INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 11-12, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Habit OPCO, 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the "Staffing Requirements Facility Summary Reports" (SRFSR) for three of the facilities in the Project, the Project failed to ensure that there was one full-time clinical supervisor for every eight full-time equivalent (FTE) counselors in the Project.
The findings include:
The SRFSR for the three facilities reviewed that make up part of the the project list a total of 11 full-time counselors and 3 full-time lead counselors. The total of the hours per week provided to the project by counselors equates to 14 FTE counselor positions within the project.
The SRFSR for the three facilities reviewed within the project revealed that no employees were listed as a full-time clinical supervisor. The SRFSR listed each of the three facility having a part-time clinical supervisors as facility directors; therefore they are unable to provide full-time clinical supervision. A full-time equivalency of 14 counselors would require a minimum of 1 full-time clinical supervisors and one part-time clinical supervisor within the project.
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Plan of Correction
Habit OPCO will change the title and responsibilities of two of the projects current Facility Directors to Clinical Directors (by December 17, 2012). The new responsibilities ensure that the Clinical Directors will work as Clinical Supervisors as defined in PA regulations for Drug and Alcohol Treatment Facilities. This change will ensure that Habit OPCO has an appropriate amount of Clinical Supervision for sixteen (16) clinicians in the Pennsylvania Project. Habit OPCO currently employs fifteen (15) clinicians. Additionally, to ensure that this does not recur, Habit OPCO will begin recruiting for a third (3rd) Clinical Director for the project, with an anticipated start date no later than February 2013. This will ensure that Habit has sufficient Clinical Supervision for twenty-four (24) clinicians. By December 17, 2012, Habit OPCO will appoint a Facility Director to oversee all four facilities. Notification of this change (for electronic plans of correction) will be submitted to the Pennsylvania Department of Drug and Alcohol Programs no later than December 21, 2012. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review personnel records, the facility failed to employ a counselor who met the requirements for the qualifications for the position of counselor in one of three records reviewed.
The findings included:
Ten personnel records were reviewed on October 11, 2012. Three of these staff were designated as counselors. Employee # 5 did not have documentation of one year of clinical experience at the time of hire and therefore was not qualified for their designated position as counselor.
Employee # 5 was hired as a counselor on July 23, 2012. A review of the the employee's resume failed to include one year of clinical experience. The facility director was asked to provide additional documentation from the employee's last position to determine whether the employee's job consisted of clinical duties. The additional documentation provided clearly indicated the employee did not have clinical job experience.
The facility director confirmed this finding on October 11, 2012 and was not disputed.
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Plan of Correction
Employee number 5 was notified that his credentials were insufficient to qualify him for the position of counselor. His case load was reduced to a 1:34 ratio effective 10/12/12. The extra hour in the staff members schedule will be used for additional supervision.
Effective immediately, Habit OPCO will monitor any additional hires to ensure compliance with this standard.
Future hires who have "case management" experience will be asked to provide the facility with a copy of their previous job description(s) to verify compliance with the regulation.
If the staff member's education and experience do not qualify the staff member as a counselor, the staff member may be hired as a counselor assistant.
Ongoing compliance with this requirement will be monitored by the Admin Assistant and the Facility Director.
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704.11(a)(2) LICENSURE Overall Training 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:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the facility's policy and procedures and administrative documentation, the facility failed to document an overall plan for addressing training needs, as required by regulation.
The findings include:
On October 11, 2012, the facility's policy and procedures and administrative documentation were reviewed. Per the agency policy and procedures, the facility director will collect training data and he/she will formulate a comprehensive training plan by the end of January each year. The regulation requires an overall plan for addressing training needs to be completed as a component of a staff development program. According to the facility's policy, the training year is based on the calendar year (January 2012 - December 2012). The facility was authorized to open on February 1, 2012. The facility failed to document the completion of an overall training plan for the February 2012 to December 31, 2012 training year.
