INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on November 28, 2011 to December 1, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kirkbride 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) 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.
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Observations
Based on the review of the staffing requirements facility summary report and personnel records, the facility failed to document that each counselor met the qualifications for the position in three of ten personnel records reviewed.
The findings included:
Sixty-nine personnel records were reviewed on the staffing requirements summary report on November 28, 2011, through December 1, 2011. Ten counselor personnel records were reviewed. The facility failed to document qualifications for counselor in three of ten personnel records, # 6, 7 and 10.
A review of personnel record # 6 revealed no documentation that the counselor had any experience for the position. This was based on a review of the employee's application that listed less than a year of clinical experience with a Bachelor's degree in a related field.
A review of personnel record # 7 revealed the counselor had a degree in Physical Education which is not an approved degree. There was no documentation that the employee had any experience for the position.
A review of personnel record # 10 revealed no documentation that the counselor had any experience for the position based on a review of the employee's application that listed less than a year of clinical experience with a Bachelor's degree in a related field.
The findings were reviewed with the Project Director, Facility Director and Human Resources Director. The findings were not disputed.
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Plan of Correction
1. The Project Director, the Facility Director, the Clinical Director and the Clinical Operations Supervisor have reviewed the qualifications of all Primary Therapists hired within the past year.
2. Two of the three employees have remained in positions as Primary Therapists. A third employee was transferred to a Behavioral-Health Technician position in the Acute Program.
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704.8(c) LICENSURE Full Caseload Assignment
704.8. Qualifications for the position of counselor assistant.
(c) In addition to training, assignment of a full caseload shall be contingent upon the supervisor's positive assessment of the counselor assistant's individual skill level.
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Observations
Based on the review of the staffing requirements facility summary report and personnel records, the facility failed to ensure that a counselor assistant received a positive assessment prior to assigning a full caseload in one of one personnel records reviewed.
The findings included:
Sixty-nine personnel records were reviewed on the staffing requirements summary report on November 28, 2011, through December 1, 2011. One counselor assistant record was reviewed. The facility failed to document a positive assessment for a counselor assistant in one of one personnel record, # 14. At the time of the inspection the counselor assistant was carrying a full caseload.
The findings were reviewed with the Project Director, Facility Director and Human Resources Director. The findings were not disputed.
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Plan of Correction
1. The employee in question was hired as a counselor assistant. However, during the course of the on-site survey, the status of the employee #14 was changed to Primary Therapist.
2. This was conducted in consultation with the on-site surveyors.
3. The Clinical Compliance Director and the Human Resources Director will ensure that all newly hired counselors and counselor assistants have a positive assessment prior to being assigned to a caseload. |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on the review of the staffing requirements facility summary report and personnel records, the facility failed to to ensure that an assessment of training needs was completed by all staff. Documentation was not provided for support staff.
The findings included:
The annual onsite licensing inspection was conducted November 28, 2011, to December 1, 2011 at this facility. As part of the inspection, personnel records were reviewed. Sixty nine personnel records were reviewed that required an assessment of training needs. The facility did not document individual assessments of training needs for the support staff.
The Project Director was interviewed on November 30, 2011. The Project Director confirmed that a needs assessment was not completed on each support staff member for the 2011 training year.
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Plan of Correction
1. The Project Director will ensure that an assessment of training needs -- which are used to create the facility's annual training plan -- are completed among all employees, including support staff.
2. The Project Director will initiate the surveys in March 2012 to ensure sufficient time to complete the assessments as part of the development of the annual training plan.
3. Documentation of the assessments by support staff will be maintained in a binder together with the annual training plan, once completed. The binder will be maintained by the Project 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 the review of the staffing requirements facility summary report and personnel records, the facility failed to provide documentation of individual training plans in 48 out of 69 personnel records.
The findings included:
Sixty-nine personnel records were reviewed on the staffing requirements summary report on November 28, 2011, through December 1, 2011. All personnel records required an individual training plan. The facility did not document individual training plans for the July 1, 2010 - June 30, 2011 training year in 48 records according to the staffing requirements report.
