INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 8, 2023 through February 9, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, ADAPPT House 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in one of one applicable personnel record reviewed.Employee #3 was hired as a counselor on October 4, 2021. The HIV/AIDS training and the TB/STD training were due to be completed no later than October 4, 2022. However, the TB/STD training was not completed at the time of inspection.This is a repeat citation from the February 15, 2022 annual licensing renewal inspection.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
On 2/23/23, employee #3 completed her TB/STD training. All other employees shall complete the TB/STD training by March 15, 2023. Facility Director will ensure that this training has been completed by all employees. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records, the facility failed to ensure that a sufficient number of staff persons were CPR-certified and trained in first aid during the project's hours of operation.The facility's hours of operation are Sunday through Saturday, 24 hours a day. The facility failed to provide CPR and first aid staff coverage during the third shift security hours, which are from 10:00PM to 6:00AM, for the reviewed timeframe.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All employees will have completed the CPR training which is scheduled for March 6, 2023. Facility Director will ensure that all employees will complete this training by March 6, 2023. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure the completion of 25 clock hours of annual training required for counselors during the facility ' s January 2022 through December 2022 training year in one of two applicable personnel records reviewed.Employee #4 was hired as a counselor on April 16, 2018. The personnel record documented 4 hours of training during the reviewed training year.These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Facility Director will ensure that all counselors complete a minimum of 25 hours of annual training to include but not limited to (i) Client record keeping. (ii) Confidentiality. (iii) Pharmacology. (iv) Treatment planning. (v) Counseling techniques. (vi) Drug and alcohol assessment. (vii) Codependency. (viii) Adult Children of Alcoholics (ACOA) issues. (ix) Disease of addiction. (x) Aftercare planning. (xi) Principles of Alcoholics Anonymous and Narcotics Anonymous. (xii) Ethics. (xiii) Substance abuse trends. (xiv) Interaction of addiction and mental illness. (xv) Cultural awareness. (xvi) Sexual harassment. (xvii) Developmental psychology. (xviii) Relapse prevention. All counselors will complete 40 hours of training provided by GEO. Facility Director will monitor counselors monthly to assure that training hours are being completed.
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection conducted on February 9, 2023, the facility failed to keep the grounds of the facility safe and free from danger to the safety and well-being of clients, employees, and visitors.The following items were observed during the inspection, all of which posed a health and/or safety hazard for the clients and staff:-A cabinet, located in the kitchenette area, had an exposed electrical box allowing for a possible electrical shock -Cluster room #8 did not have a functioning light fixture allowing for a possible trip hazard.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In accordance with Policy 705.2 Building exterior and grounds. The residential facility shall: (2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards. On February 9, 2023, ADAPPT maintence covered the exposed electrical box. By March 4, the cabinet will be removed from the kitchen due to it not being needed.
In accordance with Policy 705.2 Building exterior and grounds. The residential facility shall: (2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards. On February 9, 2023, cluster room #8 had the light bulb replaced. Facility Director will train Maintenance supervisor on the importance of safety and will monitor all rooms to ensure that all lights are in working condition on a daily basis.
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705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection conducted on February 9, 2023, the facility failed to provide slip-resistant surfaces in all bathtubs and showers. All the showers located in Cluster 6/7 did not have a slip-resistant surfaces. Additionally, the shower located in the handicap bathroom did not have a slip-resistant surface.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.6. Bathrooms. The residential facility shall: (4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers. On February 9th, staff purchased slip resistant surfaces for all shower stalls in the facility. Facility Director will train Maintenance supervisor on the importance of safety and will monitor bathroom areas to ensure that all slip-resistant surfaces are intact and that there is no danger to residents. This will be checked on a daily basis by inspection staff and monitored by Facility Director |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection conducted on February 9, 2023, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times. The community bathroom shower, located in Cluster 6/7, had what appeared to be mold or mildew on a bathroom mat.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
705.6. Bathrooms. The residential facility shall: (7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
All staff will be trained in cleanliness of bathrooms in accordance with Policy 705.6. When completing daily inspections, staff will make sure that there is no mold or mildew on bathroom mats or in the shower areas. Facility Director will ensure that this is included in daily inspections.
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705.7 (b) (4) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(4) Ensure that storage areas for foods are free of food particles, dust and dirt.