The facility director was interviewed on October 11, 2012. The facility director confirmed that a plan for addressing training needs of staff had not been completed.
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Plan of Correction
As of January 31, 2012, the facility had only two (2) employees (a nurse manager and a facility director). The Facility Director believed that a training plan was not necessary as all employees were required to complete their orientation training.
Due to the anticipated hire of security and clinical staff members a training plan was not developed.
The facility director will poll staff members to determine which trainings are needed and will develop a comprehensive training plan to meet those needs.
The survey will be completed by November 9, 2012, and a final report will be issued by December 3, 2012, and will cover the remainder of 2012 and calendar year 2013.
The facility director will ensure that the plan is developed annually, ongoing.
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on the review of personnel records and administrative training documentation, the facility failed to document individual training plans in six of eight required records.
The findings include:
Ten personnel records were reviewed on October 11, 2012. Eight records required an individualized training plan, that must be developed annually with input from both the employee and their supervisor. The facility was authorized to open on February 1, 2012. All new staff must have an individual training plan developed upon employment. The Department allows for this to be completed within 30 days of hire. The facility failed to document an individual training plan for personnel records # 1, 3, 5, 9, and 10. Employee # 7's training plan was documented late.
Employee # 1 was hired October 14, 2008 for the position of project director. The facility failed to have an individual training plan for this employee at the time of the inspection.
Employee # 3 was hired on April 16, 2012 as a counselor and promoted to lead counselor on August 27, 2012. The facility failed to have an individual training plan for this employee at the time of the inspection.
Employee # 5 was hired on July 23, 2012 as a counselor. The facility failed to have an individual training plan for this employee at the time of the inspection
Employee # 9 was hired on August 1, 2012 as a nurse. The facility failed to have an individual training plan for this employee at the time of the inspection.
Employee # 10 was hired on June 25, 2012 as a Secretary. The facility failed to have an individual training plan for this employee at the time of the inspection
This finding was discussed with the facility director and was not disputed.
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Plan of Correction
Individualized training plan forms will be distributed to all staff members at the completion of their orientation period. Both the supervisor and the staff member will participate in the creation of a training plan.
The same form will be distributed to employees during December annually (for the following calendar year).
The Admin Manager will ensure that the forms are properly disseminated, completed, and filed. Ongoing.
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on an overheard counseling session during the facility licensure inspection, the facility failed to ensure privacy in order that counseling sessions could not be seen or heard outside the counseling room.
The findings include:
On October 12, 2012 a counseling session between a counselor and patient were overheard by the licensing specialist. The licensing specialist was located in an office next to the office where the counseling session was taking place. The counseling session was overheard from the office during the licensing visit. This was also verified by the facility director at 9:40 a.m. on October 12, 2012.
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Plan of Correction
This observation was made while the auditor was placed in an office next to a counselor.
Currently, no counselors are physically located next to any other, and are spaced by at least one office.
The facility will utilize electronic white sound noise machines and install them in counseling areas. The machines were observed by an onsite inspector on 11/7-11/8, 2012.
The Security associate will tour the facility to ensure that the white noise machines muffle the sound of ongoing counseling sessions. These tours will occur weekly and will be documented in the safety / sanitation checklist. Ongoing.
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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
Based on the review of personnel records, the facility failed to document fire extinguisher training upon staff employment.
The findings include:
Ten personnel records were reviewed on October 11, 2012 to verify that staff had been instructed in the use of a fire extinguisher upon employment. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel records # 4, 8, and 9. The facility documented the completion of fire extinguisher training late in personnel records # 2, 3, 6, 7, and 10.
Employee # 2 was hired on 11/29/2011. Fire extinguisher training was due upon hire. The facility documented fire extinguisher training on 3/30/2012.
Employee # 3 was hired on 4/16/2012. Fire extinguisher training was due upon hire. The facility documented fire extinguisher training on 10/9/2012.
