Crossroads 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:
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Plan of Correction
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709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records and the policy and procedure manual, the facility failed to document a clear, single policy and procedure in regards to case consultations.
The findings include:
A review of the policy and procedure manual took place on May 7, 2012. Two conflicting case consultation policies were documented within the policy and procedure manual. The first policy stated "Each client's progress should be reviewed at least quarterly at a case conference consisting of representatives from the various client service components. Where the length of treatment is less that 90 days, at least one case conference should be conducted for each client." The second policy stated "Case consults will be completed by the first 30 days and each 30 days thereafter (long term); 14 days and each 14 days thereafter (short term); 30 days and 30 days thereafter (halfway house & IOP); 30 days and each 60 days thereafter (outpatient) of the treatment process."
An interview with the clinical supervisor took place on May 7, 2012. The aforementioned information was confirmed.
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Plan of Correction
Division Director will review the Policy and Procedure manual and assure that case consultation policies are updated and do not contain conflicting information.
Program Director will review updated case consultation policy and train all clinical staff according to the updated case consultation policy. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on a review of client records, the facility failed to ensure that verbal medication orders are put in writing and signed within 24 hours thereafter by the prescribing physician in six of six client records.
The findings include:
Six detoxification client records were reviewed on May 7, 2012. All verbal medication orders are required to be signed within 24 hours by the prescribing physician. Client records # 1, 2, 3, 4, 5 and 6 contained verbal medication orders that was not signed by the prescribing physician within 24 hours.
Client #1 was admitted on May 4, 2012. A verbal order dated May 4, 2012 had no documentation of the prescribing physician signature.
Client #2 was admitted on March 21, 2012. A telephone/verbal order dated April 30, 2012 had no documentation of the prescribing physician signature.
Client #3 was admitted on May 3, 2012. A verbal order dated May 3, 2012 had no documentation of the prescribing physician signature.
Client #4 was admitted on February 16, 2012. A verbal order dated February 16, 2012 had no documentation of the prescribing physician signature.
Client #5 was admitted on April 25, 2012. A verbal order dated April 25, 2012 had no documentation of the prescribing physician signature.
Client #6 was admitted on April 4, 2012. A verbal order dated April 4, 2012 had no documentation of the prescribing physician signature.
An interview with the RN nurse manager took place on May 7, 2012. The aforementioned information was confirmed at that time.
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Plan of Correction
All verbal orders will be signed by the prescribing physician within 24hrs.
Nurse Manager and Medical Director will review this requirement with all facility physicians.
Nurse Manager will review medical charts weekly to assure physician signatures are obtained within 24 hours for all verbal orders.
Nurse Managers weekly chart review findings will be reviewed and reported in the monthly QI/UR meetings. |
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 a review of client records, the facility failed to document a discharge summary within seven days of discharge in three of four client records.
The findings include:
Four discharged residential treatment and rehabilitation client records were reviewed on May 7, 2012. A discharge summary, which is to be completed within seven days of discharge, per facility policy, was required in all four client records. The facility did not document a discharge summary within seven days of discharge in client records # 8, 9 and 10.
Client #8 was admitted to residential treatment and rehabilitation on February 22, 2012 and was discharged on March 21, 2012. A discharge summary was due to be completed by March 28, 2012. There was no discharge summary in client record #8.
Client #9 was admitted to residential treatment and rehabilitation on March 19, 2012 and was discharged on April 16, 2012. A discharge summary was due to be completed by April 23, 2012. There was no discharge summary in client record #9.
Client #10 was admitted to residential treatment and rehabilitation on February 8, 2012 and was discharged on March 9, 2012. A discharge summary was due to be completed by March 16, 2012. There was no discharge summary in client record #10.
An interview with the clinical supervisor took place on May 7, 2012 at which time it was confirmed that the aforementioned client records were missing the required documentation.
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Plan of Correction
Program Director will train clinical staff on the required time frames to complete discharge summaries (within 7 days after discharge).
Program Director will complete monthly chart audits to assure discharge summaries are completed in a timely manner.
Program Director will report/review chart audit findings in the monthly QI/UR meeting.
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