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Observations
Based on a physical plant inspection conducted on February 9, 2023, the facility failed to ensure that storage of areas for foods were free of food particles, dust, and dirt. At the time of the inspection, there were multiple cabinets in the kitchenette area that had what appeared to be food particles located in them.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
705.7. Food service. (b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall: (4) Ensure that storage areas for foods are free of food particles, dust and dirt. In accordance with Policy 705.7, all staff with be trained and will then train residents on keeping the facility clean and free from particles, dust and dirt in the kitchen and throughout the facility. When completing daily inspections, staff will make sure that there is no food particles or coffee grounds in the kitchen area. Facility Director will ensure that this is included in daily inspections. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection, conducted on February 9, 2023, the facility failed to secure hard copy client records within locked storage containers. There were multiple cardboard boxes full of client charts located in several counselor offices.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In accordance with DDAP Policy 709.28. Confidentiality. (b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
The facility purchased 2 locking file cabinets. The file cabinets are now located in the Facility Directors office where she only has a key. All closed files will be placed in these file cabinets alphabetically. All client files will be placed in the locked file cabinet by March 15, 2023. Current client records will be kept in counselors' office where these can be locked and secured. All clinical staff with be directed to keep no files in boxes of any kind and all client files with be placed in a locked cabinet. Facility Director will ensure that all client files are in locked cabinets
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on release of information forms in two of ten client records reviewed.Client #5 was admitted on June 8, 2022 and was discharged on June 9, 2022. A release of information form to an emergency contact was signed and dated by the client on June 9, 2022; however, the name of the person, agency, or organization was not documented on the release form. Client #10 was admitted on May 26, 2022 and was discharged on July 25, 2022. A release of information form to an emergency contact was signed and dated by the client on May 26, 2022; however, the name of the person, agency, or organization was not documented on the release form. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By April 1, 2023. Facility Director will
ensure that all documents include the name of the person, agency, or organization to whom a disclosure was to be made to on release of information forms. Facility Director will monitor this by completing a 1 week and 30 day check on all charts. Facility Director will meet with all counselors by March 15th and provide a refresher training to clinical staff members regrading all client documents and the clinical documentation process. The project manager will monitor the process for 90 days or until compliance is achieved
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of disclosure on consent to release information forms in one of ten client records reviewed. Client #7 was admitted on August 24, 2022 and was discharged on October 24, 2022. There was a release of information form to a government agency that was signed and dated by the client on August 25, 2022; however, the purpose of the disclosure was not documented on the release form. Additionally, there were separate release of information forms to three outside individuals that were all signed and dated by the client on August 30, 2022; however, the purpose of the disclosure was not documented on any of the release forms. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In accordance with Policy 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: (3) Purpose of disclosure. By March 15, 2023, Facility Director will ensure that all documents include the name of the person, agency, or organization to whom a disclosure was to be made to on release of information forms. All forms will include the purpose of the disclosure. Facility Director will monitor this by completing a 1 week and 30 day check on all charts. Facility Director will meet with all counselors and provide a refresher training to clinical staff members regrading all client documents and the clinical documentation process. Facility Director will train clinical staff on the importance of all release of information to include name of the person, agency, or organization to whom a disclosure was to be made to on release of information forms. All forms will include the purpose of the disclosure. The project manager will monitor the process for 90 days or until compliance is achieved. |
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
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client in three of ten client records reviewed.Client #2 was admitted on December 14, 2022 and was active at the time of inspection. A release of information form to a medical provider was signed and dated by the client on December 15, 2022; however, there was no documentation that a copy of the release form was offered to the client.Client #4 was admitted on August 31, 2022 and was discharged on October 31, 2022. A release of information form to a managed care organization was signed and dated by the client on August 31, 2022; however, there was no documentation that a copy of the release form was offered to the client.Client #7 was admitted on August 24, 2022 and was discharged on October 24, 2022. There was separate release of information forms to three outside individuals that were signed and dated by the client on August 30, 2022; however, there was no documentation that a copy of any of the release forms were offered to the client.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By April 1, 2023. Facility Director will