Employee # 4 was hired on 10/1/2012. Fire extinguisher training was due upon hire. The facility failed to documented fire extinguisher training in this personnel record.
Employee # 6 was hired on 3/12012. Fire extinguisher training was due upon hire. The facility documented fire extinguisher training on 4/4/2012.
Employee # 7 was hired on 1/24/2012. Fire extinguisher training was due upon hire. The facility documented fire extinguisher training on 4/2/2012.
Employee # 8 was hired on 11/11/2011. Fire extinguisher training was due upon hire. The facility failed to documented fire extinguisher training in this personnel record.
Employee # 9 was hired on 8/1/2012. Fire extinguisher training was due upon hire. The facility failed to documented fire extinguisher training in this personnel record.
Employee # 10 was hired on 6/25/2012. Fire extinguisher training was due upon hire. The facility documented fire extinguisher training on 10/9/2012.
This finding was confirmed by the facility director and was not disputed.
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Plan of Correction
The facility will ensure that all staff members have fire extinguisher training as required by 705.28.
The facility Director will ensure that all staff members who have not obtained training in the use of extinguishers will be trained by: November 16, 2012.
The admin assistant will verify that each staff member has been instructed regarding the location and operation of extinguishers upon hire.
Ongoing.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill logs, the facility failed to conduct unannounced fire drills at least once per month in four of eight months reviewed.
The findings include:
The fire drill logs were reviewed on October 11, 2012. There was no documentation of unannounced fire drills for the months of February 2012, March 2012, May 2012 and August 2012.
An interview took place with the facility director on October 11, 2012. It was confirmed that no fire drills were conducted during those months.
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Plan of Correction
Habit OPCO's security associate is responsible for actuating the fire alarm and evacuating the building. A fire drill schedule has been developed for the remainder of 2012 and for the entire 2013 calendar year. This list has been provided to the security associate and the admin manager (11/5/2012). The admin manager will be responsible for ensuring that the security associate completes drills as scheduled. ONGOING |
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
Based on the review of personnel records, the facility failed to document that all personnel on were trained to perform assigned tasks during emergencies upon staff employment.
The findings include:
Ten personnel records were reviewed on October 11, 2012 to verify that staff had been trained to perform assigned tasks during emergencies upon employment. The facility failed to document the completion of training to perform assigned tasks during emergencies upon staff employment in personnel records # 8 and 9.
Employee # 8 was hired as a contract physician on 11/11/2011. Training to perform assigned tasks during emergencies was due upon hire. The facility failed to document emergency training for this contracted personnel member.
Employee # 9 was hired on August 1, 2012 as a nurse. Training to perform tasks during emergencies was due upon hire. The facility failed to document emergency training for this employee.
This finding was confirmed by the facility director.
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Plan of Correction
The facility will review the two (2) staff members in question and ensure that they are trained by November 16, 2012. The existing orientation checklists will include tasks associated with emergency preparedness. All personnel hired in the future will be trained in these tasks upon hire.
The training will be documented in the personnel file. ONGOING.
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of patient records, the facility allowed for the release of specific patient information that exceeded the limits imposed by 4 Pa. Code 255.5 in six of eight records reviewed.
The findings include:
Eight patient records were reviewed on October 11-12, 2012. All patient records were required to include an informed and voluntary consent from the client prior to the disclosure of information. Six patient records included an informed voluntary consent for the insurance company that exceeded 4 Pa. Code 255.5. Patient records, # 1, 2, 3, 4, 6, and 7, included consents for the insurance company that permitted them to receive a copy of the patient's psychosocial evaluation and discharge summary. This exceeded 4 Pa. Code 255.5.
This finding was discussed with the facility director and was not disputed.
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Plan of Correction
Computer generated consent forms in the EHR have been modified (effective 11/9/2012), to offer only the five (5)areas identified in 255.5.
Accordingly, counselors can select (via checkbox) from:
(1) Whether the client is or is not in treatment.
(2) The prognosis of the client.