The Project Director was informed of the findings. The findings were not disputed.
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Plan of Correction
1. The facility has decided to link the annual individual training plan completion to the annual evaluations completed for all employees.
2. Beginning in March 2012, the Project Director will ensure that all Individualized Training Plans are completed for all employees by May 31, 2012 in anticipation of the next training year.
3. The facility's training year matches the facility's fiscal year, which is July 1 through June 30.
4. When the Individual Training Plans are completed for the 2012-2013 training year, the Project Director will report the findings to the Executive Committee, internally called Dashboard, for oversight and monitoring.
5. Training plans for the balance of the training year, which concludes June 30, 2012, will be developed for employees without training plans for the current training year. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on the review of the staffing requirements facility summary report and personnel records, the facility failed to document HIV/AIDS and TB/STD training in three of thirty personnel records.
The findings included:
Sixty-nine personnel records were reviewed on the staffing requirements summary report on November 28, 2011, through December 1, 2011. Thirty personnel records required to have documentation of HIV/AIDS and TB/STD training. The facility failed to document HIV/AIDS and TB/STD training in three of thirty personnel records, # 9, 19, and 48.
Personnel record # 9 is a counselor and was hired on November 11, 2002. TB/STD training was due to be completed no later than November 11, 2003. Documentation of this training was not available at the time of the review.
Personnel record # 19 is support staff and was hired on June 24, 2009. TB/STD training was due to be completed no later than June 24, 2011. Documentation of this training was not available at the time of the review.
Personnel record # 48 is support staff and was hired on August 24, 2005. HIV/AIDS training was due to be completed no later than August 24, 2007. Documentation of this training was not available at the time of the review.
The Facility Director was informed of the findings. The findings were not disputed.
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Plan of Correction
1. The Project Director has initiated a review of all personnel files of all employees to ensure compliance with the one- and two-year requirements for the mandatory trainings of HIV/AIDS and TB/STD.
2. From the review will emerge a list of employees, including the three cited in the survey, who still require the mandatory trainings.
3. Arrangements will made to sponsor the mandatory trainings on-site.
4. The Project Director will report the status of employees monthly to the Executive Committee, internally called Dashboard, for oversight and monitoring.
5. On a monthly basis, the Human Resources Department will provide the Project Director with a list of all employees who have not completed the mandatory trainings. The facility on a monthly basis provides the state-mandated trainings through a state-certified trainer who is contracted with the facility. Priority will be given to new employees who are identified as required to complete the trainings within the first year of employment. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of the facility staff schedules, the facility failed to document CPR and first aid training for sufficient number of staff during project operation hours.
The findings included:
The review of the facility staff schedules was conducted November 28, 2011, to December 1, 2011. Based on a review of the facility's staff schedules from October 25, 2011, through November 27, 2011, the facility failed to provide a sufficient number of staff persons trained in Cardio Pulmonary Resuscitation (CPR) and first aid (FA) during the project's hours of operation.
On November 29, 2011, copies of staff CPR and first aid cards and the October and November work schedules provided by the facility were reviewed.
Based on the work schedule and the CPR and first aid cards provided by the facility, the van drivers were not trained in CPR and first aid.
The Facility Director was informed of the findings. The findings were not disputed.
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Plan of Correction
1. The three van drivers completed CPR training and were certified during the on-site inspection.
2. The facility has four in-house trainers who are authorized by the American Red Cross to provide CPR and First Aid training.
3. The expiration dates of the three drivers' CPR certifications has been added to a spreadsheet maintained by the Human Resources Department.
4. The Human Resources Department will create a monthly tickler system to determine the expiration dates of employees' CPR certifications.
5. The monthly list of about-to-expire certifications will be provided monthly to the Staffing Committee for oversight and monitoring. |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on a review of current client census information and clinical staff hours, the facility failed to ensure that the staff to client ratio remained at or below one full time equivalent (FTE) counselor for every eight clients. The ratio was 10:1.
