INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on January 13, 2020 through January 15, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, The Healing Way was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(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
During a licensing inspection conducted on January 13, 2020 through January 15, 2020, the project failed to develop a mechanism to collect feedback on completed trainings in two out of nine personnel files reviewed. Employee #1 was hired on January 2, 2018 and was a current employee at the time of the licensing inspection. There was no indication that the project collected training feedback on any of the trainings this employee obtained during the 2019 training year.Employee #7 was hired on April 16, 2018 and was a current employee at the time of the licensing inspection. There was no indication that the project collected training feedback on any of the trainings this employee obtained during the 2019 training year.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The following plan of action has been addressed, the Project Director has developed a comprehensive staff development program for THW personnel. This includes the policies and procedures for the program indicating who is responsible and the time frames of completion of the following component. The Program Director has developed a mechanism to collect feedback on completed training as of 2/3/2020. The Program Director will ensure the collection of the required feedback form on completed training's and file in employee personnel charts upon completion.
Employee #1 was retrained on the importance of completing feedback forms after the completion of each training.
Clinical Supervisor will monitor and maintain new hire and current employee project collected training feedback forms on a monthly basis to ensure compliance in this area.
Employee #7 was trained on the completion of required feedback forms after each training's and placed in current employee chart.
As of 2/3/2020 new hire and current employees will be provided a project collected training feedback form after all training provided and will be placed in each employee personnel file.
The Clinical Supervisor will monitor and maintain all employee charts randomly to ensure each employee will remain in compliance in these area.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
During a licensing inspection conducted on January 13, 2020 through January 15, 2020, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment in six out of nine personnel records reviewed.Employee #1 was hired on January 2, 2018 and was a current employee at the time of the licensing inspection. This employee was not instructed in the use of the fire extinguisher upon hire and the documented training did not take place until December 19, 2019.Employee #2 was hired on July 22, 2019 and was a current employee at the time of the licensing inspection. This employee was not instructed in the use of the fire extinguisher upon hire and the documented training did not take place until December 19, 2019.Employee #4 was hired on October 4, 2019 and was a current employee at the time of the licensing inspection. This employee was not instructed in the use of the fire extinguisher upon hire and the documented training did not take place until December 19, 2019.Employee #5 was hired on October 28, 2019 and was a current employee at the time of the licensing inspection. This employee was not instructed in the use of the fire extinguisher upon hire and the documented training did not take place until December 19, 2019.Employee #6 was hired on November 18, 2019 and was a current employee at the time of the licensing inspection. This employee was not instructed in the use of the fire extinguisher upon hire and the documented training did not take place until December 19, 2019.Employee #9 was hired on September 29, 2019 and was a current employee at the time of the licensing inspection. This employee was not instructed in the use of the fire extinguisher upon hire and the documented training did not take place until December 19, 2019.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The following plan of action has been addressed and placed in all current employee personnel file as of 2/3/2020. During group supervision staff were provided with updated fire safety training to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies situations.
As of 2/3/2020 Employee#1 was retrained on fire safety and documentation has been placed in employee personnel records.
The Clinical Supervisor will monitor employee charts randomly to ensure that all employee training are up to date. Additionally, all charts wil be reviewed monthly by the Program Director to ensure accuracy in this area.
The following plan of action has been addressed, staff were retrained on the fire safety. Additionally charts reviews are being conducted by The Healing Way Management on a monthly basis to ensure accuracy of required training.
During group supervision, Employee #2, chart have been up dated on fire safety and placed in their employee file. Employee # 4,5 and 6 chart have been retrained on fire safety and placed in employee personnel chart. The Program Director and Clinician Supervisor will conduct random chart monitoring to ensure accuracy and compliance in this area. The CEO has developed an audit form in order to monitor completion of annual training
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
During a licensing inspection conducted on January 13, 2020 through January 15, 2020, the facility failed to ensure all personnel on all shifts are trained to perform assigned tasks during emergencies in six out of nine personnel records reviewed. Employee #1 was hired on January 2, 2018 and was a current employee at the time of the licensing inspection. The employee did not receive training to perform assigned tasks during emergencies until December 23, 2019.Employee #2 was hired on November 13, 2019 and was a current employee at the time of the licensing inspection. The employee did not receive training to perform assigned tasks during emergencies until December 23, 2019.Employee #3 was hired on November 13, 2019 and was a current employee at the time of the licensing inspection. The employee did not receive training to perform assigned tasks during emergencies until December 23, 2019.Employee #4 was hired on October 4, 2019 and was a current employee at the time of the licensing inspection. The employee did not receive training to perform assigned tasks during emergencies until December 23, 2019.Employee #5 was hired on October 28, 2019 and was a current employee at the time of the licensing inspection. The employee did not receive training to perform assigned tasks during emergencies until December 23, 2019.Employee #6 was hired on November 18, 2019 and was a current employee at the time of the licensing inspection. The employee did not receive training to perform assigned tasks during emergencies until December 23, 2019.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 2/3/2020 the following plan of action has been addressed. Staff were provided with updated training to ensure all shifts are trained to perform assigned tasks during emergencies.
