INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 26, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. West Chester 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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704.6(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
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Observations
Based on a review of personnel records, it was determined that one employee hired as a clinical supervisor did not meet the qualification requirements for the position.
Employee # 3 was promoted to the position of clinical supervisor on June 19, 2023 and was current in that position at the time of the inspection. At the time of promotion, the employee had a qualifying bachelor ' s degree, but only two years of clinical experience, not the required minimum of three years.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At the time of the inspection, this employee met the qualifications as outlined in 704.6 (b); therefore, no corrective actions or shifts in position were required for this employee.
In the event of a vacancy for this position and to prevent reoccurrence, Program Director and Deputy Director will review resume to ensure experience and credentials are in alignment with 704.6 (b). Furthermore, if an exception is requested, program will submit prior to the time of hire.
Party (ies) Responsible: Program Director and Deputy 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 a physical plant inspection on April 26, 2024, the facility failed to keep the grounds of the facility in good repair at all times as evidenced by the following:
1)The men's storage closet on the second floor had plaster and paint decay revealing the metal mesh underneath.
2)There was peeling plaster and paint on the interior wall under the window near women ' s exit
3)Immediately outside the women's exit and patio, a corner of an exterior wall had a large hole
This is a repeat citation from the June 1, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As a means of ensuring compliance with the abovementioned licensing standards, Program Director will review this licensing standard and expectations with all staff during next General Staff Meeting (May 30, 2024) to ensure awareness of expected practice and compliance.
Program Director and/or designee will monitor the grounds monthly during completion of monthly safety report/inspection to ensure building exterior is free and clear of any hazards. Program Director and/or designee will inform necessary party/ies to ensure that any identified issues are rectified within forty-eight (48) hours.
On a rotating basis, the Quality Assurance Department will also monitor Program's compliance with the abovementioned standard, which will be completed during their physical plant tours and completion of the physical plant audit tool. Any issues identified will be brought to the immediate attention of the Program Director and rectified within forty-eight (48) hours.
In reference to the abovementioned areas of noncompliance, Program Director resubmitted maintenance work orders via agency maintenance ticketing system. Program Director and Director of Maintenance outlined a plan of correction to include the following:
- Utilization of Agency Construction/Maintenance Project Staff to solicit three bids to address the peeling plaster (#c).
- Once bids are secured, work will begin and be completed within 60 days.
- For the Men's Storage Closet and peeling plaster (#b), facility maintenance staff will address these concerns within the next two weeks.
Party (ies) Responsible: Program Director, Recovery Support Professionals, All Staff, Facility/Agency Maintenance Staff
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection on April 26, 2024, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. Both communal bathrooms on the second floor had shower stalls with missing tiles, cracked tiles, and a black substance on the caulking. Between shower stalls in one bathroom was an area with a peeling baseboard trim.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As a means of ensuring compliance with the abovementioned licensing standards, Program Director will review this licensing standard and expectations with all staff during next General Staff Meeting (May 30, 2024) to ensure awareness of expected practice and compliance.
Upon completion of daily chores, Recovery Management Staff will monitor bathrooms to ensure that each bathroom is functional, clean, and sanitary. Program Director and/or designee will monitor the grounds monthly during completion of monthly safety report/inspection to ensure bathrooms are maintained in accordance with licensing standards. During daily and/or monthly checks, and/or Program Director and/or designee will inform necessary party/ies to ensure that any identified issues are documented and reported to appropriate parties via agency maintenance system within forty-eight (48) hours.
On a rotating basis, the Quality Assurance Department will also monitor Program's compliance with the abovementioned standard, which will be completed during their physical plant tours and completion of the physical plant audit tool. Any issues identified will be brought to the immediate attention of the Program Director and rectified within forty-eight (48) hours.
