INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring and inspection, and a complaint investigation conducted on August 31, 2023, through September 1, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Northeast Family Health Care LLC, dba Lansdowne Treatment Services 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of eight personnel records, the facility failed to maintain documentation that counselor assistants received direct observation as part of their close supervision, in one applicable record.
Employee # 7 was hired by the facility on October 1, 2022 and transitioned to the position of counselor assistant on June 14, 2023. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The counselor, who was hired as counselor assistant on June 14, 2023, was provided direct observation however this was not documented in the supervision notes. All clinical supervisors have been retrained on how to document direct observations in supervision notes. Supervision notes will be reviewed by ED to ensure compliance. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 35:1.
Employee # 5 has been in the counselor position since May 30, 2023. Employee # 5 was reported to have 40 hours per week devoted to their 36 clients on their caseload.
Employee # 7 has been in the counselor assistant position since June 14, 2023. Employee # 7 was reported to have 40 hours per week devoted to their 39 clients on their caseload.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility ' s work week. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.
The FTE counselor ' s caseload calculation for Employee # 5 is as follows: 40/40 = 1(FTE); 36/1 = 36, which equals to a client/counselor ratio of 36:1.
The FTE counselor ' s caseload calculation for Employee # 7 is as follows: 40/40 = 1(FTE); 39/1 = 39, which equals to a client/counselor ratio of 39:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Site will reapply for waiver for regulation 704.12 until the site can be fully staffed.
Agency is aggressively recruiting to fill counselor positions and will schedule a hiring event in November to recruit additional team members.
ED will monitor census weekly to ensure adequate staffing and post positions accordingly. In the event of a sudden resignation, a waiver will be requested for the gap in coverage until the position can be filled. |
705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential 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 a physical plant inspection on September 1, 2023, the facility failed to ensure that garbage was stored in covered containers that prevent the penetration of insects and rodents as two trash receptacles outside of the rear emergency exit were uncovered.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The dumpsters were uncovered only while the cleaning staff were on site emptying trash. Dumpsters are kept covered at all other times.
ED will ensure all staff are trained in keeping the lids to the dumpsters closed. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection on September 1, 2023, the facility failed to ensure that exits from the nonresidential facility were unobstructed, as a door labeled emergency exit was obstructed by several sandbags on the exterior of the building.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to flooding of the facility, the landlord had placed sandbags to prevent further flooding until construction on the parking lot could be completed. Construction has been completed and the sandbags are removed.
ED will work with landlord on alternative methods in the event of flooding to ensure all entrances are unobstructed. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of eleven client records, the facility failed to obtain an informed and voluntary consent to release information form from the client for the disclosure of information contained in one record reviewed.
Client # 7 was admitted on October 3, 2022 and was discharged on January 25, 2023. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
During the transition from previous ownership to new ownership, there were consents that were documented incorrectly, however all staff were retrained on how to complete documents in the new EMR.
Staff retrained on proper completion of consents to ensure all elements are present
ED and QI monitor compliance through monthly chart audits and retrain staff as needed. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of eleven client records, the facility failed to ensure that consent to release information forms included the purpose of disclosure in one record reviewed.
Client # 2 was admitted on December 20, 2021 and was active at the time of the inspection. The record contained consent to release information forms to three treatment providers signed by the client on March 11, 2023 that were missing the purpose of disclosure.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the transition from previous ownership to new ownership, there were consents that were documented incorrectly, however all staff were retrained on how to complete documents in the new EMR.
All incorrectly completed releases have been expired and made inactive.
ED and QI monitor compliance through monthly chart audits and retrain the staff as necessary. |
709.28 (c) (6) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of eleven client records, the facility failed to ensure that consent to release information forms included the date, event, or condition upon which the consent will expire in one record reviewed.
Client # 2 was admitted on December 20, 2021 and was active at the time of the inspection. The record contained consent to release information forms to three treatment providers signed by the client on March 11, 2023, that were missing the date, event, or condition upon which the consent will expire.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the transition from previous ownership to new ownership, there were consents that were documented incorrectly, however all staff were retrained on how to complete documents in the new EMR
All incorrectly completed releases have been expired and made inactive in the system.
ED and QI monitor compliance through monthly chart audits and retrain staff as necessary. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure that a copy of all informed and voluntary consent to release information forms was offered to the client in four of eleven client records reviewed.
