INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on March 7-8, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, RHJ Medical Center, Inc was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the 2011 annual report and administrative documentation, the facility failed to make the 2011 annual report available to the public.
The findings include:
The annual report for the 2011 year was reviewed on March 5, 2012. The facility is publicly funded and the governing body shall make the annual report available to the public. The 2011 annual report was not made available to the public.
Multiple interviews took place with the project/facility director throughout the licensing inspection. There was no documentation available for review which showed that the 2011 annual report was made available to the public.
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Plan of Correction
project/facility director will be responsible to ensure that the annual report for 2011(and annually thereafter)is made availible to the public by advertising in the local paper that the report will be availiblae at the faciltiy on a given day between 12-1pm. |
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 document follow up information as per agency policy in two of six client records.
The findings include:
Seven discharged outpatient client records were reviewed on March 7, 2012. Six of the seven discharged clients have been discharged for the amount of time required for follow up contact. Per agency policy, follow up contact will be completed within 90 days of discharge for clients not referred to other programs. Follow up was not documented within 90 days of discharge in client records #13 and 14.
Client #13 was admitted to outpatient treatment on April 16, 2008 and discharged on August 30, 2011. A follow up contact was due to be completed by November 30, 2011. There was no follow up contact documented in client record #13.
Client #14 was admitted to outpatient treatment on July 31, 2008 and discharged on August 9, 2011. A follow up contact was due to be completed by November 9, 2011. There was no follow up contact documented in client record #14.
An interview with the clinical supervisor took place on March 7, 2012 at which time it was confirmed that no follow up contact had taken place for clients # 13 and 14.
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Plan of Correction
The clinical supervisor is responsible to ensure that client follow ups are completed as required. A new protocal will be added to ensure compliance. The clinical supervisor will print from the computer a list of individuals who are due for a follow up in the current month and provide this list to the counselors. Each counselor is responsible to follow- up with their previous clients. Once the follow-ups are completed the counselors will submit the completed follow-up forms to the clinical supervisor who will check off on the master list all that have been completed and returned. The clinical supervisor will review this updated protocol with all counselors to ensure proper implementation and continued compliance. |