INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 16 through April 18, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, White Deer Run, 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(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on the review of personnel records, the facility failed to document monthly supervisory sessions for each new supervisor for the first six months of employment.The findings include:Eight personnel records were reviewed for the position of clinical supervisor on April 3, 2012. Six of those employees had been in the position for less than a year and were required to meet monthly with their supervisors for the first six months in that position. The facility had no documentation of supervision for employees #8 and 9. Employee #8 was hired on July 18, 2005 and was promoted to the position of clinical supervisor on May 14, 2011. Employee #8 was required to have documented monthly meetings with their supervisor until November 2012; however there was no documentation of supervision for client #8. Employee #9 was hired on January 15, 2005 and was promoted to the position of clinical supervisor on September 15, 2011. Employee#9 was required to have documented monthly meetings with their supervisor until March 2012; however there was no documentation of supervision for client #9.An inquiry was made with the facility director on April 16, 2012 for documentation of supervisory notes. No documentation was provided before the exit interview.
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Plan of Correction
Beginning May 21, 2012, the Clinical Director will meet with each Unit Supervisor noted in the deficiency to complete a monthly supervision for a period of six months.
All new Unit Supervisors hired will receive monthly supervision for a period of six months from their start or promotion date.
The Quality Improvement Department will send out, monthly, the required supervision list to the Clinical Director to ensure that supervisions are completed based on the regulation.
The Quality Improvement Department will notify the Regional Administrator of any supervisions that are more than 30 days past due. The Regional Administrator will conduct a supervision session with the Clinical Director to ensure that they are completed
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the employee personnel records, the facility failed to document the required period of close supervision for the position of counselor assistant. The findings include: Twelve personnel records were reviewed for the position of counselor assistant on April 17, 2012. The facility failed to document required supervision for three of those employees, specifically employees #26, 31, and 32. The counselor assistant represented in record # 26 was hired as a counselor assistant on March 26, 2012. Employee #26 had documentation that a Bachelor's degree had been conferred and therefore the employee was required to have six months of documented close supervision. As of the date of review, there was no documentation of supervision for employee #26.The counselor assistant represented in record # 31 was hired as a counselor assistant on October 10, 2011. Employee #31 had documentation that a Bachelor's degree had been conferred and therefore the employee was required to have six months of documented close supervision. As of the date of review, there was no documentation of supervision for employee #31.The counselor assistant represented in record # 32 was hired as a counselor assistant on September 7, 2011 and promoted to the position of counselor on January 9, 2012. Employee #32 had documentation that a Bachelor's degree had been conferred and therefore the employee was required to have six months of documented close supervision. As of the date of review, documentation of close supervision was only noted until February 6, 2012. There was no further documentation of supervision for employee #32An inquiry was made with the facility director on April 16, 2012 for documentation of supervisory notes. No documentation was provided before the exit interview.
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Plan of Correction
All three employees (#26, #31 and #32) had the required weekly supervision completed. The missing supervisions will be forwarded to the Quality Improvement Department by May 31, 2012.
The Quality Improvement Department will send out, monthly, the required supervision list to the Clinical Director to ensure that supervisions are completed based on the regulation.
The Clinical Director will review this list and ensure that all required supervisions are submitted to the Quality Improvement Department by the due date. If a supervision is not completed and submitted to Quality Improvement Department the Clinical Director will Counsel the Unit Supervisor in timely submission of required documentation.
The Quality Improvement Department will notify the Regional Administrator of any supervisions that are more than 30 days past due. The Regional Administrator will conduct a supervision session with the Clinical Director to ensure that they are completed.