Client # 3 was admitted on January 12, 2023 and was discharged on June 28, 2023. A release of information form to a family member was signed and dated by the client on January 12, 2023; however, there was no documentation that a copy of the form was offered to the client.
Client # 9 was admitted on February 11, 2023 and was active at the time of the inspection. Release of information forms to a family member, the funding source, and a treatment provider were signed and dated by the client on February 10, 2023; however, there was no documentation that a copy of the forms was offered to the client.
Client # 10 was admitted on December 30, 2022 and was discharged on June 27, 2023. A release of information form to the funding source was signed and dated by the client on December 30, 2022; however, there was no documentation that a copy of the form was offered to the client.
Client # 11 was admitted on August 8, 2023 and was active at the time of the inspection. A release of information form to a family member was signed and dated by the client on August 8, 2023; however, there was no documentation that a copy of the form was offered to the client.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Staff retrained on proper completion of consents to ensure all elements are present.
All incorrectly completed releases have been expired and made inactive in the system.
ED and QI monitor compliance through monthly chart audits and retrain staff as necessary |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on a review of eleven client records, the facility failed to ensure that verbal orders were authenticated in writing by a physician or other medical professional within three business days in two records reviewed.
Client # 4 was admitted on July 18, 2023 and was active at the time of the inspection. A verbal order was given on July 27, 2023, but was not authenticated in writing until August 1, 2023.
Client # 6 was admitted on July 17, 2023 and was active at the time of the inspection. A verbal order was given on August 9, 2023, but was not authenticated in writing until August 16, 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Timeframes reviewed with medical staff regarding signing orders.
ED and QI will monitor compliance through chart audits and Regional MD and CMO will address trends in weekly supervision. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of eleven client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one of one applicable record reviewed.
Client # 7 was admitted on October 3, 2022 and was involuntarily discharged on January 25, 2023. There was no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to patient being homeless, a letter was not mailed. In the event this situation arises in the future, letter will be mailed to patient's last known address.
ED will ensure that proper documentation occurs for any administrative discharge from the program prior to the patient leaving the premises and being discharged. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of three months of physician and certified registered nurse practitioner timesheets, the facility failed to provide at least one hour of physician time a week on site for every ten patients in two weeks reviewed.
During the week of April 9, 2023 through April 15, 2023, the patient census was 379. The facility was required to provide at least 37.9 physician hours. There were 31.34 hours documented.
During the week of July 9, 2023 through July 15, 2023, the patient census was 386. The facility was required to provide at least 38.6 physician hours. There were 13 hours documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Medical staff will create coverage plans with medical leadership to ensure adequate medical time.
Regional MD and CMO will address trends in weekly supervision. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on the review three months of physician time sheets, the facility failed to provide the required number of hours onsite for the physician based on the census for seven weeks reviewed. A physician must provide one-third of the required hours, with a certified registered nurse practitioner or physician's assistant providing the remaining two-thirds of the required hours.
During the week of April 9, 2023 through April 15, 2023, the patient census was 379. The physician was required to provide one-third of the 37.9 hours, which equals to 12.6 hours. The physician provided 0 hours.
During the week of June 4, 2023 through June 10, 2023, the patient census was 382. The physician was required to provide one-third of the 38.2 hours, which equals to 12.7 hours. The physician provided 12.5 hours.
During the week of June 11, 2023 through June 17, 2023, the patient census was 390. The physician was required to provide one-third of the 39.0 hours, which equals to 13 hours. The physician provided 12.5 hours.
During the week of June 18, 2023 through June 24, 2023, the patient census was 392. The physician was required to provide one-third of the 39.2 hours, which equals to 13 hours. The physician provided 12.5 hours.
During the week of June 25, 2023 through July 1, 2023, the patient census was 392. The physician was required to provide one-third of the 39.2 hours, which equals to 13 hours. The physician provided 12.5 hours.
During the week of July 2, 2023 through July 8, 2023, the patient census was 387. The physician was required to provide one-third of the 38.7 hours, which equals to 12.9 hours. The physician provided 4 hours.
During the week of July 16, 2023 through July 22, 2023, the patient census was 392. The physician was required to provide one-third of the 39.2 hours, which equals to 13 hours. The physician provided 12.5 hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Medical staff will create coverage plans with medical leadership to ensure adequate medical time.
Regional MD and CMO will address trends in weekly supervision. |
715.7(a)(1-2) LICENSURE Dispensing or administering staffing
(a) A narcotic treatment program shall be staffed as follows:
(1) If it operates an automated dispensing system, one full-time nurse or other person authorized by law to administer or dispense a controlled substance shall be available for every 200 patients.
