INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 4 through 5, 2012 by staff from the Division of Drug and Alcohol Program Licensure.
Based on the findings of the on-site inspection, Gaudenzia Inc. Broad Street 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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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records and a review of the Staffing Requirements Facility Summary Report, it was determined that the facility failed to ensure that each counselor completed at least 25 clock hours of annual training.
The findings include:
On May 7 - 9, 2012, three employee records requiring documentation of 25 hours of annual training were reviewed. The facility failed to ensure that two of three counselors completed the required 25 hours of training, specifically, employee # 4 and 6.
Employee # 4, a counselor, was hired 12/24/07.
Employee # 4 was required to completed 25 clock hours of annual training.
However, a review of employee # 4's personnel record only contained documentation showing 11 hours of training.
Employee # 6, a counselor, was hired in 1998.
Employee # 6 was required to complete 25 clock hours of annual training.
However, a review of employee # 6's personnel record only contained documentation showing 11 hours of training.
The Human Resource Department confirmed the findings.
This is a repeat citation. The facility was previously cited on 5/13/11.
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Plan of Correction
As of October 11, 2012, Employee #4 has completed 29 clock hours of annual training. As of the same date, Employee #6 has been registared to attend the remainder of his required trainings, in order to be in compliance with the agencies policy regarding 25 clock hours of training.
Moving forward, the Director and Administrators will ensure that all staff complete the required amount of clock training hours per the Licensing standards for the 2012 - 2013 training year. The administrators will audit each staff person's training hours every quarter. The audit will include how many hours each staff person may require, as well as core trainings that may be needed in order to remain in compliance. This information will be charted out by the administrators, whereby allowing the the Director to have a snap shot view of where all of the staff are with regards to their training needs. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on the physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
The findings include:
A physical plant inspection was conducted on September 4, 2012 and September 5, 2012.
The facility failed to keep the facility in good repair at all times.
It was observed that counselor office # 2, located on the third floor, had a broken and missing window pane. The window is large, and had a large piece of plywood and tape covering the window pane.
It was observed that male bedroom # 4, located on the third floor, had stained/water damaged ceiling tiles which were wet and heavy with water. During the inspection, water was observed dripping onto the carpet which was saturated with water. The damaged ceiling tiles and dripping water were at the head of a resident bed. At the time of inspection, this bedroom had one male occupant. This presented a potential hazard of the ceiling tiles falling on the resident's bed. The resident of the bedroom was interviewed and he confirmed that his bedroom had a leak and he notified staff regarding such.
The Facility Director confirmed the findings.
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Plan of Correction
The window in counselor office #2 has been ordered. The window had to be special ordered due to the width, length and bowed shape of the window. Once the window arrives, it will be installed. The instillation will also include a new window frame. The maintenance department will adhere another piece of plywood over the window pane complete with sealed plastic for weather proofing, until the special ordered glass arrives. This will be completed by 11/30/12. The tentative date for the installation of the new glass will be November 30, 2012.
The ceiling tiles in male bedroom #4 have been replaced. It has also been determined that the roof is in need of repair on that particular side of the building. Until the roof is repaired the male occupant has been removed from the room and into another beedroom. Bedroom #4 is currently not being occupied until all repairs have been completed. The roofing company is slated to come out to repair the roof by 11/30/12. Until this date, a temporary patch will be installed. This will be completed by 11/30/12. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on the physical plant inspection, the facility failed to store all trash, garbage, and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents.
The findings include:
A physical plant inspection was conducted on September 4, 2012, at approximately 10:30 AM and again at 2 PM.
Trash was observed piled so high that the lid of the lone dumpster was open and unable to be closed to prevent the penetration of insects and rodents. In addition, the dumpster had trash overflowing and there were cardboard boxes, broken furniture, pipes and other trash littering the ground around the dumpster.
The Program Supervisor confirmed the findings.
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Plan of Correction
The regular trash days for the program are Mondays, Wednesday's and Friday's. As 9/3/12 was a Holiday, the trash was not picked up until the evening of Tuesday, 9/4/12, after 5:00pm. All of the trash, including the broken furniture, pipes, and cardboard boxes were disposed of by the trashmen. Moving forward, the Program Supervisor has obtained the name of the Managing Supervisor within the trash company that Gaudenzia has contracted with. The Program Supervisor will call the company and asked to speak to the Supervisor if the trash is not picked up in a timely fashion.
