INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 19-21, 2013 by staff from the Program Licensure Division. Based on the findings of the on-site inspection, Pocono Mountain Recovery Center, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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 a review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of two records reviewed.
The findings include:
Six personnel records which required documentation of the qualifications for the position of counselor were reviewed on November 21, 2013. The facility failed to provide proper documentation of counselor qualifications in personnel record # 4.
Employee # 4 was hired as a counselor on 6/3/13. This employee is currently a Certified Alcohol and Drug Counselor (CADC) counselor in the state of New Jersey. However, the employee does not have reciprocity into Pennsylvania. This employee's current New Jersey CADC certification does not meet the certification requirements for the position of counselor.
The Project Director confirmed the findings.
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Plan of Correction
Counselor #4 received his Certified Alcohol and Drug Counselor credential from the Pennsylvania Certification Board, date of issue 12/27/2013. This document was received in the US Mail on 1/6/2014, and the correction was achieved. The Clinical Director and the Executive Director will determine that any counselor employed at PMRC will have valid credentialing within the requirements stipulated by the Commonwealth of Pennsylvania. All prospective candidates for the position of counselor will meet the Pennsylvania requirements to be a counselor prior to being hired for that specific position, and these credentials will be corroborated with the Pennsylvania Certification Board or the appropriate licensing agency. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on observation the facility failed to ensure privacy so that counseling sessions could not be seen outside the counseling room in one of the group counseling rooms inspected.
The findings include:
A physical plant inspection was conducted between approximately 1:30 PM - 3:30 PM on November 20, 2013 which included the "T" Building that houses the Men's Resident Rooms, Fireplace Room, Staff Offices, Nurse's Station, and AA Room.
At approximately 3:15 PM., during the walk through in the AA Room, it was observed that the windows to the education/group counseling room lacked any window treatments. Thus enabling a person standing outside at ground level to view counseling sessions.
The Project Director and the Maintenance Supervisor confirmed the findings.
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Plan of Correction
Window treatments/curtains were installed in AA room 11/27/13. The clinical staff members have been instructed to have curtains closed during sessions, and this will be further monitored daily by the Clinical Director or staff designee to assure confidentiality. |
705.10 (a) (1) (ii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on observations, the facility failed to maintain a minimum of two exits on every floor, including the basement, that were separated by a minimum distance of 15 feet.
The findings include:
A physical plant inspection was conducted between approximately 1:30 PM - 3:30 PM on November 20, 2013 which included the "T" Building that houses the Men's Resident Rooms, Fireplace Room, Staff Offices, Nurse's Station, and AA Room.
It was observed that on the 2nd floor of the "T" Building, in the Case Manager's office area, the 2nd egress was a window, however, the window size is 23"x23". In the event of an emergency, the window's dimensions were not large enough to allow proper exiting.
The Project Director and the Maintenance Supervisor confirmed the findings.
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Plan of Correction
The Executive Director, Clinical Director and head of the Maintenance Department conduct weekly walk- throughs of the entire campus to assure safe fire egress exists at all times in every building. The Executive Director and the head of the Maintenance Department have consulted an architect who will recommend the desired egress windows. The installation of these windows will be monitored by both the Executive Director and the head of the Maintenance Department. New egress windows that meet the standards will be installed before 1/15/14. |
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 observation the facility failed to maintain each porch that has over an 18 inch drop with a well-secured railing.
The findings include:
A physical plant inspection was conducted on November 20, 2013 which included the "T" Building that houses the Men's Resident Rooms, Fireplace Room, Staff Offices, Nurse's Station, and AA Room.
During the walk through of the 2nd floor of the "T" Building, it was observed that one of the egress paths that the staff and clients must traverse is a roof to a permanently installed exit ladder. However, this roof is more than 18 inches above the ground and there is no well-secured railing attached to the rooftop.
The Project Director and the Maintenance Supervisor confirmed the findings.
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Plan of Correction
The "T" Building roof egress hand rail system is being drawn up by an architect, and the plans will be submitted to the township with an anticipated approval of 1/31/14 or before. Construction will begin once approval/permits are given by Pocono Township. The head of the Maintenance Department and the Executive Director will oversee this corrective action to ensure implementation. Corrective action to be completed by 2/14/14. |
705.10 (b) (1) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(1) Maintain a minimum of one operable, automatic smoke detector on each floor, including the basement and attic.
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Observations
Based upon observation, the facility failed to maintain a minimum of one operable, automatic, smoke detector in each building, including the basement and the attic.
The findings include:
A physical plant inspection was conducted between approximately 1:30 PM - 3:30 PM on November 20, 2013.
