INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 5, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site complaint investigation, Gaudenzia, Inc., Broad Street, Inc. 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 investigation and a plan of correction is due on July 16, 2009.
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Plan of Correction
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709.32(c)(1) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication.
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Observations
Based on a review of the client's medication administration records (MARs) on March 5, 2009, the facility failed to document when the client received medications, refused medications, was out of the facility or note other circumstances in accordance with the coding per MAR logs and facility policy.
Findings:
March 11, 2008 had the clients initial as receiving their 9 P.M. medications of Depakote and Seroquel and March 12, 2008 has the client's initial for receiving Seroquel at 9 P.M.. The client was in the hospital from March 10, 2008 - March 17, 2008.
April 11-17, 26, 27 & 30, 2008 documents the client as receiving their Depakote at 9 P.M. but there is no notation to indicate if the client received their Glyburide medication at 9 P.M. as the MARs were left blank. on April 25 there April 11-17, 26 &27, 2008 had no notation for the 9 A.M. Glyburide medication.
April 22, 2008 had no notation regarding the 9 P..M. Seroquel, Depakote and Glyburide medications nor the 9 A.M. glyburide but the ASA dates and return dates did not show the client as being out of the facility.
May 9, 2008 has the staff person's initials for the 9 P.M. Depakote and the 5 P.M. Coumadin medications but not the client's initials to indicate if the medication was received or a note to indicate if refused or other indicated that the client was s no notation for the Depakote or Glyburide. May 17, 2008 has no notation to indicate if the client received the Metformin or Coumadin medications. There was no indication that the client was not at the facility on May 23 - 26, 2008 yet there was no notation for the Depakote and Metformin 9 P.M. medication s nor for the 9 A.M. Metformin. There was no notation for the 9 P.M. Metformin on May 22, 2008.
June 15 -20, 2008, June 22 - 27, 2008, and June 30 ,2008 did not have any notation regarding the 9 P.M. Depakote June 28, 2008 had no notation for the 9 A.M. Metformin.
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Plan of Correction
Plan of Correction:
An In-Service training will be conducted by the Quality Assurance Director to review the policy and procedures of the MAR instrument.
The Director will conduct an in service training will review the accurate documentation of each medication, the coding used to indicate refusal of medications, hospitalizations according to the MAR logs and the agency policy.
The Nurse Manager will conduct audits on the M.A.R.s for all clients daily for two months. The Nurse Manager will report to the Director the findings. If the M.A.R.s is in compliance then Nurse Manager will conduct random checks monthly.
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709.51(a)(1) LICENSURE Criteria for Admission
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(1) Criteria for admission.
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Observations
Based upon a review of the client record on March 5, 2009, the facility failed to follow their policy and procedure relating to criteria for admission and their policy and procedure for determining the level of care. The facility failed to document that the client was appropriate for the level of care that the facility could provide and failed to document a referral to a facility that could have better served the client's needs.
Findings:
Facility policy and procedure titled: "PROCEDURE FOR LEVEL OF CARE DETERMINATIONS", dated April, 2007 stated:
"Based on information gathered from the client, family members, the referral source, the legal
system, mental health professionals, and any other involved parties, the intake interviewer shall determine whether or not the client demonstrates appropriate placement criteria for admission to the program."
"For those clients who do not meet admission criteria a referral will be made to an appropriate level of care."
Facility policy and procedure titled: "General Admission Criteria", dated April, 2007 stated:
"The client will have a recent history of chemical dependency."
The client will not be diagnosed with mental retardation
Admission Criteria (Long-Term / Short-Term Residential Programs)
"The client will be a 18 years or older, male or female."
Admission Criteria (Co-occurring)
"The client will be a 18 years or older, male or female."
"Has a persistent mental illness and chemical dependency"
Admission Criteria (Residential Intensive Non-hospital Treatment R.I.N.T)
In addition to the co-occurring program criteria, the original Broad Street R.I.N.T program had the additional criteria of
Be identified by the County Administrator as a PSH (Pennsylvania State Hospital) inversion client (Pennsylvania)
The client record included a psychiatric assessment from a behavioral hospital with a date of June 16, 2007. The assessment indicated that the client had a history of schizophrenia, was delusional, was paranoid, had poor insight, poor judgement, presented with an affect of being depressed, constricted and angry. The assessment did not indicate substance abuse, nor was the recommendation circled under "Recommended Level of Care" for "Inpatient drug rehab or detox". The assessment circled under "Recommended Level of Care" was for "Acute hospitalization".