The findings include:
A review of the current client census was conducted November 28, 2011, to December 1, 2011 at this facility. Based on a review of the facility's current client census information and clinical staff hours, the counselor to client ratio was 10:1 which exceeds the required ratio.
The Facility Director was informed of the ratio. The findings were not disputed.
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Plan of Correction
1. At the onset of the survey, the ratio of primary therapist to patients was better than 8:1.
2. However, the credentials of at least one counselor were disputed and the result was a ratio that exceeds the state requirement.
3. The facillity has since replaced staff to ensure compliance with the 8:1 ratio.
4. The ratios are reviewed daily by the Facility Director, the Clinical Director and the Clinical Operations Supervisor to ensure compliance. |
709.123(c)(5) LICENSURE Follow-up information
709.123. Treatment and rehabilitation.
(c) Client records. 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) Follow-up information.
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Observations
Based on a review of client records in the psychiatric hospital, the facility failed to document follow-up information in two of two client records.
The findings included:
Four discharge client records were reviewed on November 28, 2011, to December 1, 2011. Follow-up information was required in two of the four client records. In accordance with the facility's policy, follow-ups are to be done seven days following discharge. The facility failed to document follow up in two of two client records.
Client record # 10 documented an admission date of 9/22/2011 and discharge date of 9/26/2011. The follow up was due by 10/3/2011. There was no documentation of follow-up provided during the review.
Client record # 11 documented an admission date of 10/25/2011 and discharge date of 10/26/2011. The follow up was due by 11/2/2011. There was no documentation of follow-up provided during the review.
The Facility Director was informed that follow ups were not documented. The findings were not disputed.
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Plan of Correction
1. An in-service will be conducted with the inter-disciplinary team working on the Acute Psychiatric Unit.
2. The in-service will be conducted by the Clinical Compliance Director and will include the Attending Physicians, Social Workers and Utilization Management Coordinator.
3. Staff will be trained in completing the seven-day follow for all patients identified in the Acute Psychiatric Program as those with co-occurring disorders. These are patients who have a primary diagnosis on Axis I of a mental disorder and a secondary diagnosis on Axis II of a chemical dependency disorder.
4. An audit of discharged charts will be conducted monthly for four months to determine compliance. The audits will be conducted by the Clinical Operations Supervisor and/or the Clinical Director. Results will be reported monthly to the Executive Committee, internally called Dashboard, for oversight and monitoring. |
705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
Based on a physical plant inspection, the facility failed to maintain lounge areas with furnishings which were in good repair.
The findings were:
The physical plant inspection conducted on November 30, 2011 at 10:30 a.m. revealed that the furniture in the lounge areas had exposed stuffing, were taped to cover tears and were torn.
The Facility Director and Human Resources Director confirmed the need for repairs. The findings were not disputed.
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Plan of Correction
1. The building manager has put in place a daily housekeeping sheet to be used by housekeepers and other staff to document any repairs needed both in patient rooms and on the units.
2. From the housekeeping sheets, the building manager directs the Maintenance Department's administrative assistant to issue a work order for the appropriate Maintenance or Engineering staff to complete.
3. Monthly for four months, the results of the system will be reported to the Safety Committee for oversight and monitoring. The results will be expressed as a percentage of completed work orders: The number of work orders completed each month (numerator) will be divided against the total number of work orders issued during the month (denominator). The target for compliance will be 90 percent each month.
4. Resutls will be reported monthly to the Safety Committee for four months for oversight and monitoring. The monthly results will be compiled and presented to the Safety Committee by the Patient Safety Officer. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility fire drill log, the facility failed to document the evacuation routes used for each fire drill.
The findings included:
The fire drill log was reviewed on November 28, 2011, to December 1, 2011. The log failed to include documentation of the evacuation routes used. Fire drill log entries which failed to include the evacuation routes were conducted on the following dates: 12/23/10, 1/26/11, 4/19/11, 5/15/11, 6/22/11, 7/28/11, 8/24/11, 9/30/11 and 10/24/11.
The findings were reviewed with the Facility Director and were not disputed.