As this was an excessive amount of trash, due to the facility disposing items no longer in good repair. In the future, when the trash becomes excessive, and it is not the program's scheduled trash removal day, the Program Supervisor will call the trash complany for an extra pick up of the trash, in order to avoid an over abudence of trash accumulating, whereby creating a hazard for the members of the facility. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on the physical plant inspection, the facility failed to ventilate bathrooms by use of an exhaust fan or window.
The findings include:
A physical plant inspection was conducted on September 5, 2012, at approximately 2:30 PM. The exhaust fan in the women's bathroom located in the lounge was not operable at the time of inspection. In addition, the exhaust fan needed to be cleaned as the fan was covered with dust and dirt.
The Facility Director confirmed the findings.
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Plan of Correction
The exhaust fan in the women's bathroom located in the lounge has been replaced with a new exhaust fan.
Moving forward, the house manager's when doing their hourly house runs will check all of the exhaust fans to ensure that they are in good working condition. House Managers will also ensure that the fans are cleaned on a daily basis, as this will be a daily duty on the House Manager's Shift Chore List. |
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, the facility failed to document fire extinguisher training upon staff employment.
The findings include:
On September 4, 2012, two employee records were reviewed to verify that staff were instructed in the use of fire extinguishers upon employment. The facility did not document fire extinguisher training upon employment in one out of two employee records reviewed, # 2.
Employee # 2 was hired 6/18/12, but verification of fire extinguisher training was not documented until 7/18/12.
The Facility Director confirmed the findings.
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Plan of Correction
Moving forward, all new employees to the Broad Street Facility will receive fire extinguisher training upon employment at the facility. The training will be conducted at the facility, by the Program Supervisor. |
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 records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies upon employment.
The findings include:
On September 4, 2012, two employee records were reviewed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies. The facility did not document emergency training upon employment in one out of two employee records reviewed, # 2.
Employee # 2 was hired 6/18/12, but verification of emergency training was not documented until 7/18/12.
The Facility Director confirmed the findings.
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Plan of Correction
All new employees will receive emergency training upon being hired to the facility.
This training will be coducted and documented by the Program Supervisor. |
709.51(b)(3)(i) LICENSURE Medical histories
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records and a review of the facility's policy and procedures manual, the facility failed to document medical histories in accordance with facility policy in four of fourteen records.
The findings include:
On September 4 - 5, 2012, fourteen records requiring documentation of the client's medical history were reviewed. The facility failed to document a medical history according to policy in four of fourteen records reviewed, specifically record # 2, 5, 10, and 14.
The facility policy states the medical history will be documented within 5 days.
Client # 2 was admitted to the program on 5/25/12. The medical history was to be documented within 5 days, 5/30/12. The facility documented the medical history late on 6/28/12.
Client # 5 was admitted to the program on 6/21/12. The medical history was to be documented within 5 days, 6/26/12. The facility documented the medical history late on 7/1/12.
Client # 10 was admitted to the program on 8/10/12. The medical history was to be documented within 5 days, 8/15/12. The facility failed to document a medical history as of 9/5/12.
Client # 14 was admitted to the program on 6/26/12 and discharged on 8/6/12. The medical history was to be documented within 5 days, 7/1/12. The facility failed to document a medical history for the client's duration of treatment.
This is a repeat citation. The facility was previously cited on 5/11/12.
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Plan of Correction
The medical section of the bio-psychsocial histories for the following records, have been updated to reflect a clear and concise medical history of each individual. The charts that the corrections were made on are as follows records: #2,5,10 and 14. Also note that the counselors and social worker will attend a training on how to throughly complete a bio-psychsocial by 11/30/12. The clinical supervisor will be responsible for auditing the charts, especially the bio-psychsocial to ensure throughness and completeness. This audit will occur weekly. |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records and a review of the facility's policy and procedures manual, the facility failed to document a drug or alcohol history in accordance with facility policy in four of fourteen records.
The findings include:
On September 4 - 5, 2012, fourteen records requiring documentation of the client's drug or alcohol history were reviewed. The facility failed to document a drug or alcohol history according to policy in four of fourteen records reviewed, specifically record # 2, 5, 10, and 14.
The facility policy states the drug or alcohol history will be documented within 5 days.