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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 the Staffing Requirements Facility Summary Report (SRFSR) completed by the project, the facility failed to document individual training plan for each employee upon employment or annually in accordance with the facility's policy.The findings include:According to the SRFSR completed by the project's staff, the facility's training year runs from January 1st to December 31st. The facility's policy regarding staff development states, Training plans are due by January 15th of the current training year. The SRFSR was reviewed on April 2, 2012 through April 4, 2012. Of the two hundred fifty-six personnel identified on the SRFSR, the facility documented that 92 employees either did not have a training plan upon employment, did not have an annual training plan by January 15th, or did not have documentation of a training plan at all. Employee #14 was hired 8/17/11, the training plan is to be documented upon hire. The training plan for employee #14 had not been completed until 11/9/11.Employee #15 was hired on 1/9/12, the training plan is to be documented upon hire. The training plan for employee #14 had not been completed until 4/12/12.Employee #29 was hired on 6/22/11, the training plan is to be documented upon hire. The training plan for employee #29 had not been completed until 11/17/11.Employee #33 was hired on 9/9/11, the training plan is to be documented upon hire. The training plan for employee #33 had not been completed until 11/14/11.Employee #34 was hired on 5/31/11, the training plan is to be documented upon hire. The training plan for employee #34 had not been completed until 11/14/11.The training plan was not documented for employees # 7, 16, 17, 18, 19, 20 and 32, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53,54, 55, 56,57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105, 106 107, 108, 109, 110, 111, 112, 113, and 114. The Quality Assurance staff was informed of the findings during the exit interview.
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Plan of Correction
By July 15, 2012 The Administrative Assistant will ensure all employees who do not have a current training plan on file will have one completed and filed with the Quality Improvement Department.
Effective immediately, all new hires will be given a training plan to review and complete with the hiring manager. The hiring manager will forward the completed training plan to the Quality Improvement Department.
By November 30 of each year the Quality Improvement Department will notify the facility of training plans to be completed by all staff members for the following year. The Administrative Assistant will collect all of the facility's training plans for the current year and compare to a list of current staff received from Human Resources. The Administrative Assistant will forward the completed training plans to Quality Improvement by January 1 of the following year.
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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 staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff. The findings include: The SRFSR was reviewed on April 2, 2012 through April 4, 2012. The facility failed to document the required training hours in record #115.Staff #115 was hired as a maintenance technician on September 29, 2008, HIV/AIDS and TB/STD training was due by September 29, 2010. As of the licensing inspection, there was no documentation of infectious disease training for employee #115. This was reviewed confirmed with the QI staff on April 4, 2012 and again at the site with the facility director on April 16, 2012.
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Plan of Correction
The Director of Risk Management and Safety will ensure that this employee #115 will attend HIV/AIDS training on May 23, 2012 and TB/STD training on May 30, 2012.
The Nurse Educator is currently maintaining a list of employees and the due dates based on their hire date and job classification. This list will be forwarded to the facility supervisors and Regional Administrator each month to ensure that staff are receiving these required trainings.
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705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based upon the physical plant inspection, the facility failed to maintain all structures on the grounds of the facility so as to be free from any danger to health and safety.The findings include:The physical plant inspection was conducted on April 18, 2012, at approximately 9:30am.The left, rear exit from building # 11 led to a drop-off of 24 inches as there was no porch, platform, landing, ramp, or set of steps outside the door. In addition, the wooden sill of the exit door was rotting and part of the sill on the left side was missing.The wooden steps in the rear of building #17, near the laundry area, were deteriorating and not properly affixed. The steps were unstable when they were stepped on. The findings were confirmed by the Coordinator Risk Management & Safety during the physical plant inspection.
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Plan of Correction
The left rear exit noted in this deficiency is actually on Building #12. On May 17, 2012 a set of steps were installed and the wooden sills were replaced.
The steps on the rear of Building #17 were replaced on April 18, 2012.
The Director of Risk Management and Safety, along with safety technicians will conduct monthly inspections on each and every building. Any repairs noted during these inspections will be communicated to the Maintenance Coordinator for immediate repair.
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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 upon the physical plant inspection, the facility failed to 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 findings include:The physical plant inspection was conducted at approximately 9:30am on April 18, 2012. Building # 15 is a maintenance building located on the lower side of the property. Licensing Staff observed that there were several groups of items laying on the ground on the side of the building and across the driveway from the building. The Coordinator of Risk Management and Safety confirmed that the items were to be discarded or recycled.The findings were re-confirmed by the Coordinator Risk Management & Safety during the physical plant inspection.
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Plan of Correction
Three recycling containers were placed on the facility on April 27, 2012. On April 27, 2012 The Director of Risk Management and Safety met with the Maintenance Coordinator to ensure that all recyclables from Building #15 were placed in the containers and non-recyclables discarded of immediately. This was completed on April 30, 2012.