During the physical plant walk through it was noted that the following areas lacked smoke detectors:
-Gym/Maintenance Building (one story without basement).
-Serenity Center (Counselor's Offices) (one story without a basement).
-ADA Building (one story without a basement). This building will be split into two separate client bedrooms. Neither one of the bedrooms were equipped with smoke detectors.
NOTE: This is a new building and is not yet used nor occupied by any clients.
-3rd floor (attic) of the "T" Building. There was only a heat detector on the floor. The facility was utilizing this space for storage of items of an administrative/holiday nature.
-Main Admin Building Basement, There was only a heat detector present. The facility was utilizing this space for extra storage (non-client related).
The Project Director and the Maintenance Supervisor confirmed the findings.
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Plan of Correction
The Gym/Maintenance Building, the Serenity Center, the ADA Building, the 3rd floor attic of the "T" Building and the main administration building basement were all fitted with automatic operable smoke detectors and alarms by AIC Alarm Company on 11/29/13. Each deficiency in the above named and cited buildings has been remediated. The head of the Maintenance Department and the Executive Director were the responsible parties ensuring this corrective action was taken. The head of the Maintenance Department and the designated maintenance person will monitor the smoke detection systems on at least a monthly basis. The alarm systems will also be tested on a monthly basis by the head of the Maintenance Department to assure this problem does not reoccur. |
705.10 (b) (4) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(4) Maintain a manual fire alarm system that is audible throughout the facility in a residential facility where four or more residents reside.
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Observations
Based upon the physical plant inspection, the facility failed to maintain a manual fire alarm system that is audible throughout the facility where four or more residents reside.
The findings include:
A physical plant inspection was conducted between approximately 1:30 PM - 3:30 PM on November 20, 2013.
During the walk through of the ADA Building (one story without basement), it was observed that this building will be split into two separate client bedrooms with two clients in each bedroom. The building was not equipped with a manual fire alarm system.
NOTE: This is a new building and is not yet used nor occupied by any clients.
The Project Director and the Maintenance Supervisor confirmed the findings.
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Plan of Correction
Already completed by AIC Alarm Company 11/29/13.
ADA building has a manual fire alarm system installed by AIC Alarm Company on 11/29/13.
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705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based upon the physical plant inspection, the facility failed to ensure that all fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
The findings include:
A physical plant inspection was conducted between approximately 1:30 PM - 3:30 PM on November 20, 2013.
The Gym area of the Gym/Maintenance Building contained one fire extinguisher that did not have an inspection tag; therefore, it was not possible to determine when or if the fire extinguisher had ever been inspected.
The Project Director and the Maintenance Supervisor confirmed the findings.
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Plan of Correction
The head of the Maintenance Department and the Executive Director had AIC Alarm Company correct the fire extinguisher in the Gym/Maintenance Building that did not have a tag. All fire extinguishers were examined at this time by AIC Alarm Company and reviewed with the head of the Maintenance Department. The Maintenance Department will monitor all extinguishers daily to assure this does not happen again. The head of the Maintenance Department and the Executive Director will be responsible to have all fire extinguishers inspected annually by the Fire Department of Pocono Township. An additional fire extinguisher was added to the kitchen area on 12/16/13 as suggested at the time of inspection,. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel training records, the facility failed to ensure that each employee received the required training in the use of a fire extinguisher.
The findings included:
Eight personnel records were reviewed on November 21, 2013. All eight were required to have documented fire extinguisher training. The facility did not document that the employee had received fire extinguisher training for employees # 1, 2, and 3.
Employee # 1 was hired on June 29, 2013. The training record was reviewed and no documentation was recorded to indicate that the employee had received fire extinguisher training.
Employee # 2 was hired on December 26, 2012. The training record was reviewed and no documentation was recorded to indicate that the employee had received fire extinguisher training.
Employee # 3 was hired on February 1, 2013. The training record was reviewed and no documentation was recorded to indicate that the employee had received fire extinguisher training.
The Project Director and Clinical Supervisor confirmed the findings.
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Plan of Correction
The Executive Director has reviewed the personnel files to assure that all employees have documentation that they have been trained in the use of a fire extinguisher. The three employees in question were trained and documented in their respective files as of 11/22/13. A Quality Assurance panel of the Clinical Director, Executive Director and Administrative Assistant will meet on the first Monday of each month to conduct reviews of personnel files to assure that fire extinguisher training has been conducted and documented in every employee's file. All employees will be retrained on a yearly basis in the use of a fire extinguisher, and this will be documented in their respective personnel files. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel training records, the facility failed to ensure that each employee received the required emergency training.