Employee#1 was retrained during staff meeting on performing assigned tasks during emergencies and documentation has been placed in employee personnel record.
The Clinical Supervisor will monitor employee charts randomly to ensure that all employee training are up to date. Additionally, all charts will be reviewed monthly by the Program Director to ensure accuracy in this area.
Chart reviews are being conducted by The Healing Way Management team on a monthly basis to ensure accuracy of required training.
During group supervision, Employee #2,3, 4, 5 and 6 charts have been updated on emergency situation and placed in their employee personnel records. The CEO has develop an audit form to assist with monitoring employee training to ensure accuracy and compliance in this area.
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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
During a licensing inspection conducted on January 13, 2020 through January 15, 2020, the project director failed to prepare, annually update and sign a written manual delineating project policies and procedures.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
As of 2/3/2020 the Project Director will prepare, monthly collection of clinical training's and data in order to progress towards preparing annual updates. The Project Director will sign a written manual delineating project policies and procedures in order to remain compliance in this area on a monthly basis. |
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
During a licensing inspection conducted on January 13, 2020 through January 15, 2020, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information in 1 out of 17 client records reviewed.Client #4 was admitted on August 9, 2016 and was discharged on August 8, 2019. In this client's record, there was documentation of disclosures made to a funding source. There was no documentation that the project obtained informed and voluntary consent from the client prior to making the disclosures.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and Program Director has developed a revised Confidentiality form which will be updated and signed in all new and current client charts. Additionally, Therapist will continue to regularly monitor charts to ensure compliance in required documentation. Therapist will update charts as required yearly to remain in compliance.
The Clinical Supervisor and Program Director has developed a revised Confidentiality form, which will be reviewed with clients and signed and placed in active charts. All clients will be offered a copy of informed and voluntary consent for ROI before placed in active charts.
As of 2/3/2020 all documentation of disclosure made to any funding source will display projected informed and voluntary consent from the client prior to making the disclosure. Therapist are progressively working with clients to have newly revised ROI forms signed that corresponds with appropriate documentation of informed and voluntary consent from the client prior to making the disclosure.
A copy of the newly developed Confidentiality form will be placed in the revised intake assessment packet. The Clinical Supervisor formulated will monitor charts randomly to ensure compliance in this area.
Staff was retrained on the completion of the newly developed voluntary consent forms. Additionally, monthly charts reviews are conducted by The Healing Way Clinical Supervisor and all charts will be reviewed by the Program Director randomly to ensure compliance in this area
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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
During a licensing inspection conducted on January 13, 2020 through January 15, 2020, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in 3 out of 17 client records reviewed.Client # 15 was admitted on November 29, 2019 and discharged on November 29, 2019. An informed and voluntary consent to disclose form signed and dated November 29, 2019 to a government office allowed for the release of patient information, blood work results, and relapse information of urine drug screens. An informed and voluntary consent to disclose form signed and dated November 29, 2019 to the emergency contact did not include the specific information to be disclosed.Client # 16 was admitted on November 26, 2019 and was still an active client at the time of the inspection. An informed and voluntary consent to disclose form signed and dated December 31, 2019 to a government office allowed for the release of patient information, biopsychosocial evaluation, and urine drug screens. Client # 17 was admitted on July 12, 2019 and was still an active client at the time of the inspection. An informed and voluntary consent to disclose form signed and dated December 11, 2019 to a government office allowed for the release of patient information, biopsychosocial evaluation, urine drug screens, blood work results, and also identifies other, but does not identify what other is. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 2/3/2020 a copy of the newly developed Confidentiality forms were reviewed, signed and placed in client #16, and 17 active chart. The newly developed ROI forms will be placed in The Healing Way intake assessment packet. |
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
