Observations
Based on a review of the facility's Staffing Requirements Facility Summary Report form and personnel information, the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS within the first year of employment for clinical staff and within two years of employment for non-clinical staff in one of one records reviewed.
The findings include:
From June 1, 2011 to June 3, 2011, the facility's Staffing Requirements Facility Summary Report form was reviewed for documentation of HIV/AIDS training. Also, on June 3, 2011 a copy of employee # 7's medical license, resume, and other personnel information was reviewed to determine if employee # 7 received HIV/AIDS training.
Employee # 7, the program psychiatrist, was hired August 7, 2007, HIV/AIDS training was due August 7, 2009. However, the Staffing Requirements Facility Summary Report form completed by the facility on June 1, 2011 did not include documentation that employee # 7 completed HIV/AIDS training. Also, the resume of employee # 7 indicated that employee # 7 graduated medical school May 1991.
This was still out of compliance at the time of the follow-up conducted on January 26, 2012.
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Plan of Correction
Employee #7, Program Psychiatrist attended HIV/AIDS training. He completed the training on 7/12/2011. His training certificate was received on 1/27/2012. A copy of the certificate is now on site at the Washington House facility. The Program Director will be responsible for ensuring that employee #7 (psychiatrist)stays up to date with required trainings to prevent this employee from being out of compliance with required trainings. The Program Director will contact the agency's training department semi annually to ensure that all staff receive and complete HIV/AIDS and STD/TB on time to ensure compliance.
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Observations
Based on a review of client records, the facility failed to document a physical examination in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Physical Examination Laboratory Studies," states:
"A client entering a Gaudenzia (residential) program shall receive a complete physical examination by a qualified physician within 7 days of admission (DOH), except on holiday or weekend. Other exceptions are:
1.The client received a complete physical examination no longer than one month prior to
admission; that the program staff can obtain the results in writing; and the nurse on duty is
able to ascertain no noticeable medical problems.
2.Any physical examination not performed by the Gaudenzia physician will be
reviewed and signed off by him/her within 24 hours of client's admission to the residential program.
3.Pennsylvania CBH clients are to have a completed physical within 72 hours-exceptions are
holiday or weekend.
Documentation of the results of the physical examination shall include but not be limited to: evidence of injury, neurological findings, investigation of the organ systems for potential infectious disease, pulmonary, liver and cardiac abnormalities, dermatological sequelae of addiction, vital signs, examination of general appearance, head, ears, eyes, nose, throat, chest, abdomen, extremities, skin assessment, concurrent problems and the physician's overall impression of the client."
On January 26, 2012, seven client records requiring documentation of a physical examination were reviewed. The facility did not document a physical examination according to their policy and procedures in six of seven records reviewed, specifically, client records # 1, 2, 3, 4, 5, and 7.
Client # 1, a CBH client, was admitted September 29, 2011. The physical examination was due October 4, 2011; however, the physical examination was not completed until October 25, 2011. Also, the physical examination did not include the physician's overall impression of the client.
Client # 2, a CBH client, was admitted October 14, 2011. The physical examination was due October 19, 2011; however, the physical examination was not completed until November 22, 2011. Also, the physical examination did not include the physician's overall impression of the client.
Client # 3, a CBH client, was admitted November 1, 2011. The physical examination was due November 4, 2011; however, the physical examination was not completed until December 13, 2011. Also, the physical examination did not include the physician's overall impression of the client.
Client # 4, a CBH client, was admitted November 10, 2011. The physical examination was due November 15, 2011; however, the physical examination was not completed until December 27, 2011.
Client # 5, a CBH client, was admitted November 15, 2011. The physical examination was due November 18, 2011; however, the physical examination was not completed until December 20, 2011.
Client # 7, a CBH client, was admitted November 28, 2011. The physical examination was due December 1, 2011; however, the physical examination was not completed until December 20, 2011.
The findings were confirmed during an ongoing dialogue with the facility director on January 26, 2012 from approximately 3:00 P.M. to 3:30 P.M.
This is a repeat citation. The facility was cited on June 2, 2011 for noncompliance with this standard.
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Plan of Correction
Clients coming from facilities with a doctor on site will have a written copy of their most recent physical examination sent to the progam;this physical will be completed 30 days prior to admission and sent to this program prior to their admit date. In the category of clients coming to the facility from a program that doesn't have a doctor on site, those clients will have a physical examination completed by their primary care physician or a qualified medical person within seven business days of admission.
The program nurse will be responsible for ensuring that all CBH clients receive a physical examination within a 72 hour period of admission, she will also be responsible for ensuring that physical examinations for new admissions(in the above mentioned category)occurs within seven business days of their admission to ensure compliance. In addition, the program nurse will also be responsible for reviewing physical examination forms to ensure that the physician's overall impressions of a client appear on the examination form. The program nurse will contact the physician immediately if he/she did not document their impressions of the client during the physical. The program nurse will request that the doctor's impression be completed and returned to her within 7 business days. |