INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 25 through 27, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Home Nursing Agency 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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709.81(b)(3)(i) LICENSURE Intake and admission
709.81. 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 the review of client records, the facility's policy and procedures, and an interview with the clinical supervisor, the facility failed to document medical histories in three of six partial hospitalization (P.H.) client records.
The findings include:
Six P.H. records were reviewed on April 26, 2011. A medical history was to be completed in six outpatient client records. Records # 12, 14, and 15 did not have documentation of a current medical history.
Facility policy titled Referral, Assessment & Intake Process: Clinical Number: 8020; states:
At the time of admission The scheduler will request individual (sic) to fill out the Family Medical History.
P.H. Client #12, was admitted on March 7, 2011, Client #12 was assessed by the Single County Authority on March 1, 2011, in which a medical history was completed; however there was no documentation that the medical history had been reviewed with the client upon admission to the facility.
P.H. Client #14, was admitted on September 21, 2010 and discharged on November 30, 2010. A medical history form was completed on September 21, 2010 but did not document the client's personal medical history or symptoms and illnesses.
P.H. Client #15, was admitted on December 13, 2010 and discharged on March 21, 2011. A medical history was due by December 13, 2010. As of the date of inspection no medical history had been completed for client #15.
An interview with the clinical supervisor on April 27, 2010 around 12:40pm confirmed the medical history forms were not in the clients' records.
This is a repeat citation.
The facility was cited on April 7, 2010, for failing to document a medical history in outpatient client records.
In response to the citation issued on April 7, 2010, the facility's plan of correction submitted on 5/07/2010 and approved on 5/10/2010, stated the following:
"Individuals entering D&A services will be required to complete the medical history at the time of assessment. The assessment counselor will be responsible to confirm that the medical history is completed and the assigned primary counselor will re-confirm that the completed medical history is present upon development of initial treatment plan.
By June 1, 2010 an admission chart checklist will be conducted on all individuals entering our D&A services by the medical records staff. Monthly random chart audits will be completed and reviewed by the D&A Clinical Services Manager."
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Plan of Correction
Effective May 1, 2011, all individuals who complete an assessment at our facility will be asked to complete a medical history form. This form will be reviewed with the individual by the assessment counselor during the assessment. The department assistant will review the chart for completed medical history form. In cases in which individuals who come to us already having an assessment completed, the primary counselor will meet and review the completed medical history form with the individual and document the review.
Random chart audits comleted monthly by Clincal Services Manager and staff will ensure compliance with this Plan of Correction. |
709.81(b)(6) LICENSURE Intake and admission
709.81. 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 an interview with the clinical supervisor, the facility failed to document a psychosocial assessment in one of six partial hospitalization (P.H.) client records and failed to document a psychosocial assessment that included the client's composite picture, problems and needs that could not be resolved through treatment, assets and strengths, support systems, preferred coping mechanisms, negative factors that could interfere with treatment, attitude towards treatment, and the counselors' conclusions/impressions in four of six (P.H.) client records reviewed.
The findings include:
Six P.H. client records were reviewed on April 26, 2011. Six client records required the completion of psychosocial evaluations. Four client records did not include a clinical assessment of the client; and only included client historical information, specifically records #11, 13, 15, and 16. One of the records did not have documentation of any psychosocial assessment, specifically record # 12.
Client # 11 was admitted on April 11, 2011. The psychosocial evaluation was completed on April 4, 2011 and did not include a clinical assessment of the client's composite picture, assets and strengths, coping mechanisms, and negative factors that could interfere with treatment.
Client # 13 was admitted on January 11, 2011. The psychosocial evaluation was completed on January 11, 2011 and did not include a clinical assessment of the client's problems and needs that could not be resolved through treatment, assets and strengths, coping mechanisms, negative factors that could interfere with treatment, and attitude towards treatment.
Client # 15 was admitted on December 13, 2010 and discharged on March 21, 2011. The psychosocial evaluation was completed on December 13, 2010 and did not include a clinical assessment of the client's assets and strengths, negative factors that could interfere with treatment, and attitude towards treatment.
Client # 16 was admitted on August 24, 2010 and discharged on December 2, 2010. The psychosocial evaluation was completed on August 24, 2010 and did not include a clinical assessment of the client's assets and strengths, support systems, and negative factors that could interfere with treatment.