In reference to the abovementioned area of noncompliance (cracked/missing tiles), Program Director resubmitted maintenance work orders via agency maintenance ticketing system. Program Director and Director of Maintenance outlined a plan of correction to include the following:
- Utilization of Agency Construction/Maintenance Project Staff to repair/replace the cracked and missing tiles.
- Facility maintenance staff will address these concerns within the next thirty (30) days.
Party (ies) Responsible: Program Director, Recovery Support Professionals, Facility Maintenance Staff, All Staff |
705.7 (b) (4) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(4) Ensure that storage areas for foods are free of food particles, dust and dirt.
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Observations
Based on a physical plant inspection on April 26, 2024, the facility failed to ensure that storage areas for foods are free of food particles, dust and dirt as 18 cans of sweet potatoes in the basement food storage area had dust and plaster debris from the nearby wall on top.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 26, 2024, when Program staff noted the abovementioned deficiency, Food Service Staff/Manager removed dust and dirt from identified cans.
As a means of ensuring compliance with the abovementioned licensing standards, Program Director will review this licensing standard and expectations with all staff during next General Staff Meeting (May 30, 2024) to ensure awareness of expected practice and compliance, which includes the continued monitoring of the basement food service area to ensure that all stored food is free of particles, dust, and dirt.
On a weekly basis, the Food Service Designee will perform a routine inspection of the basement food storage area, which will include, but not be limited to, ensuring that all food/cans are free of dirt, dust, and other particles. Food Service Manager and Program Director will monitor the Inspection Logs during monthly supervisory sessions to add an additional layer of oversight to ensure compliance with established licensing standards.
On a rotating basis, the Quality Assurance Department will also monitor Program's compliance with the abovementioned standard, which will be completed during their physical plant tours and completion of the physical plant audit tool. Any issues identified will be brought to the immediate attention of the Program Director and rectified within forty-eight (48) hours.
Party (ies) Responsible: Program Director, Food Service Manager/Staff
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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection on April 26, 2024, the facility failed to keep cold food at or below 40 degrees Fahrenheit, as refrigerator # 5 in the kitchen was 45 degrees. Staff temperature logs from January 2024 reflect that each day between January 1, 2024 and January 18, 2024, refrigerator # 5 was recorded over 40 degrees.
This is a repeat citation from the June 1, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 26, 2024, when Program staff noted that one of the refrigerators continued to read in excess forty degrees, Food Service Manager contacted contracted repair to have the freezer checked to determine the cause of elevated temperature. Technicians arrived on-site on April 28, 2024, and they were able to ascertain and fix the cause of the elevated temperature.
As a means of ensuring compliance with the abovementioned licensing standards, Program Director will review this licensing standard and expectations with all staff during next General Staff Meeting (May 30, 2024) to ensure awareness of expected practice and compliance, which includes the continued monitoring and documentation of inside and outside refrigerator/freezer temperatures.
The Food Service Manager and/or designee will review the temperature logs and contact contracted technicians if the temperatures are outside of the established storage temperatures. Any temperatures that are outside of expected/safe zones will be flagged with a highlighter as a means of drawing attention to them. If a trend or pattern is found, Food Service Manager will place a service call/request. Program Director will monitor the temperature logs during monthly supervisory sessions with Food Service Manager to add an additional layer of oversight to ensure compliance with established licensing standards.
On a rotating basis, the Quality Assurance Department will also monitor Program's compliance with the abovementioned standard, which will be completed during their physical plant tours and completion of the physical plant audit tool. Any issues identified will be brought to the immediate attention of the Program Director and rectified within forty-eight (48) hours.
Party (ies) Responsible: Program Director, Food Service Manager/Staff
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705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
Based on a physical plant inspection on April 26, 2024, the facility failed to maintain outside steps exceeding two steps with a well-secured handrail. Three stairs outside of the emergency exit from the interior stairwell did not have a handrail.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As a means of ensuring compliance with the abovementioned licensing standards, Program Director will review this licensing standard and expectations with all staff during next General Staff Meeting (May 30, 2024) to ensure awareness of expected practice and compliance, which includes the maintenance of all fire exits to ensure they are equipped with well-secured handrails.