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Plan of Correction
1. The Project Director and the Patient Safety Officer will meet with the Supervisor of the Security Department to revise the sheets used to document monthly fire drills.
2. The Project Director and the Patient Safety Officer will ensure that the evacuation routes are notated on the fire drill documentation sheets.
3. The documentation of fire drills is reported monthly to the Safety Committee for oversight and monitoring. Both the Project Director and the Patient Safety Officer are members of the Safety Committee. |
709.22(d)(1) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(1) Selecting a project director as the person officially responsible to the governing body.
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Observations
Based on a review of the facility's policy and procedure, the facility failed to identify the process for selecting a project director.
The findings included:
The facility policy and procedure manual and the corporate Bylaws were reviewed on November 28, 2011. No process for selection of a project director by the Board was specified in the documentation in the By Laws or in written facility policy.
During a dialogue with the Project Director on November 29, 2011, the Project Director acknowledged that there was no process for selection. The findings were not disputed.
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Plan of Correction
1. Although the facility has a policy outlining the relationship of the Project Director to the Board of Directors, there was no policy outlining how the Project Director is selected by the board.
2. The Project Director and the President/Chief Executive Officer will draft a policy outlining the selection process for the Project Director.
3. The policy will be presented to the Board of Directors for approval at the next quarterly meeting, which is as of yet not scheduled. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on a review of facility documentation, the facility failed to make an annual report available to the public which included a financial statement of income and expenses.
The findings included:
The annual report for the fiscal year July 1, 2010, to June 30, 2011, was requested for review during the onsite inspection of November 28 to December 1, 2011. The annual report did not include a financial statement of income and expenses.
The findings were reviewed with the Project Director and were not disputed.
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Plan of Correction
1. Although the facility's annual report was advertised to the public and although an annual report was provided during the on-site inspection, the annual report did not include income and expenses.
2. The President/Chief Executive Officer will revise the 2010-2011 annual report to include statements concerning income and expenses.
3. Beginning with the 2011-2012 fiscal year, the annual report will include statements concerning income and expenses. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of facility documentation, the facility failed to document an annual audit of financial activities.
The findings included:
The fiscal documents were reviewed during the onsite licensing inspection conducted from November 28 to December 1, 2011. The certified public accountant's dated and signed comments at the beginning of the fiscal document indicated that the document was a review only, not an audit.
During a dialogue with the Project Director on November 29, 2011, the Project Director acknowledged the documentation. The findings were not disputed.
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Plan of Correction
1. The Chief Financial Officer has engaged an auditing firm to complete a financial audit for the 2010-2011 fiscal year. At the time of the survey, the 2010-2011 audit was the audit in question.
2. The auditing process is expected to begin in April 2012 and may last three months to completion.
3. The Board of Directors will ensure that audits for the previous fiscal year are completed within six months of the last day of the previous fiscal year. |
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 the review of the staffing requirements facility summary report and personnel records, the facility failed to document the completion of an annual work performance evaluation in eleven of twenty personnel records.
The findings included:
Sixty-nine personnel records were reviewed on the staffing requirements summary report on November 28, 2011, through December 1, 2011. Twenty personnel records were reviewed. Fifteen personnel records required the completion of an annual work performance evaluation. The facility failed to document a current annual work performance evaluation in personnel records # 3, 4, 6, 8, 9, 11, 12, 13, 16, 18, and 19.
Employee # 3 was hired on September 8, 20003. The last documented work performance evaluation was on June 23, 2010. At the time of the inspection, the facility failed to document a work performance evaluation for 2011.
Employee # 4 was hired on September 3, 2008. The last documented work performance evaluation was on June 29, 2010. At the time of the inspection, the facility failed to document a work performance evaluation for 2011.
Employee # 6 was hired on January 19, 2011. A work performance evaluation was developed; however, there was no documentation that ensured it was completed within a year. The evaluation was not dated.
Employee # 8 was hired on February 20, 2006. The last documented work performance evaluation was on June 29, 2010. At the time of the inspection, the facility failed to document a work performance evaluation for 2011.