Client # 12 was admitted on March 7, 2011. As of the date of inspection, there was no documentation of a psychosocial evaluation.
On April 27, 2011 an interview was conducted with the clinical supervisor, which confirmed the psychosocial assessments were non-evaluative or missing.
This is a repeat citation.
The facility was cited on June 26, 2007 and February 27, 2008, for failing to document psychosocial assessments in partial hospitalization client records.
In response to the citation issued on June 26, 2007, the facility's plan of correction submitted on 07/09/2007 and approved on 07/13/2007, stated the following:
"Clinical Services Manager will educate intake/assessment counselors by
July 31, 2007 on how the evaluation should provide a 'composite picture' of the individual in relationship to the collected historical information in order to identify
possible relationships, conditions and causes leading to the client ' s current
situations."
In response to the citation issued on February 27, 2008, the facility's plan of correction submitted on 03/26/2008 and approved on 04/11/2008, stated the following:
"Admissions Supervisor met with staff on 3/13/08 to educate the assessment counselors on a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation. This evaluation will include:
A clear description of the client's presenting and underlying problems; Client needs or problems that can or cannot be resolved through treatment or that might inhibit treatment; Client strengths that can contribute to the resolution of identified problems; the client supports; negative factors that might affect treatment; client ' s coping mechanisms; conclusion regarding the client ' s appearance, behavior and reactions during the intake process; and conclusions regarding the client ' s attitude toward and ability to participate in the recommended treatment.
Admissions staff will continue to monitor charts quarterly and Admissions Team Manager will review audits and discuss needed corrections as they arise."
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Plan of Correction
By 5-31-11, the Clinical Services Manager will conduct an in-service education with all staff on appropriate clinical impressions related to the psychosoical evaluations. Staff will be educated and reminded to ensure psychosocial assessment is present, complete, and specific to the indivdiual's strengths and treatment needs. Staff will be sent to screening and assessment trainings as needed. Random chart audits completed monthly by Clinical Services Manger and staff will ensure compliance with this Plan of Correction. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. 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 the review of client records, the facility's policy and procedures, and an interview with the clinical supervisor, the facility failed to document medical histories in three of ten client records.
The findings include:
Ten outpatient (O.P.) records were reviewed on April 27, 2011. A medical history was to be completed in ten outpatient client records. Records # 2, 4, and 10 did not have documentation of a current medical history.
Facility policy titled Referral, Assessment & Intake Process: Clinical Number: 8020; states:
At the time of admission The scheduler will request individual (sic) to fill out the Family Medical History.
O.P. Client #2, was admitted on March 7, 2011, Client #2 was assessed by the Single County Authority on February 21, 2011, in which a medical history was completed; however there was no documentation that medical history had been reviewed with the client upon admission to the facility.
O.P. Client #4, was admitted on March 18, 2011, Client #4 was assessed by the Single County Authority prior to admission. A medical history was completed; however there was no documentation that medical history had been reviewed with the client upon admission to the facility.
O.P. Client #10, was admitted on September 27, 2010 and discharged on February 28, 2011. A medical history was due by September 27, 2010. As of the date of inspection no medical history had been completed for client #10.
An interview with the clinical supervisor on April 27, 2010 around 12:40 PM confirmed the medical history forms were not in the clients' records.
This is a repeat citation.
The facility was cited on April 7, 2010, for failing to document a medical history in outpatient client records.
In response to the citation issued on April 7, 2010, the facility's plan of correction submitted on 5/01/2010 and approved on 5/10/2010, stated the following:
"Individuals entering D&A services will be required to complete the medical history at the time of assessment. The assessment counselor will be responsible to confirm that the medical history is completed and the assigned primary counselor will re-confirm that the completed medical history is present upon development of initial treatment plan. By June 1, 2010 an admission chart checklist will be conducted on all individuals entering our D&A services by the medical records staff. Monthly random chart audits will be completed and reviewed by the D&A Clinical Services Manager."