During a licensing inspection conducted on January 13, 2020 through January 15, 2020, the project failed to document that a copy of the client consent form was offered to the client in 5 out of 17 client records reviewed.Client #1 was admitted on January 14, 2019 and was active at the time of the inspection. This client's record contained a consent form to the emergency contact, dated January 14, 2019, that did not document whether a copy of the consent form was offered to the client. Additionally, there was a consent for another treatment facility, dated January 14, 2019, that did not document whether a copy of the consent form was offered to the client. Client #4 was admitted on August 9, 2016 and was discharged on August 8, 2019. There was a consent for another treatment facility, dated February 26, 2019, that did not document whether a copy of the consent form was offered to the client. Client #7 was admitted on September 20, 2017 and active at the time of the licensing inspection. This client's record contained a consent form to the emergency contact, dated September 23, 2019, that did not document whether a copy of the consent form was offered to the client. Client # 8 was admitted October 6, 2016 and was active at the time of the licensing inspection. This client's record contained a consent form to the emergency contact, dated September 26, 2019, that did not document whether a copy of the consent form was offered to the client. Client #9 was admitted on January 16, 2018 and was active at the time of the licensing. This client's record contained a consent form to the emergency contact, dated January 6, 2020, that did not document whether a copy of the consent form was offered to the client. Client #15 was admitted on November 29, 2019 and discharged on November 29, 2019. This client's record contained a consent form to a government office, dated November 29, 2019, that did not document whether a copy of the consent form was offered to the client.Client #16 was admitted on November 26, 2019 and was active at the time of the inspection. This client's record contained a consent form to an emergency contact, dated December 31, 2019, that did not document whether a copy of the consent form was offered to the client.Client #17 was admitted on July 12, 2019 and was active at the time of the inspection. This client's record contained a consent form to an emergency contact, dated December 11, 2019; a consent form to a laboratory dated December 11, 2019; and a consent form to a government agency Dated December 11, 2019 that did not document whether a copy of the consent form was offered to the client.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
As of 2/3/2020 client #1, 4, 9 and 7 newly develop consent forms have been reviewed, offered, signed, and placed in active charts. The Clinical Supervisor and Program Director will randomly audit charts to ensure compliance in this area.
Therapist were retrained on newly develop ROI forms while addressing the importance of offering a copy to client and documenting whether a copy of the consent was offered by marking the required check box. Client #1, 7, 8, 9, 15, 16, and 17 ROI forms were reviewed. Each form were update with documentation displaying whether a copy of the consent form was offered and filed in client active chart. Therapist will continue to regularly monitor charts to ensure compliance in ROI documentation.
The Clinical Supervisor and Program Director have developed a revised Release of Information form that document whether a copy of the consent form was offered to the client as of 2/3/2020.
The Clinical Supervisor and Therapist will review each ROI form appropriately and will progressively work with each client to have forms signed which corresponds with the effective dates, signatures and documentation displaying whether a copy of the consent was offered to the client. Each client record will obtain a newly developed consent form.
Additionally, the Program Director will randomly audit client records to ensure compliance in this area.
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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
During a licensing inspection conducted on January 13, 2020 through January 15, 2020, the project failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in 3 out of 17 client records reviewed.Client #3 was admitted on October 5, 2016 and was discharged on November 15, 2019. This client was not informed, in writing, of the project ' s decision to terminate the client's treatment and therefore the reason for termination was also not documented. Client #4 was admitted on August 9, 2016 and was discharged on August 8, 2019. This client was not informed, in writing, of the project ' s decision to terminate the client's treatment and therefore the reason for termination was also not documented.Client #12 was admitted on August 21, 2019 and was discharged on October 25, 2019. This client was not informed, in writing, of the project ' s decision to terminate the client's treatment and therefore the reason for termination was also not documented.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The following plan of action have been addressed, during group supervision Therapist was trained in the importance of notifying clients in writing of a decision to involuntarily terminate treatment. The Clinical Supervisor will regularly monitor charts to remain in compliance in this area. Additionally, the Program Director has developed an audit form to be utilized when auditing charts to ensure accuracy of notifying client in writing of decision to involuntarily terminate treatment. |
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
During a licensing inspection conducted on January 13, 2020 through January 15, 2020, the program failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years.Patient # 2 was admitted on January 10, 2019 and was discharged on August 14, 2019. In February 2019 and June 2019, the patient had 1.5 hours of individual therapy and 0 hours of group therapy. In March 2019, the patient had 30 minutes of individual therapy and 0 hours of group therapy. In April 2019 and May 2019, the patient had 0 hours of individual therapy and 0 hours of group therapy. There was no documentation of patient no shows or cancellations during those time periods.Patient # 6 was admitted on December 13, 2017 and discharged on May 1, 2019. In February 2019, the patient had 1.5 hours of individual therapy and 0 hours of group therapy. In March and April 2019, the patient had 0 hours of individual therapy and 0 hours of group therapy. There was no documentation of patient no shows or cancellations during those time periods.Patient # 7 was admitted on September 20, 2017 and was active at the time of the licensing inspection. In July 2019 the patient had 0 hours of individual therapy and 0 hours of group therapy. There was no documentation of patient no shows or cancellations during those time periods.These findings were reviewed with program staff during the licensing process.