Employee # 9 was hired on November 11, 2002. The last documented work performance evaluation was on November 15, 2008. At the time of the inspection, the facility failed to document a work performance evaluation for 2011.
Employee # 11 was hired on October 26, 2008. The last documented work performance evaluation was on June 14, 2010. A performance evaluation was due on June 14, 2011. A work performance evaluation was developed; however, there was no documentation that ensured it was completed within a year. The evaluation was not signed and dated.
Employee # 12 was hired on June 21, 2005. The last documented work performance evaluation was on July 15, 2010. At the time of the inspection, the facility failed to document a work performance evaluation for 2011
Employee # 13 was hired on August 11, 2008. The last documented work performance evaluation was on July 8, 2010. At the time of the inspection, the facility failed to document a work performance evaluation for 2011.
Employee # 16 was hired on June 24, 2009. No documentation was provided of a current work performance evaluation for June 2011.
Employee # 18 was hired on June 24, 2009. The last documented work performance evaluation was on August 28, 2009. At the time of the inspection, the facility failed to document a work performance evaluation for 2011.
Employee # 19 was hired on June 24, 2009. The last documented work performance evaluation was on May 12, 2010. At the time of the inspection, the facility failed to document a work performance evaluation for 2011.
The findings were reviewed with the Facility Director. The findings were not disputed.
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Plan of Correction
1. The facility has developed a system for annual evaluations that assigns a particular department to a particular month for the purpose of annual evaluations.
2. The assignment of each department to a month is undertaken regardless of the actual anniversary dates of employees within that department.
3. The Project Director will ensure that the Human Resources Department on a monthly basis develops a list of employees within the designated department who are in need of an annual evaluation.
4. The Human Resources Department will report back to the Project Director by the end of the month the status of all employees within the designated department who have completed performance evaluations in their personnel files. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in fourteen of twenty-one records.
The findings included:
Twenty-one client records were reviewed on November 28, 2011, to December 1, 2011. The facility failed to ensure that an informed and voluntary consent to release information was obtained in fourteen of twenty-one records, # 1, 2, 3, 4, 5, 6, 7, 8, 11, 12, 16, 18, 20 and 21.
A review of client record # 1 revealed information was released to another entity without a documented consent on 11/27/2011. Client was admitted on 11/28/2011.
A review of client record # 2 revealed information was released to a funding source without a documented consent on 11/27/2011.
A review of client record # 3 revealed information was released to a funding source without a documented consent on 6/21/2011.
A review of client record # 4 revealed information was released to a funding source without a documented consent on 9/25/2011.
A review of client record # 5 revealed information was released to a funding source without a documented consent on 10/24/2011.
A review of client record # 6 revealed information was released to a funding source without a documented consent on 9/26/2011.
A review of client record # 7 revealed information was released to a funding source without a documented consent on 9/26/2011.
A review of client record # 8 revealed information was released to another treatment provider without a documented consent on 11/29/2011.
A review of client record # 16 revealed information was released to another treatment provider without a documented consent on 11/29/2011.
A review of client record # 18 revealed information was released to several treatment providers without a documented consent on 9/12/2011, 9/21/2011 and 9/28/2011.
A review of client record # 20 revealed information was released to a funding source without a documented consent on 5/18/2011.
A review of client record # 16 revealed information was released to another treatment provider without a documented consent on 10/10/2011.
The findings were reviewed with the Project Director, Facility Director, Board president, another Board member and staff on December 1, 2011. The findings were not disputed.
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Plan of Correction
1. An in-service with all Licensed Independent Practitioners, Primary Therapists and Social Workers will be conducted by the Clinical Compliance Director.
2. The requirement that a release of information consent accompany all information relayed verbally or in writing to third parties will be underscored as part of the re-training.
3. The facility will plan an on-site training with a state-certified trainer on confidentiality in the spring.
4. Following the training, chart audits will be conducted for four months to ensure compliance with the requirements. Results will be reported monthly to the Executive Committee, internally called Dashboard, for oversight and monitoring for a period of four months. |
709.28(c)(2) 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. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of client records, the facility failed to ensure that an informed and voluntary consent to release information included the specific information to be disclosed in five of twenty-one records.
