INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 7 - 10 and March 21 - 23, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cove Forge Behavioral Health System at Williamsburg was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on April 21, 2011.
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Plan of Correction
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records and an interview with the Human Resources Specialist, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment in three of nine personnel records.
The findings include:
Sixteen employee records were reviewed on March 8 - 9, 2011. Nine employees were new hires since the last inspection and required instruction on the use of the fire extinguishers upon staff employment. The facility failed to document that fire extinguisher training was completed upon employment in employee records # 6, 10, and 15.
Employee # 6 was hired on November 22, 2010. The facility did not document the completion of fire extinguisher training until December 6, 2010. Fire extinguisher training was not completed upon employment of employee # 6.
Employee # 10 was hired on June 22, 2010. The facility did not document the completion of fire extinguisher training until July 9, 2010. Fire extinguisher training was not completed upon employment of employee # 10.
Employee # 15 was hired on February 21, 2011. The facility did not document the completion of fire extinguisher training until March 2, 2011. Fire extinguisher training was not completed upon employment of employee # 15.
On March 10, 2011, the human resources specialist was interviewed and confirmed that fire extinguisher training was not completed upon employment in employee records # 6, 10 and 15.
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Plan of Correction
705.10. Fire safety. (c) Fire extinguisher. The residential facility shall: (4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
The residential facility will instruct all staff in the use of fire extinguishers.
The Human Resources Manager met with program managers on March 24th to review the protocol for fire extinguisher training.
The training will be offered twice every Thursday and will be documented and placed in the HR/Staff Development file.
Responsible Staff:
The facility program managers will be responsible for sending their new hires within 7 days of employment.
Human Resources will be monitoring for compliance for three to six months.
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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 and an interview with the Assistant Administrator and the Nurse Unit Manager, the facility failed to ensure that verbal medication orders were signed within 24 hours thereafter by the prescribing physician in seven of sixteen client records.
The findings include:
Twenty client records were reviewed on March 21 - 23, 2011. Sixteen client records were reviewed for verbal medication orders. Per regulation and facility policy, verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician. The facility failed to document that the verbal medication orders were signed within 24 hours thereafter by the prescribing physician in client records # 1, 2, 3, 5, 9, 12 and 14.
Client # 1 was admitted into treatment on March 18, 2011. A verbal order for Tolnaftate 1% cream BID, Tussin DM PRN, Tylenol 325 mg PRN, Zantac PRN and melatonin PRN was accepted and put in writing by the nurse on March 18, 2011. The verbal order was due to be signed by the prescribing physician no later than March 19, 2011. The prescribing physician did not sign the verbal order until March 21, 2011.
Client # 2 was admitted into treatment on March 18, 2011. A verbal order for Subutex 8 mg was accepted and put in writing by the nurse on March 19, 2011. The verbal order was due to be signed by the prescribing physician no later than March 20, 2011. The prescribing physician did not sign the verbal order until March 21, 2011.
Client # 3 was admitted into treatment on September 29, 2010 and discharged on October 4, 2010. A verbal order for Bentyl 20 mg PRN, Phenergan 25 mg PRN and Vistaril 50 mg PRN was accepted and put in writing by the nurse on September 29, 2010. The verbal order was due to be signed by the prescribing physician no later than September 30, 2010. The prescribing physician did not sign the verbal order. Another physician, who did not prescribe this medication, signed the verbal order on September 30, 2010.
Client # 5 was admitted into treatment on January 14, 2011. A verbal order for Bentyl 20 mg PRN, Phenergan 25 mg PRN, Vistaril 50 mg PRN, Trazodone 50 mg QHS and Neurontin 300 mg BID was accepted and put in writing by the nurse on February 11, 2011. The verbal order was due to be signed by the prescribing physician no later than February 12, 2011. The prescribing physician did not sign the verbal order. Another physician, who did not prescribe this medication, signed the verbal order on February 12, 2011.