(2) If it operates a manual or nonautomatic dispensing system, one full-time nurse or other person authorized by law to administer or dispense a controlled substance shall be available for every 150 patients.
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Observations
Based on an observation of the dispensing system on September 1, 2023, the facility failed to ensure that when operating a manual or nonautomatic dispensing system, one full-time nurse or other person authorized by law to administer or dispense a controlled substance shall be available for every 150 patients. The dispensing process was observed between 07:10 A.M. and 07:40 A.M., during which time a manual dispensing system was being utilized. The facility had only one dispensing staff familiar with manual dispensing during that time frame rather than the required three.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the onboarding process for all new nurses, they will be trained on the process of manual dosing and display competence in the process of manual dosing before being permitted to dose patients independently.
ED and Nursing will observe process for competency during the new hire training period. Additional training will be provided annually as a refresher.
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715.7(b) LICENSURE Dispensing or Administering Staffing
(b) Dispensing time shall be prorated for patient census. There shall be sufficient dispensing staff to ensure that all patients are medicated within 15 minutes of arrival at the dispensing area.
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Observations
Based on an observation of the dispensing system on September 1, 2023, the facility failed to ensure that patients were medicated within 15 minutes of arrival. The dispensing process was observed between 07:10 A.M. and 07:40 A.M., and no patient who arrived within that timeframe received their medication within that timeframe. Additionally, the waiting room had approximately 22 patients waiting for the duration of the timeframe.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ED will create new protocol for on-site system shutdown management.
In the event that EMR check-in is down, patients who are present for dosing will be sent to the front desk to manually check in and lists will be provided to nursing. Any patients who are on site for other services (intake, counseling, etc.) will be placed in a separate waiting area to ensure that all patients who need to be checked in for dosing only are served in a timely manner.
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715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of eleven patient records, the facility failed to ensure that emergency contact information was obtained in one record reviewed.
Patient # 6 was admitted on July 17, 2023 and was active at the time of the inspection. The record did not contain emergency contact information.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff have been trained on documenting refusal to provide emergency contact information. Refusal should be documented in the intake note or a non-billable note if the refusal is evident after the intake has been complete.
ED and QI will monitor compliance through monthly chart audits. ED will work with EMR team on a report of patients with missing emergency contacts to ensure proper documentation occurs for all current active patients. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on a review of patient records, the facility failed to ensure that medication orders were complete according to the facility ' s policy and procedures in two of eleven records reviewed. According to the Project ' s policy on medication orders, complete medication orders contain the signature of the physician.
Patient # 4 was admitted on July 18, 2023 and was active at the time of the inspection. A medication order was entered on August 11, 2023, and was not signed by the prescriber until August 16, 2023. A medication order was entered on August 25, 2023, and was not signed by the prescriber until August 30, 2023.
Patient # 6 was admitted on July 17, 2023 and was active at the time of the inspection. A medication order was entered on August 16, 2023, and was not signed by the prescriber until August 22, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Timeframes reviewed with medical staff regarding signing orders.
ED and QI will monitor compliance through chart audits and Regional MD and CMO will address trends in weekly supervision. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy in five of seven applicable records.
Patient # 1 was admitted on February 7, 2023 and was active at the time of the inspection. The patient was required to have at least one hour of individual psychotherapy per month and 1.5 hours of group therapy per month. The patient did not receive any individual therapy during the month of June, and only 15 minutes of individual therapy during July and April. The patient had no group therapy sessions documented during April, May, June, or July 2023.
Patient # 2 was admitted on December 20, 2021 and was discharged on November 2, 2022. The patient was required to have at least one hour of individual psychotherapy per month and 1.5 hours of group therapy per month. The patient did not receive any individual therapy during the month of June, and only 45 minutes of individual therapy during July and May. The patient had no group therapy sessions documented during May, June, or July 2023.
Patient # 3 was admitted on January 12, 2023 and was discharged on June 28, 2023. The patient was required to have at least one hour of individual psychotherapy per month and 1.5 hours of group therapy per month. The patient did not receive any individual therapy during May or March 2023. The patient had no group therapy sessions documented during February, March, April, or May 2023.
Patient # 9 was admitted on February 11, 2023 and was active at the time of the inspection. The patient was required to have at least one hour of individual psychotherapy per month. The patient did not receive any individual therapy during May or July 2023.