The findings included:
Twenty-one client records were reviewed on November 28, 2011, to December 1, 2011. The facility failed to ensure that an informed and voluntary consent to release information included specific information to be disclosed in five of twenty-one records, # 5, 8, 11, 12 and 16.
The findings were reviewed with the Project Director, Facility Director, Board president, another Board member and staff on December 1, 2011. The findings were not disputed.
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Plan of Correction
1. An in-service with all Licensed Independent Practitioners, Primary Therapists and Social Workers will be conducted by the Clinical Compliance Director. 2. The requirement that a release of information consent accompany all information relayed verbally or in writing to third parties will be underscored as part of the re-training. 3. The facility will plan an on-site training with a state-certified trainer on confidentiality in the spring. 4. Following the training, chart audits will be conducted for four months to ensure compliance with the requirements. Results will be reported monthly to the Executive Committee, internally called Dashboard, for oversight and monitoring for a period of four months. The audits will focus on not only the presence of the consent, but also an inspection to ensure that the content permitted for release meets state standards.
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709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on the review of client records, the facility failed to ensure that a copy of a client consent was offered to the client in seven of twenty-one records.
The findings included:
Twenty-one client records were reviewed on November 28, 2011, to December 1, 2011. The facility failed to ensure that a copy of a consent was offered to the client in seven of twenty-one records, # 8, 9, 10, 11, 12, 13 and 16.
The findings were reviewed with the Project Director, Facility Director, Board president, another Board member and staff on December 1, 2011. The findings were not disputed.
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Plan of Correction
1. An in-service with all Licensed Independent Practitioners, Primary Therapists and Social Workers will be conducted by the Clinical Compliance Director. 2. The requirement that a release of information consent accompany all information relayed verbally or in writing to third parties will be underscored as part of the re-training. The re-training also will highlight the section of the release that questions the patient about whether he/she desires a copy of the releasae. 3. The facility will plan an on-site training with a state-certified trainer on confidentiality in the spring. 4. Following the training, chart audits will be conducted for four months to ensure compliance with the requirements. Results will be reported monthly to the Executive Committee, internally called Dashboard, for oversight and monitoring for a period of four months.
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709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records in the detoxification program, the facility failed to document psychosocial evaluation in three of seven client records.
The findings included:
Seven client records were reviewed on November 28, 2011, to December 1, 2011. A completed psychosocial evaluation was required in all client records. The facility failed to document psychosocial evaluations in three of seven client records, # 5, 6 and 7. Records # 5, 6 and 7 provided patient information.
The Facility Director was informed of the lack of clinical impressions. The findings were not disputed.
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Plan of Correction
1. The Clinical Compliance Director and the Clinical Operations Supervisor will revise the narrative psychosocial evaluation format.
2. The revisions will ensure that all information identified by standard is captured.
3. The resvised template will guide clinicians in completing each element of the psychosocial assessment, i.e., a section will be devoted to strengths and another section will be devoted to weaknesses.
4. The revisions will retain, however, the narrative format of the psychosocial assessment.
5. Once the assessment has been revised, the Clinical Compliance Director and the Clinical Operations Supervisor will conduct a training for all staff who complete the psychosocial assessment.
5. Monthly, the Medical Records Department, which audits all medical records of discharged patients, will report to the Executive Committee the completion rate of the psychosocial evaluation. The audits will be reported to the Executive Committee, internally called Dashboard, for oversight and monitoring. |
709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
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Observations
Based on a review of client records in the detoxification program, the facility failed to document discharge summaries in two of five client records.
The findings included:
Seven client records were reviewed on November 28, 2011, to December 1, 2011. A completed discharge summary was required in five client records. The facility failed to document discharge summaries in two of five client records, # 4 and 5.
A review of client record # 4 documented a discharge date of 9/26/2011. The discharge summary was due 10/3/2011. No discharge summary was documented at the time of the review.