Client # 2 was admitted to the program on 5/25/12. The drug or alcohol history was to be documented within 5 days, 5/30/12. The facility documented the drug or alcohol history late on 6/28/12.
Client # 5 was admitted to the program on 6/21/12. The drug or alcohol history was to be documented within 5 days, 6/26/12. The facility documented the drug or alcohol history late on 7/1/12.
Client # 10 was admitted to the program on 8/10/12. The drug or alcohol history was to be documented within 5 days, 8/15/12. The facility failed to document the drug or alcohol history as of 9/5/12.
Client # 14 was admitted to the program on 6/26/12 and discharged on 8/6/12. The drug or alcohol history was to be documented within 5 days, 7/1/12. The facility failed to document a drug or alcohol history for the client's duration of treatment.
This is a repeat citation. The facility was previously cited on 5/11/12.
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Plan of Correction
The drug and alcohol histories in records # 2,5,10, and 14 have been correct to reflect complete drug and alcohol histories. Moving forward the Clinical Supervisor will be responsible for ensuring that the complete bio-psychsocial,which includes the drug and alcohol history is completed within 5 days per the facility policy. The Clinical Supervisor will ensure to document the date when the history is due, based on the admission date of the individual. The Clinical Supervisor will follow-up 1 day prior to the due date, to ensure that the bio-psychsocial is being completed. On the 5th day the bio-psychsocial will be given to the Clinical Supervisor for approval and signatures. An in-service will be conducted by 11/30/12 for all of the counselors and social worker. This inservice will include information pertaining to how to document a complete and through bio-psychsocial. The inservice will also include information noting that this document is a live document which is on-going for the duration of the individuals length of stay at the facility. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records and a review of the facility's policy and procedures manual, the facility failed to document a personal history in accordance with facility policy in four of fourteen records.
The findings include:
On September 4 - 5, 2012, fourteen records requiring documentation of the client's personal history were reviewed. The facility failed to document a personal history according to policy in four of fourteen records reviewed, specifically record # 2, 5, 10, and 14.
The facility policy states the personal history will be documented within 5 days.
Client # 2 was admitted to the program on 5/25/12. The personal history was to be documented within 5 days, 5/30/12. The facility documented the personal history late on 6/28/12.
Client # 5 was admitted to the program on 6/21/12. The personal history was to be documented within 5 days, 6/26/12. The facility documented the personal history late on 7/1/12.
Client # 10 was admitted to the program on 8/10/12. The personal history was to be documented within 5 days, 8/15/12. The facility failed to document a personal history as of 9/5/12.
Client # 14 was admitted to the program on 6/26/12 and discharged on 8/6/12. The personal history was to be documented within 5 days, 7/1/12. The facility failed to document a personal history for the client's duration of treatment.
This is a repeat citation. The facility was previously cited on 5/11/12.
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Plan of Correction
Moving forward, the counselors, and social worker will receive a in-service on how to throughly complete a bio-psychsocial, which will include the personal history. The inservice will also reitterate that the bio-psychsocial is a living document, to which information as gathered can be added, with a date that the information was obtained.
The charts numbered: 2,5,10,and 14, were completed with a more through personal history. Moving forward, the Clinical Supervisor will check all bio-psychsocial for completeness and throughness, as well as timeleness, which will not exceed 5 days from admission. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and a review of the facility's policy and procedures manual, the facility failed to document a psychosocial evaluation in accordance with facility policy and/or document a psychosocial evaluation that provided an evaluative assessment of the client's problems/needs, assets/strengths,coping mechanisms, and negative factors.
The findings include:
On September 4 - 5, 2012, fourteen client records requiring documentation of a psychosocial evaluation were reviewed. The facility failed to document a psychosocial evaluation according to policy and/or document a psychosocial evaluation that provided an evaluative assessment of the client's problems/needs, assets/strengths,coping mechanisms, and negative factors in eleven of fourteen records reviewed, specifically client records # 2, 3, 4, 5, 6, 7, 8,10, 11, 13 and 14.
The facility policy states that the psychosocial evaluation will be documented within 5 days.
Client # 2 was admitted to the program on 5/25/12. The psychosocial evaluation was to be documented within 5 days, 5/30/12. The facility documented a psychosocial late on 6/28/12. In addition, the psychosocial evaluation did not include an evaluative assessment of the client's problems/needs, assets/strengths,coping mechanisms, and negative factors.