Client # 9 was admitted into treatment on January 28, 2011 and discharged on March 8, 2011. A verbal order for Tolnaftate 1% cream BID, Tussin DM PRN, Tylenol 325 mg PRN and Zantac PRN was accepted and put in writing by the nurse on January 28, 2011. The verbal order was due to be signed by the prescribing physician no later than January 29, 2011. The prescribing physician did not sign the verbal order until January 30, 2011.
Client # 12 was admitted into treatment on March 1, 2011. A verbal order for Bentyl 20 mg PRN, Phenergan 25 mg PRN, Vistaril 50 mg PRN and Flexeril 10 mg daily was accepted and put in writing by the nurse on March 1, 2011. The verbal order was due to be signed by the prescribing physician no later than March 2, 2011. As of the time of the review on March 21 - 23, 2011, the prescribing physician had not signed the verbal order.
Client # 14 was admitted into treatment on February 27, 2011. A verbal order for Bentyl 20 mg PRN, Phenergan 25 mg PRN and Vistaril 50 mg PRN was accepted and put in writing by the nurse on February 27, 2011. The verbal order was due to be signed by the prescribing physician no later than February 28, 2011. The prescribing physician did not sign the verbal order. Another physician, who did not prescribe this medication, signed the verbal order on March 15, 2011.
The Assistant Administrator and Nurse Unit Manager were interviewed throughout the licensing process and confirmed that these verbal orders were not signed within 24 hours by the prescribing physician.
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Plan of Correction
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
The facility physicians will comply with the facilities verbal order policy which requires signature, date, and time, within 24 hours of a verbal order.
The Assistant Administrator met with the physicians on April 1st , for medical staff meeting and addressed the need for physicians to be compliant with the facility policy regarding verbal orders. Beginning April 1st, the Nursing Department Coordinator will audit 5 charts weekly for 4 weeks to ensure compliance.
Responsible Staff:
Facility Physicians
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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records and an interview with the Clinical Supervisor, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in two of three client records.
The findings include:
Twenty client records were reviewed on March 21 - 23, 2011. Three client records were required to include written notification of a decision to involuntarily terminate the client's treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client records # 17 and 19.
Client # 17 was admitted into treatment on January 28, 2011 and was involuntarily terminated from the project on February 15, 2011. There was no documentation of written notification of involuntary termination to the client, at the time of the licensing inspection, on March 21 - 23, 2011.
Client # 19 was admitted into treatment on December 27, 2010 and was involuntarily terminated from the project on December 24, 2010. There was no documentation of written notification of involuntary termination to the client, at the time of the licensing inspection, on March 21 - 23, 2011.
The Clinical Supervisor was interviewed on March 23, 2011. The Clinical Supervisor confirmed that clients # 17 and 19 had been involuntarily terminated from treatment and had not been provided with written notification.
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Plan of Correction
709.33. Notification of termination. (a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
On March 23, 2011,Adult Program Director conducted a meeting and reviewed the Notification of Termination Form with the Clinical Counselors. The discussion included the purpose and completion of the form.
Responsible Staff:
Adult Program Supervisors will conduct monthly audits of 5 charts for the next 12 months.
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709.63(a)(5) LICENSURE Record of Services
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:
(5) Record of services provided.
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Observations
Based on a review of client records and an interview with the Nurse Unit Manager, the facility failed to document a record of services provided in two of four short-term detoxification client records.
The findings include:
Twenty client records were reviewed on March 21 - 23, 2011. Four client records pertained to the short-term detoxification activity and were required to include a record of services provided to the client. The facility failed to complete a record of services provided in client records # 3 and 4.
Client # 3 was admitted into treatment on September 29, 2010 and discharged on October 4, 2010. Client record # 3 included a blank record of services form. This form includes a place to document counselor meetings, nurse meetings, individual/group sessions, aftercare planning, the duration of service, the date and the name of the provider. Client # 3 participated in one group session on September 30, 2010. This group session was documented in a progress note. This group session was not documented on the record of services.
Client # 4 was admitted into treatment on August 31, 2010 and discharged on September 5, 2010. Client record # 4 included a blank record of services form. This form includes a place to document counselor meetings, nurse meetings, individual/group sessions, aftercare planning, the duration of service, the date and the name of the provider. Client # 4 participated in two individual sessions on September 1 and 3, 2010. These individual sessions were documented in a progress note. These individual sessions were not documented on the record of services.