(3) The nature of the project.
(4) A brief description of the progress of the client.
(5) A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
Any additional information to be released (such as information needed for a patient who is guest dosing or transferring), will be completed in narrative within the EHR.
Staff members will be trained at the November general staff meeting (November 16, 2012).
Compliance with the new consent standards will be monitored via monthly random chart audits by the Facility Director and/or the Lead Clincian. Ongoing. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on a review of the facility's policy and procedures, the facility failed to ensure that verbal medication orders were put in writing and signed within 24 hours thereafter by the prescribing physician, as required by regulation and facility policy and procedure, in five of five patient records.
The findings include:
Eight patient records were reviewed on October 11-12, 2012. Five patient records contained documentation of verbal orders from a physician. According to facility policy, all verbal medication orders are required to be signed within 24 hours by the prescribing physician. Patient records # 2, 3, 4, 5, and 6 contained documentation of a verbal medication order that was not signed by the prescribing physician within 24 hours.
Patient #2 was admitted on April 3, 2012 and discharged July 5, 2012. The record contained verbal orders dated May 26, 2012. The prescribing physician signed off on the verbal order on May 29, 2012.
Patient #3 was admitted on May 25, 2012 and discharged on August 9, 2012. The record contained verbal orders dated July 2, 2012. The prescribing physician signed off on the verbal order on July 17, 2012. Additionally, the record contained verbal orders dated August 2, 2012. The prescribing physician signed off on the verbal order on August 9, 2012.
Patient #4 was admitted on March 23, 2012 and discharged July 12, 2012. Th record contained verbal orders dated April 20, 2012. The prescribing physician signed off on the verbal order on April 24, 2012. Additionally, the record contained a verbal order on June 7, 2012. The order was not signed by the prescribing physician. The order was signed by a physician other than the prescribing physician on June 14, 2012. The record also contained a verbal order dated June 29, 2012. The verbal order was signed by the prescribing physician on July 17, 2012.
Patient #5 was admitted on July 26, 2012. The record contained a verbal order dated September 11, 2012. The prescribing physician signed off on the verbal order on September 15, 2012.
Patient # 6 was admitted on July 17, 2012. The record contained a verbal order dated October 4, 2012. The prescribing physician signed off on the verbal order on October 9, 2012.
The issue of verbal orders not being signed off by the prescribing physician within 24 hours was confirmed by the facility director and was not disputed.
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Plan of Correction
The Physician will be provided remote access to the VNC Server via software and/or the distribution of a mobile computing device. The Physician has been notified that there is an expectation that the verbal orders are signed within 24 hours. She acknowledged a verbal understanding of same. The physician will have the software by 11/14/2012. Use of this software and compliance with the requirement will be monitored by the Facility Director and the Nurse Manager via random monthly chart audits. ONGOING. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of patient records, the facility failed to document the lengths and patterns related to the client's progression of drug and alcohol use in six of seven records reviewed.
The findings were:
Eight patient records were reviewed on October 11-12, 2012. Seven records were reviewed for documentation of drug and alcohol history that included lengths and patterns related to the client's progression of use. The facility failed to document the lengths and patterns related to the client's progression of use in patient records # 1, 3, 4, 5, 6, 7, and 8.
This finding was discussed with the facility director and lead counselor and was not disputed.
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Plan of Correction
Plan of Correction:
Clinicians have been in-serviced on the need to document lengths and patterns related to the client's progression of drug and alcohol.
Patient charts will be audited on a randomized monthly basis (by the Facility Director and the Lead Clinician) to ensure compliance. |
709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based on a review of patient records, the facility failed to document a physical examination that included the patient's general appearance in eight of eight records reviewed.
The findings include:
Ten patient records were reviewed on October 11-12, 2012. The facility failed to document general appearances on the physical examination forms in patient records # 1, 2, 3, 4, 5, 6, 7, and 8.