Client # 3 was admitted to the program on 6/15/12. A psychosocial evaluation was documented on 6/18/12; however, it did not include an evaluative assessment of the client's client's problems/needs, assets/strengths, support systems, coping mechanisms, and negative factors.
Client # 4 was admitted to the program on 6/20/12. A psychosocial evaluation was documented on 6/22/12; however, it did not include an evaluative assessment of the client's client's problems/needs, assets/strengths, support systems, coping mechanisms, and negative factors.
Client # 5 was admitted to the program on 6/21/12. The psychosocial evaluation was to be documented within 5 days, 6/26/12. The facility documented a late evaluation on 7/2/12.
Client # 6 was admitted to the program on 7/6/12. A psychosocial evaluation was documented on 7/9/12; however, it did not include an evaluative assessment of the client's client's problems/needs, assets/strengths, support systems, coping mechanisms, and negative factors.
Client # 7 was admitted to the program on 7/17/12. A psychosocial evaluation was documented on 7/18/12; however, it did not include an evaluative assessment of the client's client's problems/needs, assets/strengths, support systems, coping mechanisms, and negative factors.
Client # 8 was admitted to the program on 8/3/12. The psychosocial evaluation was to be documented within 5 days, 8/8/12. The facility The facility failed to document a psychosocial evaluation as of 9/5/12.
Client # 10 was admitted to the program on 8/10/12. The psychosocial evaluation was to be documented within 5 days, 8/15/12. The facility failed to document a psychosocial evaluation as of 9/5/12.
Client # 11 was admitted to the program on 8/15/12. The psychosocial evaluation was to be documented within 5 days, 8/20/12. The facility failed to document a psychosocial evaluation as of 9/5/12.
Client # 13 was admitted to the program on 8/27/12. The psychosocial evaluation was to be documented within 5 days, 9/1/12. The facility failed to document a psychosocial as of 9/5/12.
Client # 14 was admitted to the program on 6/26/12 and discharged on 8/6/12. The psychosocial evaluation was to be documented within 5 days, 7/1/12. The facility failed to document a psychosocial evaluation as of 9/5/12.
The Program Director did not dispute the findings.
This is a repeat citation. The facility was previously cited on 5/11/12.
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Plan of Correction
The counselors and social worker will receive an inservice on the throughness and completeness of a bio-pschsocial by 11/30/12. Records # 2,3,4,5,6,7,8,10,11,13,and 14, bio-psychsocial were re-reviewed by the counselors,and re-submitted, to include completeness of strengths, needs, problems, coping mechanisms, and negativ3e factors. Moving forward, the Clinical Program Supervisor will be responsible for ensuring that the bio-psychsocial is completed, in a timely (5 days upon admission) and throughly. The Clinical Supervisor will ensure compliance by completing weekly chart audits. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records and a review of the facility's policy and procedures manual, the facility failed to document a preliminary treatment plan within the first 5 days in accordance with facility policy in six of eleven records.
The findings include:
On September 4 - 5, 2012, eleven client records requiring documentation of preliminary treatment and rehabilitation plan were reviewed. The facility failed to document preliminary treatment plan per policy in six of eleven client records reviewed, specifically client records # 3, 5, 6, 8, 10, and 14.
The facility's policy states: " Initial individualized treatment plan within first 5 days"
Client # 3 was admitted to the program on 6/15/12. The preliminary treatment plan was due by 6/20/12. The facility documented the preliminary treatment plan late on 7/12/12.
Client # 5 was admitted to the program on 6/21/12. The preliminary treatment plan was due by 6/26/12. The facility documented the preliminary treatment plan late on 7/12/12.
Client # 6 was admitted to the program on 7/6/12. The preliminary treatment plan was due by 7/11/12. The facility documented the preliminary treatment plan late on 7/20/12.
Client # 8 was admitted to the program on 8/3/12. The preliminary treatment plan was due by 8/8/12. The facility failed to document a preliminary treatment plan as of 9/5/12.
Client # 10 was admitted to the program on 8/10/12. The preliminary treatment plan was due by 8/15/12. The facility failed to document a preliminary treatment plan as of 9/5/12.
Client # 14 was admitted to the program on 6/26/12. The preliminary treatment plan was due by 7/1/12. The facility failed to document a preliminary treatment plan as of 9/5/12.