The findings included:
Eight personnel records were reviewed on November 21, 2013. All eight were required to have documented emergency training. The facility did not document that the employee had received emergency training for employees # 1, 2, and 3.
Employee # 1 was hired on June 29, 2013. The training record was reviewed and no documentation was recorded to indicate that the employee had received emergency trianing.
Employee # 2 was hired on December 26, 2012. The training record was reviewed and no documentation was recorded to indicate that the employee had received emergency training.
Employee # 3 was hired on February 1, 2013. The training record was reviewed and no documentation was recorded to indicate that the employee had received emergency training.
The Project Director and the Clinical Supervisor confirmed the findings.
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Plan of Correction
The Executive Director has reviewed the personnel files to assure that all employees on all shifts are trained to perform assigned tasks during an emergency. This training of Employees #1, 2 and 3 is documented in their personnel records as of 11/22/13. The Quality Assurance panel of the Clinical Director, Executive Director and Administrative Assistant will meet on the first Monday of each month to conduct reviews of personnel files to assure that each employee has received emergency training and that this training is documented in every employee's files. |
709.32(a) LICENSURE Medication Control
709.32. Medication control.
(a) Projects which furnish pharmaceutical services shall comply with all applicable Federal, State and local ordinances, statutes and regulations regarding the storing, compounding, administering or dispensing of medication.
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Observations
Based on a review of administrative documentation and verbal communication with the head nurse, the facility failed to document a quarterly inspection of storage areas in compliance with federal, state, and local regulations.
The findings include:
The facility failed to maintain documentation of quarterly inspection of storage areas which could include:
Disinfectants and drugs for external use are stored separately from oral nad injectable drugs;
Drugs requiring special conditions for storage to insure stability are properly stored;
Outdated drugs are removed;
Administation of controlled drugs are adequately documented;
Controlled substances and other abusable drugs are stored in accordance with federal, state, and program regulations; and
Copies of drug-related regulations are available in apprpriate areas.
The facility's quarterly inspection inventory was reviewed on November 20, 2013, at approximately 3:00 PM. The first documented quarterly inspection was conducted by a contracted pharmacist in the month of October, 2013.
The facility opened on March, 14, 2013 and should have had documented quarterly inspections in June 2013 and September 2013. The facility's head nurse reported that quarterly inspections were completed by the facility's nursing staff, however, there was no documentation provided.
The Project Director and Clinical Supervisor confirmed the findings.
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Plan of Correction
PMRC has contracted with a Pennsylvania licensed pharmacist to conduct quarterly inspections of drug storage areas to assure compliance with federal, state and local regulations. These quarterly inspections will be documented and address all listed areas of concern. The documents will be retained in the nursing office and maintained by the Nurse Manager.
Copies of drug-related regulations are available in the Medical Department at the head nurse's desk area, maintained by the Nurse Manager.
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709.51(b)(1) LICENSURE Disclosure to client
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on the review of eleven client records, the facility failed to provide documentation showing that the criteria for admission, treatment, completion and discharge were disclosed to the client during the intake process in eleven of eleven client records.
The findings include:
Eleven client records were reviewed on November 19 through 21, 2013. Documentation of disclosure were required in all eleven records. The facility did not document disclosure to the client during the intake process in client records #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11.
The Project Director confirmed the findings.
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Plan of Correction
Each client will sign a form that addresses the criteria for admission, treatment, completion and discharge. This will be placed in the client's chart, and the client will be offered a copy of this document. A training session has been conducted for all clinical staff on the criteria for admission, treatment, completion and discharge form. The Quality Assurance staff member will advise the Quality Assurance panel, which meets on the first Monday of each month, that this form is being completed in each chart. Client files will be reviewed during this meeting by the Clinical Director, Case Managers and the Executive Director to assure this documentation is complete. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on the review of client records, the facility failed to document that the treatment plan was developed with the client in six of eleven records.
The findings included:
On November 19 through November 21, 2013, eleven client records were reviewed in which ten of the eleven records were required to include an individual treatment and rehabilitation plan developed with the client. Client records #3, 5, 7, 9, and 11 were missing the dates of when the plan was developed. Client record #1 was not signed by the client. In addition, treatment plans were also generic in nature. Treatment plan templates appear to be used for treatment plan development. Templates used were identical in all files reviewed.
Client record #1 - Client was admitted September 5, 2013 and was discharged on October 5, 2013. The facility failed to document the client's signature on the developed treatment plan.
Client record #3 - Client was admitted June 12, 2013 and was discharged on July 10, 2013. The facility failed to document the date that the treatment plan was developed.
Client record #5 - Client was admitted April 26, 2013 and was discharged on June 5, 2013. The facility failed to document the date that the treatment plan was developed.