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Plan of Correction
The physician was inserviced on the need to include a note regarding general appearance while conducting physical examinations. Ongoing compliance with this requirement will be monitored through random monthly chart audits by the nurse manager and/or facility director. ONGOING. |
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 the review of patient records, the facility failed to document a psychosocial evaluation in six of seven records as required.
The findings include:
Eight patient records were reviewed on October 11-12, 2012. Seven patient records were reviewed for a psychosocial evaluation as required by the regulations. The facility's policy and procedures required the psychosocial evaluations to be documented within thirty days of admission. The facility failed to document psychosocial evaluations in patient records # 3, 4, 5, 6, 7, and 8.
Patient # 3 was admitted on May 25, 2012 and discharged on August 9, 2012. The psychosocial evaluation was due by June 25, 2012. The facility failed to document a psychosocial evaluation in this patient record as of the date of the inspection.
Patient # 4 was admitted on March 23, 2012 and discharged on July 12, 2012. The psychosocial evaluation was due by April 23, 2012. The facility failed to document a psychosocial evaluation in this patient record as of the date of the inspection.
Patient # 5 was admitted on July 26, 2012. The psychosocial evaluation was due by August 26, 2012. The facility failed to document a psychosocial evaluation in this patient record as of the date of the inspection.
Patient # 6 was admitted on July 17, 2012. The psychosocial evaluation was due by August 17, 2012. The facility failed to document a psychosocial evaluation in this patient record as of the date of the inspection.
Patient # 7 was admitted on March 27, 2012. The psychosocial evaluation was due by April, 27, 2012. The facility failed to document a psychosocial evaluation in this patient record as of the date of the inspection.
Patient # 8 was admitted on May 24, 2012. The psychosocial evaluation was due by June 24, 2012. The facility failed to document a psychosocial evaluation in this patient record as of the date of the inspection.
This finding was discussed with the facility director and was not disputed.
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Plan of Correction
The counselors had completed the biopsychosocial histories, but had not completed the interpretive summary as required by regulation.
Counselors have been in- serviced on the need to complete the biopsychosocial and interpretive summary within the time frames proscribed by regulations. Ongoing compliance will be monitored by the Lead Clinician and the Facility Director via random monthly chart audits. ONGOING.
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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 the review of patient records, the facility failed to develop an individual treatment and rehabilitation plan with the patient in four of seven patient records.
The findings include:
Eight patient records were reviewed on October 11-12, 2012. Seven of the eight patient records records were required to have an individual treatment and rehabilitation plan developed with the patient within thirty days of admission, as per agency policy.
Patient records # 3, 4, 5, and 7 did not contain individual treatment and rehabilitation plans that were developed with the client within thirty days of admission.
Patient #3 was admitted on May 25, 2012 and discharged on August 9, 2012. An individual treatment and rehabilitation plan was due to be developed with the client by June 25, 2012. The individual treatment and rehabilitation plan was developed on July 20, 2012.
Patient # 4 was admitted on March 23, 2012 and discharged on July 12, 2012. An individual treatment and rehabilitation plan was due to be developed with the client by April 23, 2012. The individual treatment and rehabilitation plan was developed on May 1, 2012.
Patient #5 was admitted July 26, 2012. An individual treatment and rehabilitation plan was due to be developed with the client by August 26, 2012. The individual treatment and rehabilitation plan was developed on September 14, 2012.
Patient #7 was admitted March 27, 2012. An individual treatment and rehabilitation plan was due to be developed with the client by April 27, 2012. The individual treatment and rehabilitation plan was developed on May 4, 2012.
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
The Counselors were in serviced on the need to complete treatment plans in a timely manner and were shown how to use the "services due" function on the electronic health record to assist them in maintaining compliance. The Lead Clinician and Facility Director will monitor the timely completion of these plans via random monthly chart audits. ONGOING. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to document support services on the individual treatment and rehabilitation plan in four of six records reviewed.