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Plan of Correction
Moving forward, a plimary treatment plan will be documented for all residents within the first 5 days of admission per the facility policy. The plan will be reviewed at the treatment team meeting and submitted for signatures. The Clinical Supervisor will be responsible for ensuring that the plimary treatment plan is completed and submitted in a timely fashion, per the facility policy. |
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 a review of client records and a review of the facility's policy and procedures manual, the facility failed to document an individual treatment plan in accordance with facility policy in seven of fourteen records reviewed.
The findings include:
On September 4 - 5, 2012, fourteen client records requiring documentation of an individual treatment and rehabilitation plan were reviewed. The facility failed to document an individual treatment plan per policy in seven of fourteen client records reviewed, specifically client records # 3, 5, 6, 8, 10, 13 and 14.
The facility's policy states: Individualized treatment plan within first 5 days.
Client # 3 was admitted to the program on 6/15/12. The individual treatment plan was due by 6/22/12. The facility documented the treatment plan late on 7/12/12.
Client # 5 was admitted to the program on 6/21/12. The individual treatment plan was due by 6/28/12. The facility documented the treatment plan late on 7/12/12.
Client # 6 was admitted to the program on 7/6/12. The individual treatment plan was due by 7/13/12. The facility documented the treatment plan late on 7/20/12.
Client # 8 was admitted to the program on 8/3/12. The individual treatment plan was due by 8/10/12. The facility documented the treatment plan late on 9/1/12.
Client # 10 was admitted to the program on 8/10/12. The individual treatment plan was due by 8/15/12. The facility failed to document an individual treatment plan as of 9/5/12.
Client # 13 was admitted to the program on 8/27/12. The individual treatment plan was due by 9/1/12. The facility failed to document an individual treatment plan as of 9/5/12.
Client # 14 was admitted to the program on 6/26/12. The individual treatment plan was due by 7/3/12. The facility failed to document an individual treatment plan as of 9/5/12.
The Program Supervisor confirmed the findings.
This is a repeat citation. The facility was previously cited on 5/11/12.
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Plan of Correction
Moving forward, all residents within the facility will receive a treatment plan within 5 days of admission. The Clinical Supervisor will be responsible for ensuring that the treatment is completed and submitted in a timely fashion. The Director of the program will follow-up to ensue that this policy is followed through to the exact. The Director will ensure compliance by conducting weekly chart audits. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary in one of one client records.
The findings include:
On September 5, 2012, one client record requiring documentation of a discharge summary was reviewed. Within one week after discharge, there should be entered into the client's case record a discharge summary describing the reasons for treatment, services offered, response to treatment and client's status or condition upon discharge. The facility failed to document a discharge summary in one of one client record reviewed, specifically client record # 14.
Client # 14 was admitted to the program on 6/26/12 and discharged on 8/6/12.
There was no documented discharge summary in client record # 14 at the time of review on 9/5/12.
The Program Supervisor confirmed the findings.
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Plan of Correction
The discharge summary for client #14 was completed on 9/6/12. Moving forward, all discharge summaries will be completed within one week of the client's discharge. Moving forward, the counselor will complete the discharge summary within 48 hours of the individuals leaving the facility, it it is an AMA. If the individual is completing the program, the counselor will complete the discharge summary in full prior to the day of dischrge. The Clinical Program Supervisor will be responsible for ensuring that all discharges are completed in a timely fashion. This will be achieved by the clinical supervisor checking the discharge charts within one week of discharge and or completion, to ensure that the discharge summary is in place. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, and an interview with the Program Supervisor, the facility failed to verify that any work done by the client is an integral part of the treatment and rehabilitation plan.
The findings include:
On September 4 - 5, 2012, fourteen client records requiring documentation of work therapy as an integral part of treatment were reviewed. The facility failed to document work therapy on the individual treatment plan or treatment plan update in fourteen of fourteen records reviewed, client record # 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 10, 12, 13 and 14.
Clinical documentation revealed that clients participate in work therapy.
An interview with the Program Supervisor confirmed that clients participate in work outside of cleaning their personal space and that documentation had not been done.
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Plan of Correction
Moving forward all treatment plans and updated treatment plans will have the current work therapy documented. The documentation will include action steps that will afford the client to learn from the designated work therapy goal. Progress on the work therapy goals will be documented during individual sessions with the client. The Clinical Supervisor and Director will ensure that all treatment plans have documented work therapy goals prior to submission to the team for signatures and filing in the client charts. |