The Director of Risk Management and Safety, with a member of the maintenance team will conduct a monthly walk-around the facility to ensure that all recyclables are placed in the appropriate containers and non-recyclable items are disposed of immediately.
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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based upon the physical plant inspection, the facility failed to ensure that the hot water temperature did not exceed 120 degrees Fahrenheit.The findings include:The physical plant inspection was conducted at approximately 9:30am on April 18, 2012. The hot water temperature in the bathroom located near the lounge in Building # 2 registered 125.5 degrees Fahrenheit at the time of inspection.The findings were reviewed with the Coordinator Risk Management & Safety during the exit interview and were not disputed.
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Plan of Correction
On April 18, 2012, the Maintenance Coordinator adjusted the temperature on the hot water heater located in Building #2.
The Director of Risk Management and Safety, along with the safety team will check water temperatures around the facility during their monthly walk-through and report any temperatures exceeding 120 degrees Fahrenheit to the Maintenance Coordinator for adjustment.
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based upon the physical plant inspection, the facility failed to ventilate toilet and wash rooms by exhaust fan or window.The findings include:The physical plant inspection was conducted at approximately 9:30am on April 18, 2012. The two bathrooms located on the new construction side of Building # 25 were not ventilated by an exhaust fan or window.The findings were confirmed by the Coordinator Risk Management & Safety during the physical plant inspection.
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Plan of Correction
Exhaust fans were installed in the new construction area's restrooms at the time of construction, but were not functioning. By May 18th, 2012, an outside contractor will have the exhaust fans functioning to meet this regulation.
All bathrooms on the facility have exhaust fans installed.
The Director of Risk Management and Safety, along with the safety staff will ensure that all exhaust fans are working properly. Any exhaust fans that are not operational will be reported to the Maintenance Coordinator for immediate repair.
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based upon the physical plant inspection, the facility failed to ensure that there were no heaters within the facility that were not permanently mounted or installed.The findings include:The physical plant inspection was conducted at approximately 9:30am on April 18, 2012. While inspecting Building # 8, Licensing Staff observed that office 8-2 contained a portable space heater. The findings were confirmed by the Coordinator Risk Management & Safety during the physical plant inspection.
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Plan of Correction
The employee in possession of the space heater has been counseled with regard to this incident and the heater has been removed from the premises.
The Director of Risk Management and Safety, along with the safety staff will conduct monthly walk-through inspections to ensure that there are no non-permanent, installed heaters on the facility. Any heaters recovered from this inspection will be removed from the facility immediately.
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705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based upon the physical plant inspection, the facility failed to ensure that exits from rooms and from the residential facility are unobstructed.The findings include:The physical plant inspection was conducted at approximately 9:30am on April 18, 2012.The dining area for the facility was located in building # 8, which included a side annex for additional seating. The annex contained a rear exit that opened into the main lobby area of building #18. The exit was clearly marked but was locked on the annex side and obstructed by a chair on the lobby side of the door.The lower, rear exit from building # 11 was obstructed by a stack of lumber and three washing machines.Both rear exits from Building # 12 were clearly marked and had boxes and other items stacked in front of them.The findings were reviewed with the Coordinator Risk Management & Safety during the exit interview and were not disputed.
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Plan of Correction
On April 19, 2012 the door spoken in Building #8 was removed and that doorway is now an open walk way from side annex to the main lobby area.
All items obstructing the Building #11 exit were removed.
The boxes obstructing Building #12's exit have been removed.
Ongoing compliance will be managed by
the Director of Risk Management and Safety, along with the safety staff conducting monthly walk-through inspections. Items found blocking exits will be moved immediately.
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705.10 (a) (1) (iv) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based upon the physical plant inspection, the facility failed to clearly indicate exits by the use of signs.The findings include:The physical plant inspection was conducted at approximately 9:30am on April 18, 2012.Building # 11 is a two story building, with storage on the lower level and client rooms on the upper floor. There are two exits from the lower level; however, neither exit was marked by an exit sign at the time of inspection. The findings were reviewed with the Coordinator Risk Management & Safety during the exit interview and were not disputed.