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Plan of Correction
As of 2/3/2020 Therapist were provided an audit form to assist with monitoring client's individualized psychotherapy services that shall meet required State Regulations. Staff have been trained on the importance of providing 2.5 hours of psychotherapy per month during the client's first 2 years and 1 hour of individual psychotherapy. The Clinical Supervisor and Program Director will audit client charts randomly to ensure that each client meet the required psychotherapy mandated hours in order to remain in compliance.
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715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
During a licensing inspection conducted on January 13, 2020 through January 15, 2020, the program failed to provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment.Patient #4 was admitted on August 9, 2016 and was discharged on August 8, 2019. In April 2019 and May 2019, the patient had 0 hours of individual therapy and 0 hours of group therapy. There was no documentation of patient no shows or cancellations during those time periods.These findings were reviewed with program staff during the licensing process.
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Plan of Correction
As of 2/3/2020 Therapist have been provided an audit form to assist with monitoring client's individualized psychotherapy services that shall meet required State Regulations. Staff have been trained in-house on the importance of providing 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. The Clinical Supervisor and Program Director will audit client charts randomly to ensure that each client meet the required psychotherapy mandated hours in order to remain in compliance.
Staff were provided post educational training on the importance of providing documentation of client's no show or cancellation during time of missed services. Additionally the Clinical Supervisor will randomly audit charts to ensure compliance in this area.
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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
During a licensing inspection conducted on January 13, 2020 through January 15, 2020, the facility failed to document treatment and rehabilitation plan reviews and updates every 60 days in 9 out of 17 client records reviewed.Client #1 was admitted on January 14, 2019 and was active at the time of the licensing inspection. A treatment and rehabilitation plan update was completed on August 14, 2019 and the next update was due no later than October 14, 2019; however, there was no update documented in the record until December 23, 2019.Client #2 was admitted on January 10, 2019 and was discharged on August 14, 2019. A comprehensive treatment and rehabilitation plan was completed on February 8, 2019 and the update was due no later than April 8, 2019; however, there was no update documented in the record until June 5, 2019.Client #3 was admitted on October 5, 2016 and was discharged on November 15, 2019. A treatment and rehabilitation plan update was completed on March 7, 2019 and the next update was due no later than May 7, 2019; however, there was no update documented in the record until June 13, 2019.Client #4 was admitted on August 9, 2016 and was discharged on August 8, 2019. A treatment and rehabilitation plan update was completed on March 1, 2019 and the next update was due no later than May 1, 2019; however, there was no update documented in the record until June 18, 2019.Client #5 was admitted on May 28, 2015 and was discharged on December 16, 2019. A treatment and rehabilitation plan update was completed on September 11, 2019 and the next update was due no later than November 11, 2019; however, there was no update documented in the record at the time of the inspection.Client # 7 was admitted on September 20, 2017 and was active at the time of the licensing inspection. A treatment and rehabilitation plan update was completed on August 28, 2019 and the next updates were due no later than October 28, 2019 and December 28, 2019; however, there were no updates documented in the record at the time of the inspection.Client #8 was admitted on October 6, 2016 and was active at the time of the licensing inspection. A treatment and rehabilitation plan update was completed on June 24, 2019 and the next update was due no later than August 24, 2019; however, there was no update documented in the record until December 30, 2019.Client #9 was admitted on January 16, 2018 and was active at the time of the licensing inspection. A treatment and rehabilitation plan update was completed on February 8, 2019 and the next update was due no later than April 8, 2019; however, there was no update documented in the record until June 7, 2019. Additionally, A treatment and rehabilitation plan update was completed on June 7, 2019 and the next update was due no later than August 7, 2019; however, there was no update documented in the record until October 15, 2019.Client #17 was admitted on July 12, 2019 and reportedly discharged on September 20, 2019; however, he was not removed from the list of active client ' s, nor was there a discharge summary in the file. The client was readmitted on October 2, 2019 and was still active at the time of the inspection. A treatment and rehabilitation plan was completed on July 19, 2019 and the next update was due no later than September 19, 2019; however, there was no update documented in the record until December 6, 2019.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During group supervision Therapist were provided training in the importance of initial treatment and rehabilitation planning documentation.