A review of client record # 5 documented a discharge date of 11/1/2011. The discharge summary was due 11/8/2011. No discharge summary was documented at the time of the review.
The Facility Director was informed of the absence of the discharge summaries. The findings were not disputed.
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Plan of Correction
1. An in-service will be conducted with the inter-disciplinary team working on the Acute Psychiatric Unit. 2. The in-service will be conducted by the Clinical Compliance Director and will include the Attending Physicians, Social Workers and Utilization Management Coordinator. One focus of the in-service will be the completion of the discharge summaries. 3. Monthly, the Medical Records Department audits the medical records of all discharged patients. Results of the audits, which include completion of the discharge summaries, are part of that audit. Audit results will be reported monthly for four months to the Executive Committee, internally called Dashboard, for oversight and monitoring. |
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 in the drug and alcohol rehabilitation program, the facility failed to document psychosocial evaluations in nine of ten client records.
The findings included:
Ten client records were reviewed on November 28, 2011, to December 1, 2011. A completed psychosocial evaluation was required in all client records. The facility failed to document psychosocial evaluations in nine of ten client records, # 12, 13, 14, 15, 16, 17, 18, 19 and 20.
The psychosocial evaluation in client records # 12, 13, 14, 16, 17, 18 and 19 did not include a composite picture of the client.
The psychosocial evaluation in client records #12, 14, 18 and 19 did not include an evaluation of the client's problems/needs and how they would impact treatment.
The psychosocial evaluation in client records #12, 13, 15, 16, 17, 18 and 19 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluation in client records #12, 13, 15, 16, 17, 18, 19 and 20 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluation in client records #12, 13, 14, 15, 16, 17, 18, 19 and 20 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluation in client records # 12, 13, 14, 15, 16, 17, 18, and 19 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluation in client records #12, 13, 15, 18, 19 and 20 did not include an evaluation of the client 's attitude towards treatment.
The psychosocial evaluation in client records #12, 16, 18, and 19 did not include an evaluation of the counselor's conclusion and impression of the client.
The findings were reviewed with the Facility Director. The findings were not disputed.
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Plan of Correction
1. The Clinical Compliance Director and the Clinical Operations Supervisor will revise the narrative psychosocial evaluation format. 2. The revisions will ensure that all information identified by standard is captured. 3. The resvised template will guide clinicians in completing each element of the psychosocial assessment, i.e., a section will be devoted to strengths and another section will be devoted to weaknesses. 4. The revisions will retain, however, the narrative format of the psychosocial assessment. 5. Once the assessment has been revised, the Clinical Compliance Director and the Clinical Operations Supervisor will conduct a training for all staff who complete the psychosocial assessment. 5. Compliance will be maintained through chart audits conducted by the Medical Records Department with results reviewed by the Executive Committee, internally called Dashboard, for oversight and monitoring. |
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 in the drug and alcohol rehabilitation program, the facility failed to ensure that a progress note was completed after each client contact in ten of ten records.
The findings included:
Ten client records were reviewed on November 28, 2011, to December 1, 2011. Progress notes were required in all client records. The facility failed to document a progress note after each client contact in ten of ten client records, # 12, 13, 14, 15, 16, 17, 18, 19, 20 and 21. Group progress notes were completed for a week time frame, covering several group sessions. The group notes included multiple topics which require a single group note for each session.
The findings were reviewed with the Project Director, Facility Director, Board president, another Board member and staff on December 1, 2011. The findings were acknowledged as a result of a recent change.
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Plan of Correction
1. The clinical leadership of the Chemical Dependency Program will convene a work group of leaders and primary therapists to develop a new template for the documentation of group sessions.
2. The work group will be led by the Clinical Compliance Director.
3. Following recommendations of a new group template that will ensure documentation following each interaction, staff will be trained in the new template.
4. For four months following implementation, the Clinical Operations Supervisor, the Clinical Director and the Clinical Compliance Director will conduct audits of closed charts to determine completeness of the psychosocial assessment. Results will be reported monthly to the Executive Committee, internally called Dashboard, for oversight and monitoring. |