The client record included a "NOTICE OF INTENT TO FILE A PETITION FOR EXTENDED INVOLUNTARY TREATMENT AND EXPLANATION OF RIGHTS (304 B OR 305)" dated 11/28/07.
The petition filed was for a 305 (involuntary) commitment for a period of up to 180 days. The petition indicated that the client was guarded, seclusive to self, appeared preoccupied and was observed mumbling to self. The results of the examination and determination of need for continued treatment stated that the client displayed prominent negative symptoms of schizophrenia and was socially withdrawn. In addition it stated that the client was preoccupied, had a circumstantial thought process and poverty of thought content. The treatment needed was indicated to be: extended acute level of care, medications, psychotherapy, and dispositional planning. The opinion of the doctor was "The patient is severely mentally disabled and in need of (continued) treatment."
The client's drug and alcohol history and psychosocial evaluation were not completed until 21 days after the treatment plan was developed and 30 days after the date of admission. The client's date of admission was February 19, 2008. The client's drug history indicated that the client, age 39, had used marijuana from the age of 17 until the age of 25. The drug and alcohol history indicated that the client had used crack from the age of 24 to the age of 26. The client's alcohol history indicated that the client used beer off and on drinking 1-2 a day starting at age 39. The client indicated that his/her longest drug free or dry period during the last three months was three months. In response to the question "Do you have any feelings about why you continue to use drugs and /or alcohol?" the client's response was "I'm not trying to get this anymore." Under the section of the drug and alcohol history where it asks for prior treatment four hospitalization periods are listed; however, one does not identify what the hospitalization was for and the remaining three clearly indicate that it was for mental health.
A letter dated October 1, 2008 in response to complaints filed on behalf of the client following the client's discharge confirmed that the psychiatric diagnosis for the client was not a substance abuse disorder but a Schizoaffective Disorder.
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Plan of Correction
The Director will conduct training on the program's Criteria for Admissions. The Recovery Specialist, Social Worker, Intake Medical staff and the Program Supervisors will attend.
The Recovery Specialist will complete a PCPC assessment within the time period of admission to ensure the client meets the program criteria.
When a client does not meet the admission criteria, the Social Worker and Recovery specialist will complete a referral packet for another level of care.
The Program Supervisor will review and conduct an in-service training with the Counselors the on obtaining the drug and alcohol history within the three days of admission. The policy will be reviewed and a full psychosocial evaluation will be completed.
The Program Supervisor and Social Worker will assist in completing the psychosocial evaluation in the three day period according to the policy.
During the intake process, staff will complete a full Intake Assessment of each client.
The Program Supervisor, Program Director and Psychiatrist will review the AAs packet, the Intake assessment information to determine if the client meets the criteria for the program.
The current criteria will be reviewed by the Corporate Office to ensure the Axis I is Mental Health and Drug and Alcohol history.
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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 upon a review of the client record, the facility failed to document a medical history completed within 5 days of admission in accordance with the facility's policy and procedures in the client record reviewed.
Findings:
The facility failed to document a medical history within five days from the date of admission in accordance with the time frames of their own policy and procedures in client record #1.
Facility policy and procedure titled: "PROCEDURE FOR INTAKE DOCUMENTATION OF HISTORIES" dated April, 2007, stated:
"Data relevant to the client's personal history will be collected and documented in the client's record on specific history forms. Interviews will be conducted by the counselor or nurse responsible for the intake process and shall be completed during the client's first individual counseling session (all documentation must be completed within 24 hours of intake for detox clients)."
"The interview includes the following elements:
data and presenting problem
History - includes personal and family medical data and review of symptoms/illness, an assessment of the client's history and current level of pain
which includes a drug/alcohol history and a personal history; i.e. work, family history, financial history, legal history, education history, sexual history. (which includes trauma/abuse), recreational history/use of leisure time, military history, social history, cultural history and spiritual history."