Furthermore, Program Director and/or designee will monitor the grounds monthly during completion of monthly safety report/inspection to ensure fire exits are equipped with well-secured handrails. Program Director and/or designee will inform necessary party/ies to ensure that any identified issues are rectified within forty-eight (48) hours.
On a rotating basis, the Quality Assurance Department will also monitor Program's compliance with the abovementioned standard, which will be completed during their physical plant tours and completion of the physical plant audit tool. Any issues identified will be brought to the immediate attention of the Program Director and rectified within forty-eight (48) hours.
In reference to the abovementioned area of noncompliance, Program Director submitted a maintenance work order via agency maintenance ticketing system. Program Director and Director of Maintenance outlined a plan of correction to include the following:
- Utilization of Agency Construction/Maintenance Project Staff to solicit three bids to address the installation of a handrail.
- Once bids are secured, work will begin and be completed within 60 days.
Party (ies) Responsible: Program Director, Recovery Support Professionals, All Staff, Facility/Agency Maintenance Staff
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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 seven client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of two applicable records reviewed.
Client # 3 was admitted on December 1, 2023 and was discharged Against Staff Advice (ASA) on February 2, 2024. The facility failed to follow their policy related to ASA discharges of calling the Emergency Contact within twelve hours as they failed to obtain emergency contact information upon intake, per facility policy.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
An In-Service Training will be conducted with the Clinical Staff of West Chester House on June 6, 2024, to review the agency's policy regarding Clinical Documentation timeframes and expectations. This in-service training will include, but will not be limited to, retrieval of emergency contact information and the time of admission and notification/documentation of emergency contact, within twelve hours, in the event of a resident leaving treatment against staff advise.
On a biweekly basis, Program Director will review all admissions to ensure documented attempts to retrieve emergency contact information and all discharges to ensure that any resident that left treatment against staff advise has documented notification of emergency contact within the established timeframe. Program Director will be responsible for ensuring that this workflow expectation/addition is followed, and any identified deficiencies are addressed within forty-eight (48) hours.
On a rotating basis, the Quality Assurance Department will also monitor Program's compliance with the abovementioned standard, which will be completed during their quantitative and qualitative chart audits. Any issues identified will be brought to the immediate attention of the Program Director and rectified within forty-eight (48) hours.
Party (ies) Responsible: Clinical Staff of West Chester House, Intake Specialist, Clinical Supervisor, Program Director, and Quality Assurance Department
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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.
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Observations
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent to release information form from the client for the disclosure of information contained in three records reviewed.
Client # 3 was admitted on December 1, 2023 and was discharged on February 2, 2024. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing.
Client # 4 was admitted on June 27, 2023 and was discharged on August 19, 2023. The consent to release information form to the funding source was not signed by the client until August 8, 2023; however, there was evidence of billing prior to the client signed consent to release information form.
Client # 5 was admitted on March 4, 2024 and was active at the time of the inspection. The consent to release information form to the funding source was not signed by the client until March 12, 2024; however, there was evidence of billing prior to the client signed consent to release information form.
This is a repeat citation from the June 1, 2023 annual licensing renewal inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
An In-Service Training was conducted on with Administrative Staff responsible for the completion of consent forms on May 3, 2024. During this in-service, Program Director reviewed the agency's policy as well as licensing standards regarding the timeframes for completion and expectations for consent forms. An emphasis was placed on the emphasis on ensuring the inclusion and completion of consent forms pertinent stakeholders/collateral contacts, including, but not limited to, funding sources.
In addition to this training, Program Director will meet with Administrative Staff on a biweekly basis to review the qualitative and quantitative chart audits. This review will place an emphasis on, but will not be limited to, ensuring the completion and inclusion of consent forms for pertinent stakeholders/collateral contacts. Any issues identified will be brought to the immediate attention of the Program Director and rectified within forty-eight (48) hours.