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Plan of Correction
On May 15, 2012 exit signs were placed at both exits of the lower level of Building #11.
Ongoing compliance will be managed by
the Director of Risk Management and Safety, along with the safety staff conducting monthly walk-through inspections.
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705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based upon the physical plant inspection, the facility failed to ensure that all fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.The findings include:The physical plant inspection was conducted at approximately 9:30am on April 18, 2012. A fire extinguisher located in Module B contained an inspection tag dated October 2010. In order to remain in compliance with the requirement for an annual inspection, the fire extinguisher was required to have been inspected no later than October 2011. The findings were reviewed with the Coordinator Risk Management & Safety during the exit interview and were not disputed.
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Plan of Correction
The fire extinguisher in Modular B was replaced on April 18, 2012.
Ongoing compliance will be managed by
the Director of Risk Management and Safety, along with the safety staff conducting monthly walk-through inspections. Any extinguishers found to be out of compliance at that time will be replaced immediately.
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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 upon a review of the facility's Policy and Procedures Manual and Administrative documentation, the facility failed to make an annual report available to the public upon completion of the 2010 fiscal year ending December 31, 2010.The findings include:The Policy & Procedures Manual and Administrative documentation were reviewed as part of an Administrative Review conducted from April 2 - 5, 2012. Per the Policy & Procedures Manual, the fiscal year runs from January 1st to December 31st. Administrative documentation presented to Licensing Staff included two proofs of publication dated October 19, 2011 and October 20, 2011 showing that the annual report was available: however, the report was not made available until nearly 10 months following the end of the fiscal year. The findings were reviewed with the Project Director during the exit interview.
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Plan of Correction
On April 27, 2012 the Project Director and the Quality Management Director revised the Governing Body policy which includes the time frame for completion of the annual report. On May 21, 2012 the Governing Body approved the policy revisions which state that the annual report will be made available to the general public upon completion of the financial audit for that calendar year. CRC's fiscal year is a calendar year and runs from January 1 through December 31. CRC Corporate offices will complete the 10-K and will file it with the SEC upon completion of the calendar year. The Executive Director will create the annual report after the 10-K is filed. The Governing Body will approve the annual report upon its completion. Upon approval the public will be made aware it is available for review. The Executive Director is responsible for assuring that the Annual Report is completed within the designated time frame. The Quality Management Director will monitor this process via communication with the Executive Director in weekly conference calls as well as through weekly Division conference calls. The Quality Management Director has distributed the aforementioned policy change to all administrators and key staff. |
709.26(e)(2) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(2) The employe's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
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Observations
Based upon a review of the Policy and Procedures Manual, the project failed to develop a policy regarding an employee's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.The findings include:The Policy & Procedures Manual was reviewed as part of an Administrative Review conducted from April 2 - 5, 2012. As per the General Work Rules section of the Policy & Procedures Manual, the following documentation was contained in a subsection titled, Employee Personnel Files: "You may inspect your personnel file in the presence of Human Resources or the site Facility Director. You may request copies from your file of any documents that you have previously signed. If you desire, you may add a written statement to your file explaining any disputed item."As developed, the policy failed to inform employees of their right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from their record.The findings were reviewed during the exit interview conducted with the Quality / Training Manager and Project Director.
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Plan of Correction
The Human Resource Senior Business Partner will add an addendum to the employee handbook which states an employee may indicate, in writing, that he/she wishes to have a disputed item removed from his/her Human Resource File. The revised Employee Handbook will be delivered to current employees no later than June 30, 2012. In the interim, new employees will receive a statement in their new hire packets indicating one's right to dispute, in writing, information they deem inaccurate within their Human Resource file. |
709.32(c)(1) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication.
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Observations
Based upon a review of the Policy and Procedures Manual, the facility's policy on the administration of medication failed to address limitations of individuals authorized to administer medications. The findings include:The Policy & Procedures Manual was reviewed as part of an Administrative Review conducted from April 2 - 5, 2012. The project's policy regarding the administration of medication states: "In the PA Department of Health D&A licensed facilities staff authorized to perform medication administration are licensed medical staff, licensed nursing staff, and consulting pharmacists."In Pennsylvania, pharmacists are permitted to administer medications but only under limited circumstances; however, the policy fails to delineate those limited circumstances. As of the time of inspection, the consulting pharmacists were not limited in their administration of medication. The findings were reviewed with the Project Director during the exit interview.