The findings include:
Eight patient records were reviewed on October 11-12, 2012. Six patient records were reviewed for documentation of proposed support services on the patient's individual treatment and rehabilitation plan. Patient records # 3, 4, 7 and 8 had no documentation of proposed support services on the comprehensive treatment plan.
This finding was discussed with the facility director and lead counselor on October 12, 2012 and was not disputed.
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Plan of Correction
Counselors have been in-serviced on where to document rehabilitation services on the treatment plan and in continuing care notes. The facility Director and Lead Clinician will monitor compliance with this standard by conducting monthly random chart audits. ONGOING. |
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 patient records and the facility's policy, the facility failed to document a case consultation in three of four patient records.
The findings include:
Eight patient records were reviewed on October 11-12, 2012. Per agency policy, case consultations shall be completed at least quarterly. Case consultations were required in four patient records. The facility did not document a case consultation within the quarterly time frame in patient records # 4, 7 and 8 .
Patient # 4 was admitted on March 23, 2012 and discharged on July 12, 2012. The case consultation was due by June 23, 2012. The facility failed to document a case consultation in patient record # 4.
Patient # 7 was admitted on March 27, 2012. The first case consultation was due by June 27, 2012. The facility documented the case consultation on August 19, 2012.
Patient #8 was admitted on May 24, 2012. The first case consultation was due by August 24, 2012. The facility documented the case consultation on October 2, 2012.
This finding was discussed with the facility director and was not disputed.
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Plan of Correction
The counselor and the Lead Clinician were in-serviced on the completion of case consults.
As of the date of this submission all case consults are completed.
The lead clinician and the Facility Director will verify that these are completed via random monthly chart audits. ONGOING.
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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
Based on a review of patient records, the facility failed to document a complete discharge summary that included the patient's reason for treatment, services offered, response to treatment and patient's status upon discharge in three of three patient records.
The findings include:
Eight patient records were reviewed on October 11-12, 2012. Three records were reviewed for discharge summaries. Three records did not have discharge summaries that included all required components, #2, 3, and 4.
Patient # 2 was admitted on 4/3/2012 and discharged on 7/15/2012. The discharge summary failed to document the patient's reason for treatment and the patient's status upon discharge.
Patient # 3 was admitted on 5/25/2012 and discharged on 8/9/2012. The discharge summary failed to document the patient's reasons for treatment and the patient's status upon discharge.
Patient # 4 was admitted on 3/23/2012 and discharged on 7/12/2012. The discharge summary failed to document the patient's status upon discharge.
This finding was reviewed with the facility director and was not disputed.
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Plan of Correction
Counselors have been in-serviced on the need to document all required components of the Discharge summary. The Lead Clinician and Facility Director will monitor the timely completion of these plans via random monthly chart audits. ONGOING
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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 patient records, the facility failed to document follow up information as per agency policy in two of three records.
The findings include:
Three discharged patient records were reviewed on October 11-12, 2012. Per agency policy, follow up contact will be completed within 30 days of discharge for patients not referred to other programs and within seven days for clients referred to another program. Follow up was not documented within 30 days of discharge in patient records # 2 and 3.
Client #2 was admitted on 4/3/2012 and discharged on 7/25/2012. The patient was referred to a higher level of care. A follow up contact was due to be completed by 8/1/2012. There was no follow up contact documented in patient record # 2 at time of the inspection.
Patient # 3 was admitted on 5/25/2012 and discharged on 8/9/2012. A follow up contact was due to be completed by 9/9/2012. There was no follow up contact documented in patient record # 3 at time of the inspection.
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Plan of Correction
Discharge contact will be completed as required via company policy. The admin assistant will run a report (using the EHR), on a weekly basis, to ensure that there are no services due. If services are due, the admin staff will follow-up with the clinician as required. The Facility Director or Designee will run a report (using the EHR), on a monthly basis, to ensure that there are no services due. If services are due, the clinician and/or the admin staff will follow-up as required. ONGOING. |