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Plan of Correction
Effective May 1, 2011, all individuals who complete an assessment at our facility will be asked to complete a medical history form. This form will be reviewed with the individual by the assessment counselor during the assessment. The department assistant will review the chart for the completed medical history form. In cases in which individuals come to our facility already have a completed assessment, the primary counselor will meet and review the completed medical history form with the individual. Documentation of this review will be present in the chart. Random chart audits completed monthly by the Clinical Services Manager and staff will ensure compliance with the Plan of Correction. |
709.91(b)(6) LICENSURE Intake and admission
709.91. 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 an interview with the clinical supervisor, the facility failed to document a psychosocial evaluation in two of ten outpatient (O.P.) client records and failed to document a psychosocial assessment that included the client's composite picture, problems and needs that could not be resolved through treatment, assests and strengths, support systems, preferred coping mechanisms, negative factors that could interfere with treatment, attitude towards treatment, and the counselors' conclusions/impressions in six of ten O.P. client records reviewed.
The findings include:
Ten O.P. client records were reviewed on April 27, 2011. Ten client records required the completion of psychosocial evaluations. Six client records did not include a clinical assessment of the client; and only included client historical information, specifcally records #1, 3, 5, 6, 7, and 10. Two of the records did not have documentation of any psychosocial assesment, specifcally records # 2 and 8.
Client # 1 was admitted on February 4, 2011. The psychosocial evaluation was completed on February 4, 2011. The psychosocial evaluation did not include a clinical assessment of the client; and only included client historical information.
Client # 3 was admitted on March 7, 2011. The psychosocial evaluation was completed on March 7, 2011. The psychosocial evaluation did not include a clinical assessment of the client; and only included client historical information.
Client #5 was admitted on December 2, 2010. The psychosocial evaluation was completed on August 24, 2010 and did not include a clinical assessment of the client's assests and strengths, support systems, and negative factors that could interfere with treatment.
Client #6 was admitted on November 1, 2010 and discharged on February 4, 2011. The psychosocial evaluation was completed on July 1, 2010 and did not include a clinical assessment of the client's problems and needs that could not be resolved through treatment, assests and strengths, support systems, negative factors that could interfere with treatment, and attitude towards treatment.
Client #7 was admitted on September 30, 2010 and discharged on January 21, 2011. The psychosocial evaluation was completed on September 30, 2010 and did not include a clinical assessment of the client's problems and needs that could not be resolved through treatment, assests and strengths, preferred coping mechanisms, negative factors that could interfere with treatment, attitude towards treatment, and the counselors conclusions or impressions.
Client #10 was admitted on September 27, 2010 and discharged on February 28, 2011. The psychosocial evaluation was completed on September 27, 2010 and did not include a clinical assessment of the client's assests and strengths, support systems, preferred coping mechanisms, negative factors that could interfere with treatment, attitude towards treatment, and the counselors conclusions or impressions.
Client # 2 was admitted on March 7, 2011. As of the date of inspection, there was no documentation of a psychosocial evaluation.
Client # 8 was admitted on November 22, 2010. As of the date of inspection, there was no documentation of a psychosocial evaluation.
On April 27, 2011 an interview was conducted with the clinical supervisor, which confirmed the psychosocial assessments were non-evaluative or missing.
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Plan of Correction
Effective 5-31-11, the Clinical Services Manager will conduct an
in-service education with staff on appropriate clinical impressions related to the psychosocial evaluation. Staff will be educated and reminded to ensure the psychosocial assessment is present, complete and specific to the individual's strengths and treatment needs. Staff will be sent to screening and assessment trainings as needed. Random chart audits will be completed monthly by Clincal Services Manager and staff to ensure compliance with this Plan of Correction. |
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 the review of client records, the facility's policy and procedure manual, and an interview with the clinical supervisor, the facility failed to document case consultations within the 90 day time frame in two of six outpatient (O.P.) client records.
The findings include:
Agency policy titled, Case Consultation Number: 6011 states:
The case consultation form must be completed for each client at least every 90 days.
Ten (O.P.) client records were reviewed on April 27, 2011. Case consultations were required in six O.P. client records. The facility did not document a case consultation within the 90 day time frame in O.P.. client records # 7 and 8.
O.P. Client # 7 was admitted on September 30, 2010 and discharged on January 21, 2011. A case consultation was due to be completed by December 30, 2010. There had not been a case consultation completed as of the date of this inspection.
O.P. Client # 10 was admitted on September 27, 2010 and discharged on February 28, 2011. A case consultation was due to be completed by December 27, 2010. There had not been a case consultation completed as of the date of this inspection.