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Plan of Correction
On April 27, 2012 the Medication Labeling, Preparation, Administration and Documentation policy was revised by the Project Director and the Quality Management Director. On May 21, 2012 the Governing Body approved the policy revision. The consulting pharmacist has been removed from the list of designated staff that can administer medications. The Quality Management Director has distributed the policy to the administrators and all key staff. |
709.63(a)(3) LICENSURE Progress notes
709.63. 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:
(3) Progress notes.
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Observations
Based on the review of detox client records, the facility failed to document individualized progress notes.The findings include:Six detox client records were reviewed on April 16, 2012 for documentation of progress notes. The facility failed to individualized progress notes in two out of six detox client records, specifically client records # 15 and 16.Client #15, admitted on April 13, 2012 and client #16, admitted on April 11, 2012 had nearly identical group progress notes documented on April 16, 2012, time stamped 2:00-3:00pm. The only variation in the notes was the clients ' names. Furthermore, the inspectors had exclusive possession of the clients' charts since 11:50am on April 16, 2012. The notes were not only not individualized, but also documented prior to the actual occurance of the referenced group session. The findings were discussed with the clinical supervisor later that day.
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Plan of Correction
All activities facilitated in the detoxification unit are considered structured activities and are not small group processes. Structured activity notes are prepared in response to the entire community's reaction and involvement, not individualized to each patient.
By May 21, 2012, the Clinical Director will create a template for the structured activity notes and the small group notes and will be distributed to all clinical staff.
Ongoing, the Detox Unit Supervisor will randomly select 1 chart from each clinician's caseload weekly to review the correct use of appropriate templates.
The findings will be reviewed in the clinician's individual supervision noting any areas of improvement.
The chart containing the pre-timed note was an error made by the Case Manager. The time indicated on the note wasn't during the time that a structured activity takes place. The Case Manager in error was counseled on April 20, 2012 about the importance of verifying all information on the structured activity note is accurate.
Ongoing, the Detox Unit Supervisor will randomly select a minimum of 3 charts weekly to ensure that notes have accurate information noted.
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709.53(a)(5) LICENSURE Progress 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:
(5) Progress notes.
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Observations
Based upon a review of the Policy and Procedures Manual and client records, the facility failed to ensure that individualized progress notes were completed for group sessions.The findings include:The Policy and Procedures Manual was reviewed as part of the Administrative Site Review conducted from April 2 - 5, 2012. As per the Manual, progress notes were to be documented by using the Data Assessment Plan (DAP) format. In addition, the Manual specified that individual notes are required for group sessions in residential facilities.Thirteen records requiring individualized documentation of Small Group sessions were reviewed on April 17, 2012. Three of thirteen records, specifically record #'s 5, 6, and 7, contained progress notes for Small Group sessions that were not individualized.Record # 5 contained progress notes for Small Group sessions that were conducted on March 31, 2012, April 10, 20212, April 12, 2012, and April 13, 2012. The Assessment and Plan sections of the progress notes were verbatim for all four dates. Therefore, the progress notes were not individualized.Record # 5 contained progress notes for Small Group sessions that were conducted on April 5, 2012, and April 6, 2012. The Assessment and Plan sections of the progress notes were verbatim for both dates; therefore, the progress notes were not individualized.Record #'s 6 and 7 contained a progress note for a Small Group session that was dated March 30, 2012. The Data, Assessment, and Plan sections of the progress notes in both records were verbatim; therefore, the progress notes were not individualized. The findings were reviewed with the Facility and Clinical Directors during the exit interview.
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Plan of Correction
The Clinical Director is preparing mock charts specific to treatment populations as a reference for clinical staff in the preparation of patient chart documentation. Two Unit Supervisors will conduct trainings with current Counselor, Counselor Assistants to review individualized documentation. All clinical staff will be fully trained by June 4, 2012.
Ongoing, each Unit Supervisor will randomly select 1 chart from each clinician's caseload weekly to review for individualized treatment documentation and the findings will be reviewed in the clinician's individual supervision noting any areas of improvement.
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