ensure that all clients are offered a copy of the release form. All clients will check accept or refused on the documents. Facility Director will monitor this by completing a 1 week and 30 day check on all charts. Facility Director will meet with all counselors by March 15th and provide a refresher training to clinical staff members regrading all client documents and the clinical documentation process. The project manager will monitor the process for 90 days or until compliance is achieved
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709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on an administrative review, the facility failed to maintain a data collection system and recordkeeping system that allows for the efficient retrieval of data needed to measure the project's performance.On February 8, 2023, the facility took approximately one hour to provide the DDAP representative with all the client records requested. Additionally, on February 9, 2023, the facility was unable to locate and produce two client records after the DDAP representative requested them.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In accordance with Policy 709.31. Data collection system. (a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives. The facility purchased 2 locking file cabinets. The file cabinets are now located in the Facility Directors office where she only has a key and is able to access files readily. All charts are out of boxes and are placed in the locking file cabinets located in the Facility Directors office. Staff will be trained on the importance of client file confidentiality and will place all files in the locked file cabinets. All closed files will be placed in these file cabinets alphabetically. All files will be placed in the locked file cabinet by March 15, 2023. Current client records will be kept in counselors' office where these can be locked and secured. Facility Director will ensure that all client files are secured in a locked file cabinet at all times in accordance with Policy 709.31. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on a review of client records, the facility failed to ensure that there was proper documentation of the administration of medication in one of one applicable client record reviewed.Client #10 was admitted on May 26, 2022 and was discharged on July 25, 2022. The client was prescribed medication to be administered one time a day; however, medication records were missing from July 1, 2022 through July 25, 2022.This is a repeat citation from the February 15, 2022 and February 24, 2021 annual licensing inspection.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
All clinical staff will check medication records to ensure that all records are included in the client files. Facility Director will monitor this by completing 1 week, 30 day and close chart reviews. The project manager will monitor the process for 90 days or until compliance is achieved |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in five of nine applicable client records reviewed.Client #1 was admitted on December 12, 2022 and was active at the time of inspection. The individual treatment plan was completed on December 29, 2022; however, the plan did not include type and frequency of treatment and rehabilitation services. Client #3 was admitted on December 14, 2022 and was active at the time of inspection. The individual treatment plan was completed on December 20, 2022; however, the plan did not include type and frequency of treatment and rehabilitation services.Client #8 was admitted on August 23, 2022 and was discharged on September 22, 2022. The individual treatment plan was completed on August 30, 2022; however, the plan did not include type of treatment and rehabilitation services.Client #9 was admitted on July 28, 2022 and was discharged on September 26, 2022. The individual treatment plan was completed on August 11, 2022; however, the plan did not include type of treatment and rehabilitation services.Client #10 was admitted on May 26, 2022 and was discharged on July 25, 2022. The individual treatment plan was completed on June 9, 2022; however, the plan did not include type of treatment and rehabilitation services.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 2/15/2023, all individual treatment plans will document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan. Facility Director will monitor this by completing 1 week, 30 day and close chart reviews. The project manager will monitor the process for 90 days or until compliance is achieved |
709.52(a)(3) LICENSURE Support service type
709.52. 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 a review of client records, the facility failed to document the proposed type of support services in the individual treatment and rehabilitation plan in seven of nine applicable client records reviewed.Client #1 was admitted on December 12, 2022 and was active at the time of inspection. The individual treatment plan was completed on December 29, 2022; however, the plan did not include proposed type of support service.Client #3 was admitted on December 14, 2022 and was active at the time of inspection. The individual treatment plan was completed on December 20, 2022; however, the plan did not include proposed type of support service.Client #4 was admitted on August 31, 2022 and was discharged on October 31, 2022. The individual treatment plan was completed on September 15, 2022; however, the plan did not include proposed type of support service.Client #6 was admitted on June 8, 2022 and was discharged on August 8, 2022. The individual treatment plan was completed on June 23, 2022; however, the plan did not include proposed type of support service.Client #8 was admitted on August 23, 2022 and was discharged on September 22, 2022. The individual treatment plan was completed on August 30, 2022; however, the plan did not include proposed type of support service.Client #9 was admitted on July 28, 2022 and was discharged on September 26, 2022. The individual treatment plan was completed on August 11, 2022; however, the plan did not include proposed type of support service.Client #10 was admitted on May 26, 2022 and was discharged on July 25, 2022. The individual treatment plan was completed on June 9, 2022; however, the plan did not include proposed type of support service.