Finally, on a rotating basis, the Quality Assurance Department will also monitor Program's compliance with the abovementioned standard, which will be completed during their quantitative and qualitative chart audits. Any issues identified will be brought to the immediate attention of the Program Director and rectified within forty-eight (48) hours.
Party (ies) Responsible: Administrative Staff of West Chester House, Program Director, and Quality Assurance Department
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709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of seven client records, the facility failed to follow their policy and procedures related to medication administration and recordkeeping in four of four applicable records reviewed. The facility policy indicates that staff will document on the medication administration record (MAR) the reason a medication was not given.
Client # 2 was admitted on October 4, 2023 and was discharged on January 3, 2024. The MAR did not document the reason medications were not administered on October 12, 2023, October 13, 2023, October 16, 2023, October 17, 2023, and October 18, 2023.
Client # 3 was admitted on December 1, 2023 and was discharged on February 2, 2024. The MAR did not document the reason medications were not administered on December 3, 2023, December 4, 2023, December 5, 2023, December 24, 2023, December 26, 2023, December 28, 2023, and January 4, 2024, through January 8, 2024.
Client # 5 was admitted on March 4, 2024 and was active at the time of the inspection. The MAR did not document the reason medications were not administered on April 11, 2024, April 21, 2024, and April 24, 2024.
Client # 6 was admitted on February 2, 2024 and was active at the time of the inspection. The MAR did not document the reason medications were not administered on April 15, 2024, April 16, 2024, April 17, 2024, April 21, 2024, and April 24, 2024.
This is a repeat citation from the June 1, 2023 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An In-Service Training will be conducted with the Medical Staff of West Chester House on June 3, 2024, to review the agency's policy regarding documentation expectations of medication monitoring and recording. In addition to this, an emphasis will be placed on documenting missed medications and notating the reasons for this missed medication, which includes, but is not limited to, medical refusal, etc.
Program Director will be responsible for ensuring that this workflow expectation/addition is followed during monthly audits of charts, to include the MAR. Program Director will review the MAR's on, at minimum, monthly to ensure the records are complete. Special emphasis will be given to ensuring that missing/blank administrations have a reason noted. Any incomplete MAR's will be brought to the attention of the appropriate party and immediately rectified.
Finally, on a rotating basis, the Quality Assurance Department will also monitor Program's compliance with the abovementioned standard, which will be completed during their quantitative and qualitative medical chart audits. Any issues identified will be brought to the immediate attention of the Program Director and rectified within forty-eight (48) hours.
Party (ies) Responsible: Medical Staff of West Chester House, Program Director, and Quality Assurance Department
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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 policies and procedures, the facility failed to document a psychosocial evaluation, within five days of admission, in three of seven applicable records reviewed.
Client # 2 was admitted on October 4, 2023 and was discharged on January 3, 2024. The record did not contain a psychosocial evaluation.
Client # 3 was admitted on December 1, 2023 and was discharged on February 2, 2024. The psychosocial evaluation was not completed until December 12, 2023.
Client # 4 was admitted on June 27, 2023 and was discharged on August 19, 2023. The record did not contain a psychosocial evaluation.
This is a repeat citation from the June 1, 2023 annual licensing renewal inspection.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
An In-Service Training will be conducted with the Clinical Staff of West Chester House on June 6, 2024, to review the agency's policy regarding Clinical Documentation timeframes and expectations. This in-service training will include, but will not be limited to, completion expectations and timeframes for the completion of psychosocial evaluations/assessments.
Clinical Supervisor will perform biweekly audits of program admissions to ensure completion of psychosocial evaluations/assessments within established timeframes. Any identified deficiencies will be noted and addressed within forty-eight (48) hours. Clinical Supervisor and Program Director will review audits for completeness during biweekly supervision. Program Director will be responsible for ensuring that this workflow expectation/addition is followed, and any identified deficiencies have been completed.
