INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on November 5, 2019 by staff from the Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site complaint investigation, Chances was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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 the client's record on November 5, 2019, the facility failed to document a discharge summary for client #2.
The client was admitted on 8/31/18 and discharged on 9/18/18.
The finding was discussed with facility staff during the complaint investigation.
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Plan of Correction
The Program Director will provide training with therapists on the CHANCES policy of completing a discharge summary for every client. This training will take place by or on 1/17/20.
The Program Director will monitor therapist adherence to the standard on a monthly basis during Case Conference meeting. Each discharged case will be checked to verify compliance with the discharge summary policy.
Compliance to the standard will also be monitored by Total Quality Management which reviews charts on a quarterly basis.
First quarterly review will take place by 4/15/2020.
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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 the client's record on November 5, 2019, the facility failed to document a follow-up for client #2.
The client was admitted on 8/31/18 and discharged on 9/18/18.
The finding was discussed with facility staff during the complaint investigation.
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Plan of Correction
The Program Director will provide training with therapists on the CHANCES policy of following up on discharged participants. This training will take place by or on 1/17/2020.
The Program Director will monitor therapist adherence to the standard on a monthly basis during Case Conference meeting. Each discharged client will be checked to verify compliance with the follow-up after discharge procedure.
Compliance to the standard will also be monitored by Total Quality Management which reviews charts on a quarterly basis.
First quarterly review will take place by 4/15/2020.
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