Facility policy and procedure titled: "PROCEDURE FOR INTAKE DOCUMENTATION OF HISTORIES" dated April, 2007, stated
Psychosocial Assessment: Upon completion of the psychosocial histories, the Counselor will write a narrative psychosocial assessment prior to the next scheduled individual counseling session. The assignment shall include a client description, the referral source, presenting and underlying problems, treatment issues, client coping mechanisms, factors contributing to addiction, client strengths and weaknesses, client motivation, support system, client response during the intake, receptivity to treatment and client attitude, ability to participate in treatment, client motivation, support systems, treatment recommendations, diagnosis and prognosis. Emphasis is placed on the documentation of the client's strengths, abilities and preferences (SNAP). The assessment shall be submitted promptly (not to exceed 3-5 treatment days after the client's admission to the program)
The facility failed to document a medical history within the required timeframe in client record #1.
Client #1 was admitted on 2/19/08 and the medical history was documented as completed on 3/20/08, 30 days following the date of admission.
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Plan of Correction
The Director will meet with the medical staff to review the policy on obtaining medical histories of the client in the time frame of five days.
The Registered Nurses will review the medical assessment history on weekly bases to ensure the five day deadline is upheld according to the policy.
The Nurse Manager will review the medical assessment on all new clients a weekly basis to ensure compliance.
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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 upon a review of one client record, the facility failed to document a drug and alcohol history completed within 5 days of admission in accordance with the facility's policy and procedures in the client record reviewed.
Findings:
The facility failed to document drug and alcohol histories within five days from the date of admission in accordance with the time frames of their own policy and procedures in client record #1.
Facility policy and procedure titled: "PROCEDURE FOR INTAKE DOCUMENTATION OF HISTORIES" dated April , 2007, stated:
"Data relevant to the client's personal history will be collected and documented in the client's record on specific history forms. Interviews will be conducted by the counselor or nurse responsible for the intake process and shall be completed during the client's first individual counseling session (all documentation must be completed within 24 hours of intake for detox clients)."
"The interview includes the following elements:
Identifying data and presenting problem
Medical History - includes personal and family medical data and review of symptoms/illness, an assessment of the client's history and current level of pain.
Bio-Psycho-Social which includes a drug/alcohol history and a personal history; i.e. work, family history, financial history, legal history, education history, sexual history. (which includes trauma/abuse), recreational history/use of leisure time, military history, social history, cultural history and spiritual history."
Facility policy and procedure titled: "PROCEDURE FOR INTAKE DOCUMENTATION OF HISTORIES" dated April, 2007, stated:
Psychosocial Assessment: Upon completion of the psychosocial histories, the Counselor will write a narrative psychosocial assessment prior to the next scheduled individual counseling session. The assignment shall include a client description, the referral source, presenting and underlying problems, treatment issues, client coping mechanisms, factors contributing to addiction, client strengths and weaknesses, client motivation, support system, client response during the intake, receptivity to treatment and client attitude, ability to participate in treatment, client motivation, support systems, treatment recommendations, diagnosis and prognosis. Emphasis is placed on the documentation of the client ' s strengths, abilities and preferences (SNAP). The assessment shall be submitted promptly (not to exceed 3-5 treatment days after the client's admission to the program)
The facility failed to document a drug and alcohol history within the required timeframe in client record #1. Client #1 was admitted on 2/19/08 and the drug and alcohol history was documented as completed on 3/20/08, 30 days following the date of admission.
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Plan of Correction
The Program Supervisor will review with the Counselors the
Importance of obtaining the drug and alcohol history within the three days of admission. An in service training on the policy will be reviewed and a full psychosocial evaluation will be completed within the seventy two hour time frame.
The Program supervisors and Social Worker will ensure that Drug and Alcohol history will be obtained in accordance to the policy.
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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 upon a review of one client record, the facility failed to document a personal history completed within 5 days of admission in accordance with the facility's policy and procedures in one of one client record reviewed.
Findings:
The facility failed to document a personal history within five days from the date of admission in accordance with the time frames of their own policy and procedures in client record #1.
Facility policy and procedure titled: "PROCEDURE FOR INTAKE DOCUMENTATION OF HISTORIES" dated April, 2007, stated:
"Data relevant to the client's personal history will be collected and documented in the client's record on specific history forms. Interviews will be conducted by the counselor or nurse responsible for the intake process and shall be completed during the client's first individual counseling session (all documentation must be completed within 24 hours of intake for detox clients)."