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 2/15/2023, all individual treatment plans will document the proposed type of support service on the individual treatment and rehabilitation plan. Facility Director will monitor this by completing 1 week, 30 day and close chart reviews. The project manager will monitor the process for 90 days or until compliance is achieved |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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 client records, the facility failed to a maintain a complete client record on an individual, which is to include case consultation notes, in four of seven applicable client records reviewed.Client #4 was admitted on August 31, 2022 and was discharged on October 31, 2022. There was no documentation of case consultation notes as of the date of the inspection. Client #6 was admitted on June 8, 2022 and was discharged on August 8, 2022. There was no documentation of case consultation notes as of the date of the inspection.Client #9 was admitted on July 28, 2022 and was discharged on September 26, 2022. There was no documentation of case consultation notes as of the date of the inspection.Client #10 was admitted on May 26, 2022 and was discharged on July 25, 2022. There was no documentation of case consultation notes as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 2/15/2023, all client files will include a case consultation note. Facility Director will monitor this by completing 1 week, 30 day and close chart reviews. The project manager will monitor the process for 90 days or until compliance is achieved. |
709.53(a)(9) LICENSURE Aftercare plans
709.53. 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to a maintain a complete client record on an individual, which is to include an aftercare plan, in two of six applicable client records reviewed.Client #4 was admitted on August 31, 2022 and was discharged on October 31, 2022. There was no documentation of an aftercare plan as of the date of the inspection. Client #10 was admitted on May 26, 2022 and was discharged on July 25, 2022. There was no documentation of an aftercare plan as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 2/15/2023, all client files will include an aftercare plan. Facility Director will monitor this by checking to see the aftercare plan prior to the client discharge. The project manager will monitor the process for 90 days or until compliance is achieved |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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 client records, the facility failed to a maintain a complete client record on an individual, which is to include a discharge summary, in three of seven applicable client records reviewed.Client #6 was admitted on June 8, 2022 and was discharged on August 8, 2022. There was no documentation of a discharge summary as of the date of the inspection.Client #9 was admitted on July 28, 2022 and was discharged on September 26, 2022. There was no documentation of a discharge summary as of the date of the inspection.Client #10 was admitted on May 26, 2022 and was discharged on July 25, 2022. There was no documentation of a discharge summary as of the date of the inspection.This is a repeat citation from the February 15, 2022 annual licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 2/15/2023, all client files will include a discharge summary. Facility Director will monitor this by completing the closed file chart check within 30 days of discharge. The project manager will monitor the process for 90 days or until compliance is achieved. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 a maintain a complete client record on an individual, which is to include follow-up information, in five of six applicable client records reviewed.Client #4 was admitted on August 31, 2022 and was discharged on October 31, 2022. There was no documentation of follow up information as of the date of the inspection. Client #6 was admitted on June 8, 2022 and was discharged on August 8, 2022. There was no documentation of follow up information as of the date of the inspection.Client #7 was admitted on August 24, 2022 and was discharged on October 24, 2022. There was no documentation of follow up information as of the date of the inspection.Client #9 was admitted on July 28, 2022 and was discharged on September 26, 2022. There was no documentation of follow up information as of the date of the inspection.Client #10 was admitted on May 26, 2022 and was discharged on July 25, 2022. There was no documentation of follow up information as of the date of the inspection.This is a repeat citation from the February 15, 2022 annual licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 2/15/2023, all client files will include a follow up for clients after being discharged within 7 days. Facility Director will monitor this by checking files. The project manager will monitor the process for 90 days or until compliance is achieved |
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 client records, the facility failed to comply with plans of correction that were approved by the Department. Plans of correction for the administration of medication were submitted and approved by the Department for the February 15, 2022 and February 24, 2021 annual licensing inspection. Administration of medication was again found to be a deficiency in the February 7, 2023 licensing inspection.Plans of correction for documenting that a copy was offered on release of information forms were submitted and approved by the Department for the February 15, 2022 and February 24, 2021 annual licensing inspection. Documenting that a copy was offered on a release of information form was again found to be a deficiency in the February 7, 2023 licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By March 15, 2023. Facility Director will
ensure that release of information forms are offered to all clients. Facility Director will monitor this by completing a 1 week and 30 day check on all charts. Facility Director will meet with all counselors by March 15th and provide a refresher training to clinical staff members regrading all client documents and the clinical documentation process. The project manager will monitor the process for 90 days or until compliance is achieved.
All clinical staff will check medication records to ensure that all records are included in the client files. Facility Director will monitor this by completing 1 week, 30 day and close chart reviews. The project manager will monitor the process for 90 days or until compliance is achieved |