Patient # 10 was admitted on December 30, 2022 and was discharged on June 27, 2023. The patient was required to have at least one hour of individual psychotherapy per month. The patient only received 15 minutes of individual therapy during February and April 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff have been retrained on utilizing "No Show for Session" and "Excused Absence" notes for patients who have missed sessions.
ED and clinical supervisors will review compliance weekly and address in supervision. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the receiving narcotic treatment program failed to document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose in one of one applicable record reviewed.
Patient # 9 was transferred to the facility on February 11, 2023 and was active at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff have been trained on uploading emails to charts that confirm transfers are complete
ED and clinical supervisor will ensure that all documentation received in uploaded into the chart through intake chart audits which are completed within 7 days of admission. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 eleven client records, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client within 30 days of admission, per the facility policy, in five of six applicable records reviewed.
Client # 1 was admitted on February 7, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by March 7, 2023; however, it was not completed until May 12, 2023.
Client # 3 was admitted on January 12, 2023 and was discharged on June 28, 2023. The individual treatment and rehabilitation plan was due to be completed by February 12, 2023; however, it was not completed until April 26, 2023.
Client # 4 was admitted on July 18, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by August 18, 2023; however, it was not completed prior to the date of the inspection.
Client # 9 was admitted on February 11, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by March 11, 2023; however, it was not completed until June 15, 2023.
Client # 10 was admitted on December 30, 2022 and was discharged on June 27, 2023. The individual treatment and rehabilitation plan was due to be completed by January 30, 2023; however, it was not completed until March 16, 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Documentation timeframes have been added as a standing supervision item
ED and clinical supervisors review compliance weekly |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of eleven client records, the facility failed to document treatment plan updates within the regulatory timeframe in four of seven applicable records reviewed.
Client # 1 was admitted on February 7, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 12, 2023, and the treatment plan update was due no later than July 12, 2023; however, no treatment plan updates were completed prior to the date of the inspection.
Client # 2 was admitted on December 20, 2021 and was active at the time of the inspection. A treatment plan update was completed on December 29, 2022, and the next treatment plan update was due no later than March 1, 2023; however, the update was not completed until March 16, 2023.
Client # 5 was admitted on March 29, 2022 and was discharged on July 11, 2023. A treatment plan update was completed on December 21, 2022, and the next treatment plan update was due no later than February 21, 2023; however, no additional treatment plan updates were completed prior to the client ' s discharge.
Client # 9 was admitted on February 11, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 15, 2023, and the treatment plan update was due no later than August 15, 2023; however, no treatment plan updates were completed prior to the date of the inspection.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Documentation timeframes have been added as a standing supervision item
ED and clinical supervisors review compliance weekly |
709.93(a)(8) LICENSURE Client records
709.93. 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:
(8) Case consultation notes.
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Observations
Based on a review of eleven client records and the facility ' s policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes every three months for the first year of treatment, per the facility ' s policy, in four of six applicable records reviewed.
Client # 1 was admitted on February 7, 2023 and was active at the time of the inspection. The client record did not contain documentation of case consultation notes.
Client # 3 was admitted on January 12, 2023 and was discharged on June 28, 2023. The client record did not contain documentation of case consultation notes.
Client # 9 was admitted on February 11, 2023 and was active at the time of the inspection. The client record did not contain documentation of case consultation notes.
Client # 10 was admitted on December 30, 2022 and was discharged on June 27, 2023. The client record did not contain documentation of case consultation notes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff have been retrained on required documentation and timeframes.
ED and clinical supervisors review compliance weekly |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information at 30- and 60-days post discharge, per facility policy, in three of three applicable records reviewed.
Client # 3 was admitted on January 12, 2023 and was discharged on June 28, 2023. The client record did not contain documentation of follow-up information.
Client # 7 was admitted on October 3, 2022 and was discharged on January 25, 2023. The client record did not contain documentation of follow-up information.
Client # 8 was admitted on September 16, 2020 and was discharged on May 26, 2023. The client record did not contain documentation of a 30-day follow-up.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Patient #3 was readmitted prior to follow up needing to be completed
Lack of alerts were discovered in March 2023 for the patients that transferred with the program to new ownership which has been rectified so discharge follow ups are occurring.
ED and QI will monitor compliance through monthly chart audits. Clinical supervisors will ensure completion of activities in weekly supervision.
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