"The interview includes the following elements:
Identifying data and presenting problem
Medical History - includes personal and family medical data and review of symptoms/illness, an assessment of the client's history and current level of pain
Bio-Psycho-Social which includes a drug/alcohol history and a personal history; i.e. work, family history, financial history, legal history, education history, sexual history. (which includes trauma/abuse), recreational history/use of leisure time, military history, social history, cultural history and spiritual history."
Facility policy and procedure titled: "PROCEDURE FOR INTAKE DOCUMENTATION OF HISTORIES" dated April, 2007, stated:
Psychosocial Assessment: Upon completion of the psychosocial histories, the Counselor will write a narrative psychosocial assessment prior to the next scheduled individual counseling session. The assignment shall include a client description, the referral source, presenting and underlying problems, treatment issues, client coping mechanisms, factors contributing to addiction, client strengths and weaknesses, client motivation, support system, client response during the intake, receptivity to treatment and client attitude, ability to participate in treatment, client motivation, support systems, treatment recommendations, diagnosis and prognosis. Emphasis is placed on the documentation of the client's strengths, abilities and preferences (SNAP). The assessment shall be submitted promptly (not to exceed 3-5 treatment days after the client's admission to the program).
The facility failed to document a personal history within the required timeframe in client record #1. Client #1 was admitted on 2/19/08 and the personal history was documented as completed on 3/20/08, 30 days following the date of admission.
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Plan of Correction
The Program Supervisor will conduct an in- service training on obtaining a full personal history of the client within the three day regulatory guidelines of the agency.
The Counselors will be given by the Program Supervisor an allotted time to complete their psychosocial within the three day guideline.
The Social Worker and Program Supervisors will be on stand by to ensure the completion the Psychosocial Evaluations within the three days of admission according to the agency policy.
The Director will conduct weekly audits of the psychosocial histories for three months to ensure documentation and time frames in accordance to the policy.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based upon a review of the client record, the facility failed to document a psychosocial evaluation completed within 5 days of admission in accordance with the facility's policy and procedures in one of one client record reviewed. In addition the psychosocial evaluation did not include a client description, the referral source, presenting and underlying problems, treatment issues, client coping mechanisms, factors contributing to addiction, client strengths and weaknesses, client motivation, support system, client response during the intake, receptivity to treatment and client attitude, ability to participate in treatment, client motivation, support systems, treatment recommendations, diagnosis and prognosis.
Findings:
Facility policy and procedure titled: "PROCEDURE FOR INTAKE DOCUMENTATION OF HISTORIES" dated April, 2007, stated
Psychosocial Assessment: Upon completion of the psychosocial histories, the Counselor will write a narrative psychosocial assessment prior to the next scheduled individual counseling session. The assignment shall include a client description, the referral source, presenting and underlying problems, treatment issues, client coping mechanisms, factors contributing to addiction, client strengths and weaknesses, client motivation, support system, client response during the intake, receptivity to treatment and client attitude, ability to participate in treatment, client motivation, support systems, treatment recommendations, diagnosis and prognosis. Emphasis is placed on the documentation of the client ' s strengths, abilities and preferences (SNAP). The assessment shall be submitted promptly (not to exceed 3-5 treatment days after the client's admission to the program)
The facility failed to document psychosocial evaluations within five days from the date of admission in accordance with the time frames of their own policy and procedures and to include all components as per the facility's policy and procedure. Client #1 was admitted on 2/19/08 and the Psychosocial evaluation was documented as completed on 3/20/08, 30 days following the date of admission.
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Plan of Correction
The Program Supervisor will meet with the Counselors to review the policy and procedures regarding the Psychosocial evaluation being conducted within three days.
The Clinical program Supervisor and Psychiatrist will review the Psychosocial for completeness and quality.
The Social Worker and Program Supervisors will complete the Psychosocial Evaluations within the three days of admission according to the agency policy.
The Program Supervisor will review the Psychosocial during the co-current monthly reviews to ensure updates on data and pertinent history.
The Director will conduct weekly audits to ensure documentation of full medical, personal, drug, alcohol, family, histories and all contributing factors of the client. To ensure the time frames are in accordance to the facility policies.
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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 upon a review of the client record, the facility failed to document an individualized treatment and rehabilitation plan developed with the client in accordance with the facility's policy and procedure in the client record reviewed.