The Clinical Supervisor will regularly monitor charts to ensure treatment plans are updated as required.
The Clinical Director has developed an audit form to be provided to all Therapist to ensure accuracy of all clinical charts. Therapist were trained on the importance of treatment planning during group supervision.
The Program Director developed an audit form to be utilize when auditing charts to ensure accuracy in this area. The Clinical Supervisor will audit random charts during group supervision to ensure accuracy and compliance in treatment and rehabilitation planning.
As of 2/3/2020 Therapist have been trained on 30 day initial treatment plans and 60-day comprehensive treatment planning. The Clinical Supervisor will conduct chart monitoring on a weekly basis during group supervision to ensure compliance of initial (30day) and 60 day comprehensive treatment and rehabilitation planning.
The Clinical Director has developed an audit form to be completed by Therapist to ensure accurate completion of treatment and rehabilitation planning documentation.
As of 2/3/2020 random chart reviews will be conducted by the Program Director and Clinical Supervisor to ensure accuracy of all treatment and rehabilitation planning and other required documentation within the first initial 30 day and 60 days of service. Client #2, 3, 4 and 5 have been discharge, treatment plan were not able to be developed.
Client # 1, 7. 8, 9, and 17 treatment plan have been updated and uploaded in client's record.
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
During a licensing inspection conducted on January 13, 2020 through January 15, 2020, the project failed to document discharge summaries in 3 out of 17 client records reviewed.Client #3 was admitted on October 5, 2016 and was discharged on November 15, 2019. The project failed to document a discharge summary in the record. Client #12 was admitted on August 21, 2019 and was discharged on October 25, 2019. The project failed to document a discharge summary in the record.Client #14 was admitted on November 15, 2019 and discharged on December 26, 2019. The project failed to document a discharge summary in the record.Client #15 was admitted on November 29, 2019 and discharged on November 29, 2019. The project developed a treatment and rehabilitation plan with the client and had a signed consent to treatment both dated Novembers 26, 2019. The project failed to document a discharge summary in the record.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Staff will be provided in-house training on the completion of discharge summary during group supervision. Additionally, monthly charts reviews are conducted by Clinical Supervisor to ensure compliance in this area. Program Director will provide all staff with audit forms to ensure compliance in this area. |
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
During a licensing inspection conducted on January 13, 2020 through January 15, 2020, the project failed to document follow-up information in 7 out of 17 client records reviewed.Client #2 was admitted on January 10, 2019 and was discharged on August 14, 2019. The project failed to document follow-up information in the record. Client #3 was admitted on October 5, 2016 and was discharged on November 15, 2019. The project failed to document follow-up information in the record. Client #4 was admitted on August 9, 2016 and was discharged on August 8, 2019. The project failed to document follow-up information in the record. Client #5 was admitted on May 28, 2015 and was discharged on December 16, 2019. The project failed to document follow-up information in the record. Client # 6 was admitted on December 13, 2017 and was discharged on May 1, 2019. The project failed to document follow-up information in the record. Client #14 was admitted on November 15, 2019 and discharged on December 26, 2019. The project failed to document follow-up information in the record.Client #15 was admitted on November 29, 2019 and discharged on November 29, 2019. The project failed to document follow-up information in the record, even though a treatment and rehabilitation plan had been developed and a consent to treatment signed by the client on November 29, 2019. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
During group supervision Therapist were trained in the importance of follow-up information. The Clinical Supervisor will regularly monitor charts to ensure compliance in this area. Additionally, the Program Director has developed an audit form to be provided to all Therapists to ensure accuracy of follow up information in all clients active and discharge charts. |