Client record #7 - Client was admitted May 29, 2013 and was discharged on June 27, 2013. The facility failed to document the date that the treatment plan was developed.
Client record #9 - Client was admitted October 19, 2013 and was still an active client at the time of the inspection. The facility failed to document the date that the treatment plan was developed.
Client record #11 - Client was admitted October 24, 2013 and was still an active client at the time of the inspection. The facility failed to document the date that the treatment plan was developed.
The Project Director and the Clinical Supervisor confirmed the findings.
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Plan of Correction
Each client will have a master treatment plan. This master treatment plan will reflect the client's participation by being signed by the client. Updated treatment plans will also reflect the client's participation by being signed by the client. It will be noted in the client record with the case notes to indicate client's participation in the treatment plan.
The recently introduced documentation system now provides for both the client and the counselor to sign and date the treatment plan at time of formulation. The presentation of the treatment plan to the client will also be documented in the case record notes and reflect his/her participation.
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709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to document the type of treatment and rehabilitation services on the individual treatment and rehabilitation plan in four of ten client records and the facility failed to document the frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in ten of ten client records.
The findings included:
Eleven client records were reviewed on November 19 through 21, 2013. Ten client records were due to have a completed treatment plan. The type and frequency of services was required in the individual treatment and rehabilitation plan in ten client records.
Four of ten client records failed to include documentation of the type of treatment and rehabilitation services on the individual treatment and rehabilitation plan.
Ten of ten client records failed to include documentation of the frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan.
Client record #1 - Client was admitted September 5, 2013 and was discharged on October 5, 2013. An individual treatment and rehabilitation plan was completed on 9-05-2013, but did not include documentation of the frequency of group therapy and individual therapy.
Client record #3 - Client was admitted June 12, 2013 and was discharged on July 10, 2013. The date of the individual treatment and rehabilitation plan completion is unknown, but did not include documentation of the type of services provided and the frequency of the services provided.
Client record #4 - Client was admitted August 30, 2013 and was discharged on September 4, 2013. An individual treatment and rehabilitation plan was completed on 8-30-2013, but did not include documentation of the type of services provided and the frequency of the services provided.
Client record #5 - Client was admitted April 26, 2013 and was discharged on June 5, 2013. The date of the individual treatment and rehabilitation plan completion is unknown, but did not include documentation of the type of services provided and the frequency of the services provided.
Client record #6 - Client was admitted July 28, 2013 and was discharged on August 6, 2013. An individual treatment and rehabilitation plan was completed on 7-28-2013, but did not include documentation of the frequency of group therapy and individual therapy.
Client record #7 - Client was admitted May 29, 2013 and was discharged on June 27 2013. The date of the individual treatment and rehabilitation plan completion is unknown, but did not include documentation of the type of services provided and the frequency of the services provided.
Client record #8 - Client was admitted September 4, 2013 and was still an active client at the time of the inspection. An individual treatment and rehabilitation plan was completed on 9-04-2013, but did not include documentation of the frequency of group therapy and individual therapy.
Client record #9- Client was admitted October 19, 2013 and was still an active client at the time of the inspection. The date of the individual treatment and rehabilitation plan completion is unknown, but did not include documentation of the frequency of the services provided.
Client record #10 - Client was admitted October 28, 2013 and was still an active client at the time of the inspection. An individual treatment and rehabilitation plan was completed on 10-28-2013, but did not include documentation of the frequency of group therapy and individual therapy.
Client record #11 - Client was admitted October 24, 2013 and was still an active client at the time of the inspection. The date of the individual treatment and rehabilitation plan completion is unknown, but did not include documentation of the frequency of the services provided.
The Project Director and the Clinical Supervisor confirmed the findings.
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Plan of Correction
Each client will have an individualized treatment and rehabilitation plan developed with the client that documents the type and frequency of treatment services within the plan. The Clinical Director will monitor all counselors' documentation to reflect type and frequency of services. |
709.52(a)(3) LICENSURE Support service type
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan in ten of ten client records.
The findings included:
Eleven client records were reviewed on November 19 through 21, 2013. Ten client records were due to have a completed treatment plan. The proposed type of support services was required to be documented in the individual treatment and rehabilitation plan in ten client records. The facility did not document support services in the individual treatment and rehabilitation plan in client records #1, 3, 4, 5, 6, 7, 8, 9, 10, and 11.
The Project Director and the Clinical Supervisor confirmed the findings.
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Plan of Correction
Treatment and rehabilitation proposed support services will be documented in all treatment plans. This will be monitored for compliance by the Clinical Director. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records the facility failed to complete a treatment plan update or document in the treatment plan update the client's progress as it relates to the goals stated on the comprehensive treatment plan.