On April 27, 2011 an interview was conducted with the clinical supervisor and confirmed that case consultations were not documented.
This is a repeat citation:
The facility was cited on April 30, 2009, April 7, 2010 and November 17, 2010 for failing to document case consultations in outpatient client records.
In response to the citation issued on April 30, 2009, the facility's plan of correction submitted on 5/20/2009 and approved on 6/9/2009, stated the following:
"Revise Agency's current policy/procedure for case consultations to include timeframes for completion, signature and filing by June 1, 2009. Educate staff to new process for completing case consultations on June 1, 2009.
Clinical Service Manager to conduct chart audits to ensure compliance with the regulation."
In response to the citation issued on April 7, 2010, the facility's plan of correction submitted on 5/7/2010 and approved on 5/10/2010, stated the following:
"The Clinical Services Manager will ensure that monthly chart audits are completed on individuals in the D&A program to ensure compliance with regulations and that case consultations are documented and present in the chart. At monthly staff meetings, the Clinical Services Manager will review with staff what individuals need the case consultations to be completed."
In response to the citation issued on November 17, 2010, the facility's plan of correction submitted on 1/3/201 and approved on 1/5/2011, stated the following:
"On the D&A listing of individuals in outpatient services, the date of their opening in services will be listed along with the first due date of the case consultation (at 60 days).
This listing will be reviewed at the weekly D&A team meetings to ensure that D&A counselors are aware of when case consultations are due.
The Clinical Services Manager will review the client listing regularly to update case consultation due dates."
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Plan of Correction
As of 5-31-11, staff will have been
re-educated in the process of completing case consultations within 90 days. When individuals are unavailable, cancel or do not show up for appointments, staff will complete the case consult form and document in the chart why the signature is not present. Staff will continue to engage the individual to return to services. Monthly random chart audits will be completed by the Clinical Services Manager and staff to ensure compliance with Case Consultations. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of areas of noncompliance identified during this licensing inspection that had previously been cited, the facility failed to comply with prior plans of correction approved by the Department.
The findings include:
On April 27, 2011 the facility was again found to be out of compliance with the following standards:
1. 709.81(b)(6) Psychosocial evaluations. This area of noncompliance was also identified during the June 26, 2007(plan of correction submitted on 07/09/2007 and approved on 07/13/2007), and February 27, 2008 (plan of correction submitted on 07/09/2007 and approved on 07/13/2007) licensing inspections.
2. 709.91(b)(3)(i) Medical history. This area of noncompliance was also identified during the April 7, 2010 (plan of correction submitted on 5/01/2010 and approved on 5/10/2010) licensing inspection.
3. 709.93(a)(8) Case consultation notes. This area of noncompliance was also identified during the April 30, 2009 (plan of correction submitted on 5/20/2009 and approved on 6/9/2009), April 7, 2010 (plan of correction submitted on 5/7/2010 and approved on 5/10/2010), and November 17, 2010 (plan of correction submitted on 1/3/201 and approved on 1/5/2011) licensing inspections.
4. 704.11(a)(3) A mechanism to collect feedback on completed training. This area of noncompliance was also identified during the February 27, 2008 (plan of correction submitted on 03/26/08 and approved on 04/07/2008) licensing inspections.
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Plan of Correction
The Clinical Services Manager & Facility Director will meet every other month and document in meeting minutes a review of this Plan of Correction for adherence and compliance.
The first meeting will occur on June 2, 2011 at 9:00. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of the agency policy and procedure manual and employee training records, the facility failed to document training evaluation forms during the July 1, 2009 through June 30, 2010 training year.
On April 25, 2010 the policy and procedure manual and seven employee training records were reviewed.
The facility policy titled: Education & Competency: education Program Evaluation Number: 2052.02; states: The participant will complete the evaluation form and return the completed for to the supervisor within two weeks of receiving them.
The facility failed to document the submission of feedback forms after the completion of employee training for the entire 2009-2010 training year.
On April 27, 2011 the director of quality assurance was interviewed and confirmed there were no feedback forms completed for any of the staff training courses.
This is a repeat citation
The facility was cited on February 27, 2008, for failing to document feedback forms for completed employee trainings.