The Nurse Unit Manager was interviewed on March 23, 2011 and confirmed the record of services provided was not completed in client records # 3 and 4.
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Plan of Correction
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: (5) Record of services provided
Cove Forge will have a complete client record on each individual, including the record of service for every detox client.
Responsible Staff:
The Nursing Department Coordinator met with the detox counselors on April 11, 2011 to re-educate the counselors on the purpose and completion of the record of service form.
As detox counselors meet with the clients for individuals, they will do a progress note and document it on the record of service. As detox counselors facilitate groups, they will do a group note and record it on the record of service.
The Nursing Department Coordinator will do weekly audits of detox charts for three months (April-June).
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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 and an interview with the Clinical Supervisor and Assistant Administrator, the facility failed to document the completion of discharge summaries within seven days of discharge, as per agency policy, in three of five residential treatment and rehabilitation client records.
The findings include:
Twenty client records were reviewed on March 21 - 23, 2011. Eleven client records pertained to the residential treatment activity. Five client records were closed and required the completion of a discharge summary. Per agency policy, discharge summaries will be completed by the counselor within seven days of discharge. The facility failed to document the completion of discharge summaries within seven days of discharge in client records # 16, 18 and 19.
Client # 16 was admitted into treatment on January 31, 2011 and discharged on February 10, 2011. The discharge summary was due to be completed by the counselor no later than February 17, 2011. The discharge summary was not completed by the counselor until March 21, 2011.
Client # 18 was admitted into treatment on October 16, 2010 and discharged on November 20, 2010. The discharge summary was due to be completed by the counselor no later than November 27, 2010. The discharge summary was not completed by the counselor until December 6, 2010.
Client # 19 was admitted into treatment on December 7, 2010 and discharged on December 24, 2010. The discharge summary was due to be completed by the counselor no later than December 31, 2010. The discharge summary was not completed by the counselor until January 11, 2011.
The Assistant Administrator and Clinical Supervisor were interviewed on March 23, 2011 and confirmed these discharge summaries were not completed within seven days of discharge, as required by agency policy.
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Plan of Correction
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
Adult Program Director met with the Clinical Counselors to discuss what the process is for completing and submitting discharge summaries within the 7 day time period. March 23, 2011.
Adult Program Supervisor will conduct monthly audits of 10 charts for the next 12 months.
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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 and an interview with the Clinical Supervisor, the facility failed to document follow-up attempts in two of five residential treatment and rehabilitation client records.
The findings include:
Twenty client records were reviewed on March 21 - 23, 2011. Eleven client records pertained to the residential treatment activity. Five client records were closed and required documentation of a follow-up attempt. Per agency policy, a follow-up will be completed within 28 days after a client is discharged from the program. The facility did not document a follow-up attempt in client records # 17 and 18.
Client # 17 was admitted into treatment on January 28, 2011 and discharged on February 15, 2011. A follow-up attempt was due to be completed no later than March 15, 2011. There was no documentation of a follow-up attempt in client record # 17, at the time of the review on March 21 - 23, 2011.
Client # 18 was admitted into treatment on October 16, 2010 and discharged on November 20, 2010. A follow-up attempt was due to be completed no later than December 18, 2010. There was no documentation of a follow-up attempt in client record # 18, at the time of the review on March 21 - 23, 2011.
The Clinical Supervisor was interviewed on March 23, 2011 at approximately 11:45 AM. The Clinical Supervisor reviewed client records # 17 and 18 and confirmed there was no documentation of any follow-up attempts.
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Plan of Correction
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.
The Case Management Coordinator met with the Case Managers on March 24, 2011 to review the treatment follow-up form and process for completing the form. The aftercare follow-up procedure was revised. Each case manager will complete an aftercare follow-up call on each client per the specifications on the form.
The Case Management Coordinator will monitor 10 random aftercare follow-up sheets per month from each case manager for the first 4 months. Follow-up aftercare sheets/calls will be monitored randomly thereafter.
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