The findings were:
Eleven client records were reviewed on November 19 through 21, 2013. A treatment plan update was required in nine client records.
The facility failed to complete a treatment plan update in client records #3, 5, and 7.
The facility failed to document in the treatment plan update the client's progress as it relates to the goals stated on the comprehensive treatment plan in client records #1, 3, 5, 6, 7, 8, 9, 10, and 11.
The Project Director and the Clinical Supervisor confirmed the findings.
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Plan of Correction
All treatment plans shall be reviewed with the client at least 15 days from their being formulated. This will be monitored by the Quality Assurance person, who was recently hired, as well as the Clinical Director. Counselors will be notified in advance of the review date by keeping a flow sheet on each case. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of client records, the facility failed to document a complete client record to include documentation of medication records signed by the physician in five of nine records reviewed and documentation of follow-up information in three of seven client records reviewed.
The findings include:
Nine client records which required doctor signed documentation in their medication records were reviewed from November 19-21, 2013. The facility failed to include doctor signed documentation for each medication change/dosage change in client records #1, 3, 4, 5, and 6.
Seven client records which required documentation of follow-up information were reviewed on November 19-21, 2013. The facility failed to include documentation of follow-ups conducted in client records #2, 5, and 6.
Client #1 was admitted September 5, 2013 and discharged October 5, 2013. Client #1 was prescribed medication during their stay at the facility. The medication record was required to include the signature of the doctor when medication was changed and/or medication dosage and frequency was changed. The facility failed to include the doctor's signature in the client's record.
Client #2 was admitted June 6, 2013 and discharged June 7, 2013. Client #2 was required to have follow up contact information documented in their record. The facility failed to include any follow up information in the client's record.
Client #3 was admitted June 12, 2013 and discharged July 10, 2013. Client #3 was prescribed medication during their stay at the facility. The medication record was required to include the signature of the doctor when medication was changed and/or medication dosage and frequency was changed. The facility failed to include the doctor's signature in the client's record.
Client #4 was admitted August 30, 2013 and discharged September 4, 2013. Client #4 was prescribed medication during their stay at the facility. The medication record was required to include the signature of the doctor when medication was changed and/or medication dosage and frequency was changed. The facility failed to include the doctor's signature in the client's record.
Client #5 was admitted April 26, 2013 and discharged June 5, 2013. Client #5 was prescribed medication during their stay at the facility. The medication record was required to include the signature of the doctor when medication was changed and/or medication dosage and frequency was changed. The facility failed to include the doctor's signature in the client's record. In addition, Client #5 was discharged on June 5, 2013 and follow up contact was required to occur after the discharge date. The facility failed to document any follow up information in the client's record.
Client #6 was admitted July 28, 2013 and discharged August 6, 2013. Client #6 was prescribed medication during their stay at the facility. The medication record was required to include the signature of the doctor when medication was changed and/or medication dosage and frequency was changed. The facility failed to include the doctor's signature in the client's record. In addition, Client #6 was discharged on August 6, 2013 and follow up contact was required to occur after the discharge date. The facility failed to document any follow up information in the client's record.
The Project Director and Clinical Supervisor confirmed the findings.
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Plan of Correction
Under the recently adopted record system, all documentation of medication records, records of each medication change/dosage change will be signed by the physician. This will be monitored by the Quality Assurance person and the Clinical Director.
Under the new documentation system, patient follow-up post discharge will be documented in the client's record by the designated staff. This will be monitored by the Quality Assurance person and overseen by the Clinical Director.
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709.53(b) LICENSURE Standardized Forms
709.53. Client records.
(b) The project shall develop and maintain client records on standardized project client record forms.
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Observations
Based on a review of client records, the facility failed to develop and maintain a standardized Consent to Release Information form for the facility's drug and alcohol program.
The findings include:
On November 19-21, 2013, eleven client records were reviewed. The facility failed to develop and maintain a standardized Consent to Release Information Form for the facility's drug and alcohol program in eleven of eleven records reviewed, specifically, client records #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11.
The Project Director and Clinical Supervisor confirmed the findings.
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Plan of Correction
The Consent to Release Information forms have been amended. Two of four consent forms were eliminated. One of the two remaining forms was rephrased to fully remediate the problem on 11/21/13. The clinical and medical staff have been instructed on the use of the two remaining forms. The Clinical Director, Case Managers, Quality Assurance staff member and the Executive Director will meet on the first Monday of each month to audit clients' records, and the Quality Assurance staff member will report on the use of the two standardized consent forms and assure full compliance. |