On a rotating basis, the Quality Assurance Department will also monitor Program's compliance with the abovementioned standard, which will be completed during their quantitative and qualitative chart audits. Any issues identified will be brought to the immediate attention of the Program Director and rectified within forty-eight (48) hours.
Party (ies) Responsible: Clinical Staff of West Chester House, Clinical Supervisor, Program Director, and Quality Assurance Department
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709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a preliminary treatment plan within five days of admission, in three of seven applicable records reviewed.
Client # 1 was admitted on August 16, 2023 and was discharged on October 19, 2023. The preliminary treatment plan was not completed until August 30, 2023.
Client # 4 was admitted on June 27, 2023 and was discharged on August 19, 2023. The preliminary treatment plan was not completed until July 29, 2023.
Client # 6 was admitted on February 2, 2024 and was active at the time of the inspection. The preliminary treatment plan was not completed until March 21, 2024.
This is a repeat citation from the June 1, 2023 annual licensing renewal inspection.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
An In-Service Training will be conducted with the Clinical Staff of West Chester House on June 6, 2024, to review the agency's policy regarding Clinical Documentation timeframes and expectations. This in-service training will include, but will not be limited to, completion of preliminary and rehabilitation treatment plans within the timeframes outlined in agency/regulation policies and standards.
Clinical Supervisor will perform biweekly audits of program admissions to ensure completion of preliminary and rehabilitation treatment plans within established timeframes. Any identified deficiencies will be noted and addressed within forty-eight (48) hours. Clinical Supervisor and Program Director will review audits for completeness during biweekly supervision. Program Director will be responsible for ensuring that this workflow expectation/addition is followed, and any identified deficiencies have been completed.
On a rotating basis, the Quality Assurance Department will also monitor Program's compliance with the abovementioned standard, which will be completed during their quantitative and qualitative chart audits. Any issues identified will be brought to the immediate attention of the Program Director and rectified within forty-eight (48) hours.
Party (ies) Responsible: Clinical Staff of West Chester House, Clinical Supervisor, Program Director, and Quality Assurance Department
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709.53(a)(5) LICENSURE Progress 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:
(5) Progress notes.
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Observations
Based on a review of client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed immediately after therapy sessions, in three of seven records reviewed.
Client # 1 was admitted on August 16, 2023 and was discharged on October 19, 2023. The record contained progress notes for individual sessions occurring on August 22, 2023, September 13, 2023, and October 4, 2023, that were not completed until August 31, 2023, September 25, 2023, and October 9, 2023, respectively.
Client # 3 was admitted on December 1, 2023 and was discharged on February 2, 2024. The record contained progress notes for individual sessions occurring on December 4, 2023, December 21, 2023, and January 18, 2024, that were not completed until December 11, 2023, December 28, 2023, and January 25, 2024, respectively.
Client # 6 was admitted on February 2, 2024 and was active at the time of the inspection. The record contained a progress note for an individual session occurring on February 16, 2024, that was not completed until March 20, 2024. Additionally, the record contained a progress note for an individual session occurring on March 18, 2024, that was not completed until April 5, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An In-Service Training will be conducted with the Clinical Staff of West Chester House on June 6, 2024, to review the agency's policy regarding Clinical Documentation timeframes and expectations. This in-service training will include, but will not be limited to, completion of progress notes in accordance with the timeframes outlined in agency/regulation policies and standards.
Clinical Supervisor will perform biweekly audits of clinical charts to ensure completion of progress notes in accordance with the timeframes outlined in agency/regulation policies and standards. Any identified deficiencies will be noted and addressed within 48 hours. Clinical Supervisor and Program Director will review audits for completeness and pay special attention to the timeframes of completion, which will be reviewed during biweekly supervision. Any trends/patterns that indicate note completion outside of the established timeframes will be addressed with that employee in a supervisory session, which will serve as a tool to ensure compliance and address any barriers that might be interfering with his/her ability to meet established timeframes. Program Director will be responsible for ensuring that this workflow expectation/addition is followed, and any identified deficiencies have been completed.