Findings:
Facility policy and procedure titled: "PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN " dated April, 2007, stated:
" An individualized treatment and rehabilitation plan will be developed with each client after the completion of the client's psycho-social evaluation. The counselor will create, with the client, a proposed treatment plan, based on information collected in patient histories, the bio-psycho-social and assessment and the clients [sic] problem list. The plan will be discussed with the client and changes made upon client request as appropriate. "
The facility failed to document an individualized treatment and rehabilitation plan developed with the client within five days from the date of admission and after the completion of the bio-psycho-social histories and psycho-social evaluation in accordance with facility policy and procedures.
Client #1 was admitted on 2/19/08, the client ' s individualized treatment plan was dated 2/28/08 nine days after the date of admission; however, the bio-psycho-social histories and psychosocial evaluation were not completed until 3/30/08.
Client #1 ' s treatment plan, developed on 2/28/08, identified the client's participation in the development of the plan as " Attentive - Active " ; however, the " TREATMENT TEAM/CASE CONSULTATION " dated 2/28/08, documented " Client was not available due to leaving the building @ time of treatment team meeting." In addition, the treatment team case consultation dated 2/28/08, documented the following recommendation: "Client will review & sign treatment plan when he returns back to the program." The client had not signed the treatment plan as of July 11, 2008, the date of his/her discharge.
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Plan of Correction
The Director and Program Supervisor will conduct an in service with the counselors on the Individual treatment plan format and the time frame of five days or less with the SNAP form.
The Program Supervisor will monitor and audit the clinical charts weekly for the next three months to ensure compliance.
During weekly treatment team meetings, the Director will randomly audit the treatment plans of clients within the five day period.
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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 one client record, the facility failed to document a treatment plan update at least every 30 days.
Findings:
The client record was reviewed on March 5, 2009. The facility failed to document a treatment plan update every 30 days. The one documented treatment plan update did not include an assessment of the client ' s progress in relationship to the stated goals of the comprehensive treatment plan.
Client admission date 2/19/08; treatment plan date 2/28/08; treatment plan update documented 3/27/08; discharge date 7/11/08.
Additionally, the facility did not document a treatment plan update to include revised goals to address the client ' s behavior of leaving the facility without permission.
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Plan of Correction
The Program supervisor will conduct an in service training on the policies with the treatment plan updates.
The Program Supervisor will conduct the audit of charts weekly to ensure the updated treatment plans are within the thirty day or less time frame.
The Program Supervisor will complete a treatment plan update schedule monthly with the accurate dates of compliance within the thirty day policy.
The Program Supervisor will ensure the Counselors adhere to the thirty day or less schedule.
The Director will monitor that the treatment plan schedule is followed for compliance.
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709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based upon a review of the client record the facility failed to document that services were provided on a regular and scheduled basis.
Findings:
The record of services lacked documentation to verify that the client was scheduled for and received weekly individual sessions and weekly group sessions as per the comprehensive treatment plan.
The client record lacked progress notes to verify that the client was scheduled for and received weekly individual sessions and weekly group sessions as per the comprehensive treatment plan.
A document contained in the client record labeled "Record of Service" ASA Dates/Returns" documented that the client left and returned to the facility at will for the time frames listed below:
Left the facility 2/27/08 returned 2/29/08, hospitalized from 3/10/08-3/17/08, left 4/18/08 returned 4/21/08, left 4/23/08 returned 4/25/08, left 4/28/08 returned 5/2/08, left 5/3/08 returned 5/4/08, left 5/6/08 returned 5/7/08, left 5/7/08 returned 5/8/08, left 5/8/08 returned on 5/9/08, left 5/10/08 returned 5/10/08, left again on 5/10/08 returned 5/12/08, left 5/15/08 returned 5/16/08, left 5/16/08 returned 5/18/08, left 5/27/08 returned 5/28/08, left 5/31/08 returned 5/31/08, left 5/31/08 returned 6/1/08, left 6/2/08 returned 6/3/08, left 6/11/08 returned 6/12/08, left 6/17/08 returned 6/18/08, left 6/21/08 returned 6/22/08, Left 6/23/08 returned 6/24/08, left 6/25/08 returned 6/26/08, left 7/1/08 returned 7/2/08 left 7/2/08 returned 7/3/08, left 7/5/08 returned 7/7/08, left 7/7/08 returned 7/8/08, left 7/9/08 returned 7/10/08, left 7/10/08 returned 7/11/08. Admitted to hospital on 7/11/08 and discharged from treatment on 7/11/08.