"In response to the citation issued on February 27, 2008, the facility's plan of correction submitted on 03/26/08 and approved on 04/07/2008 , stated the following:
THE CREATOR OF THE INSERVICE PROGRAM WILL:
A. Identify a minimum of two and a maximum of seven instructional objectives for the in-service
program, ensuring that the objectives are appropriate and measurable.
B. Insert the instructional objectives into the Education Program Evaluation (form #680) or
Independent Learning Module/Program (form #678).
C. Provide copies of the completed Evaluation form to the presenter or include it with the
materials given directly to the participants, if the program is an independent learning module.
II. THE PRESENTER WILL:
A. Instruct the participants to complete the evaluation form.
B. Return the completed forms to the creator of the in-service.
III. THE PARTICIPANT WILL:
A. Complete the evaluation form as follows:
Procedure 2025.02
1. Record the date of the program, program title, instructor (if applicable), name
(optional) and discipline/position.
2. Evaluate if each of the instructional objectives were not met, partially met or met.
3. Evaluate each aspect of the presentation/teaching method as very poor, poor, fair,
good, or very good.
4. Complete the Additional Comments section.
B. Return the completed form to the presenter or to the designated person, if the program was an
independent learning module.
IV. THE CREATOR OF THE INSERVICE WILL:
A. Tabulate the data.
1. Instructional Objectives - calculate the percentage that was not met, partially met, or
met for each objective. Calculate an overall percentage of the instructional objectives that
were not met, partially met or met. Items which received no response are ignored in the
calculations.
2. Presentation/Teaching Method - calculate a weighted mean score for each item, using
the following weights: very poor=0, poor=25, fair=50, good=75, and very good=100.
Calculate an overall mean score. Items which received no response are ignored in the
calculations.
3. Additional Comments - record the comments noted by the participants.
B. Create a summary of the data.
C. Distribute the summary to the presenter, as appropriate.
D. Forward a copy of the summary to:
1. If required for All staff - Secretarial Services
2. If program specific - the appropriate program
E. Create additional programs if the instructional objectives were not met.
F. Incorporate the comments and summary information into future programs.
V. SECRETARIAL SERVICES OR THE PROGRAM SECRETARY WILL:
A. File In-service Program Description and attendance list in the In-service Manual.
Procedure 2025.02
B. Maintain in-service records indefinitely for topics related to Infection Control and Safety and
for at least 5 (five) years for all other topics, unless longer time frames are required by specific
program, regulatory or accreditation guidelines.
Currently in place; 3/26/08."
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Plan of Correction
The Clinial Servicess Manager will follow Home Nursing Agency procedure #6001, Education Plan for Staff, that is applicable to the D&A program specifically. This procedure outlines when evaluation forms must be completed by staff and what information must be documented on these forms (the forms have been created to include all necesary information via regulation). The Clinical Services Manager will track all completed in-services by staff and monitor completed of necessary forms for feedback. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the policy and procedure manual and an interview with the Director of Quality Assurance, the facility failed to document an annual evaluation of the overall training plan which included a completion date.
The findings include:
On April 25, 2011 the policy and procedure manual was reviewed.
The agency policy titled, The facility policy titled: Education & Competency: education Program Evaluation Number: 2052.02; states:
Evaluate the plan:
1. Review, within one week of the program, the evaluation forms of the inservice and continuing education programs.
2. Determine, at least two months prior to the end of the fiscal year, if each staff member attend the required programs and met the education requirements.
3. compare the training needs identified on the next year's survey with the plan.
Per the agency policy and procedure manual, an annual evaluation of the training plan will be completed by May 31. As of the date of inspection, there was no documentation of an evaluation of the 2009-2010 training plan.
This was discussed with the Director of Quality Assurance on April 26, 2010. The Director of Quality Assurance confirmed that an annual evaluation of the overall training plan had not been documented.
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Plan of Correction
The Clinical Servcies Manager and the Facility Director will review Home Nursing Agency's procedure #6001, Education Plan for Staff during bi-monthly meetings and document in minutes. This procedure is specific to education in D&A services. The first meeting is 6-2-11.
This procedure outlines according to regulation what must be done for the program in regard to an education development plan for staff in D&A services. Reviewing this Education Procedure at least 6 times per year will enable us to ensure compliance. We will also document how many education hours each D&A staff has during the meeting.
For the years, 2009-2010 and
2010-2011, an evluation of the education plan will be completed by May 31, 2011. |