On a rotating basis, the Quality Assurance Department will also monitor Program's compliance with the abovementioned standard, which will be completed during their quantitative and qualitative chart audits. Any issues identified will be brought to the immediate attention of the Program Director and rectified within forty-eight (48) hours.
Party (ies) Responsible: Clinical Staff of West Chester House, Clinical Supervisor, Program Director, and Quality Assurance Department
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709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information, in four of four applicable records reviewed.
Client # 1 was admitted on August 16, 2023 and was discharged on October 19, 2023. There was no documentation of follow-up information in the record.
Client # 2 was admitted on October 4, 2023 and was discharged on January 3, 2024. There was no documentation of follow-up information in the record.
Client # 3 was admitted on December 1, 2023 and was discharged on February 2, 2024. There was no documentation of follow-up information in the record.
Client # 4 was admitted on June 27, 2023 and was discharged on August 19, 2023. There was no documentation of follow-up information in the record.
This is a repeat citation from the June 1, 2023 and June 29, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An In-Service Training will be conducted with the Clinical Staff of West Chester House on June 6, 2024, to review the agency's policy regarding Clinical Documentation timeframes and expectations. This in-service training will include, but will not be limited to, completing and documenting follow-up contact efforts/information. Program Director will ensure that clinical staff are aware of alternative contact information that can be utilized in an effort to complete follow-up contact and outline expectations for documenting this, in the event an individual leaves the program without providing any follow-up or forwarding contact information.
On a biweekly basis, Program Director will review all discharges to ensure documented attempts to follow-up with discharged clients have been completed within the established timeframes. An emphasis will be placed on ensuring that clinical staff appropriately utilize all available contact information and document those efforts on the appropriate follow-up form. Program Director will be responsible for ensuring that this workflow expectation/addition is followed, and any identified deficiencies are addressed within forty-eight (48) hours.
On a rotating basis, the Quality Assurance Department will also monitor Program's compliance with the above-mentioned standard, which will be completed during their quantitative and qualitative chart audits. Any issues identified will be brought to the immediate attention of the Program Director and rectified within forty-eight (48) hours.
Party (ies) Responsible: Clinical Staff of West Chester House, Clinical Supervisor, Program Director, and Quality Assurance Department |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for ensuring a complete client record included information relative to the client's involvement with the project to include follow-up information within 30 days of discharge was submitted and approved by the Department for the June 1, 2023, and June 29, 2022 annual licensing inspections. Ensuring a complete client record containing follow-up information was again found to be a deficiency in the April 26, 2024, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an attempt to prevent reoccurring deficiencies/citations, Program Director has taken the following steps:
- Increased training to responsible staff members to include, but not limited to, an added emphasis on documenting the review and/or utilization of all available contact and follow-up information, especially for those individuals that left treatment without providing program with contact and/or forwarding/follow-up information.
- Increased oversight/monitoring of clinical chart audits/documentation.
- Increased communication regarding the presence and/or absence of any identified deficiencies or missing follow-up contacts.
In addition to the implementation of this plan with the recent additions, Program Director will review the effectiveness of this plan on a quarterly basis and modify action steps, as needed, to ensure compliance with agency and licensing policies, regulations, and standards.
On a rotating basis, the Quality Assurance Department will also monitor Program's compliance with the above-mentioned standard, which will be completed during their quantitative and qualitative chart audits. Any issues identified will be brought to the immediate attention of the Program Director and rectified within forty-eight (48) hours.
Party (ies) Responsible: Clinical Staff of West Chester House, Clinical Supervisor, Program Director, and Quality Assurance Department
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