Psychiatric consultation dated 6/9/08 under "Clinical Impressions and Recommendations" stated that the client had been minimally compliant with treatment at the facility. He has an agreement with the Program Director which allows that he sign himself out when he leaves.
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Plan of Correction
The Program Director will conduct an in service training on the documentation Record of Service.
The Program Supervisor will collect the Record of Service with the Individual Progress and Group Notes on a weekly basis from the clinical staff.
The Program Supervisor will review the documentation to ensure the Record of Service is completed and that it will reflect the clinical groups and sessions conducted.
An audit of the Record of Service will be conducted by the Program Supervisor weekly for the next three months.
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709.52(e)(2) LICENSURE Psychiatric supt serv
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(2) Psychiatric.
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Observations
Based on a review of the client record on March 5, 2009, the facility failed to assist the client in obtaining psychiatric services and failed to follow their policy and procedure for making a referral.
Findings:
Facility policy and procedure titled: "CLIENT SUPPORT SERVICES", dated April, 2007 stated:
"The staff of [sic] shall assist the client to obtain support services as needed. Each client record shall maintain documentation of any referral made for ancillary services, via the Contact Sheet or progress note."
The appropriate Counselor or staff person shall document the type of referral including: medical dental, psychiatric/mental health, legal, support group, economic, social services, educational, employment, recreational, spiritual, and/or any other areas.
Facility policy and procedure titled: "POLICY & PROCEDURES FOR REFERRALS
C. PROCEDURE", dated April, 2007 stated:
When making a referral to other services or programs, the staff shall appropriately notify the receiving service or program of the desire for transfer, the physical and mental status of the patient, any unusual circumstances of the case, and the elements of the aftercare plan. This conversation shall take place in person or by telephone and shall be documented in the patient record.
Findings:
Based on a review of one client record, the facility failed to assist the client in obtaining psychiatric supportive services when necessary.
Findings:
A review of the client record contained documentation that indicated that the client requested to be taken for (voluntary 201) psychiatric/mental health services. The facility failed to assist the client in the 201 commitment process and left him at the door without providing any further assistance in the process.
Documentation from the Behavioral Hospital dated March 10, 2008 indicated that the client was found unaccompanied and vomiting in their lobby. The report documented the chief complaint as nausea, vomiting, chills and tremors. The report indicated that the client stated that staff from a CRR brought him there but he did not know the name of the CRR nor why they brought him there. The report indicated the client had a case manager but that the client didn't know the name of the case manager. The client was sent by the behavioral health facility to a medical facility for treatment on March 11, 2008. The client was admitted for treatment with a blood sugar level greater than 1000 and was kept at the medical facility until March 17, 2008.
The Program Director of Gaudenzia Broad Street stated on March 5, 2009 that they were unaware as to where the client was for several days. A letter dated May 6, 2008 in response to a complaint confirmed that Gaudenzia was not aware of the client's transfer to the medical center. A letter dated April 29, 2008 from the Gaudenzia Broad Street acknowledged that it was not until the medical hospital had contacted their facility that they were aware that the client was at the medical hospital.
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Plan of Correction
The following procedure was followed on March 10th 2008.
The medical staff referring clients to services was followed on March 10th 2008.
On March10th 2008 the medical staff completed a written referral form with updated information, medication and current symptoms.
The Program Director will conduct an in service to review of this procedure of referrals.
The Program Supervisor and Nurse Manager will monitor each referral in the community by ensuring that the referral is logged in the information log book daily.
The Corporate office Director of Quality Improvement will develop a policy on hospital admissions from the facility.
The staff person will stay with the client during the assessment of the client until the client is admitted to the hospital.
This will be monitored by the Program Supervisors and Nurse Manager.
The medical staff will keep a copy of each referral on site.
Each incident report that involves a referral, the medical staff will attach a copy to the incident report.
The Nurse Manager will monitor daily for the next four months.
The Program Supervisor will conduct an in service to instruct the staff to obtain a name and position of staff when escorting any client to an appointment.
The medical hospital contacted the medical staff on March11th 2008. This was documented on the communication log book.
The counselor documented on the progress note the admission of the client to the hospital
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