INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 12, 2008 through February 13, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHD Womanspace 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 and a plan of correction is due on March 19, 2008.
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Plan of Correction
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704.6(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) 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 and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
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Observations
Based on a review of personnel records, the facility failed to ensure the clinical supervisor met the qualifications for this position, #2. Employee #2 did not have two years of clinical experience.
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Plan of Correction
The Unit Director of the Womanspace Program assumes full responsibility for this project not being in compliance with the standard provided by state laws. This Unit Director is no longer an employee of Resources for Human Development or the Womanspace Philadelphia program. On 2/13/08, the Interim Director of Womanspace Phila. assumed the Clinical Supervisor responsibilities, as he meets the minimal qualifications having a Bachelors Degree in Psychology and three years clinical experience working directly with a chemically dependent person. He subsequently signed a job description on 2/13/08 including the aforementioned responsibilities. Employee # 2 was re-assigned to the Counselor position and signed a job description on 2/14/08 that removed supervisory responsibilities from her obligations. By 4/1/08 the Director will include a minimum qualification check off sheet in the hiring packet of clinical employees, which allows for an applicants qualifications to be checked against state regulations. If an applicant does not meet the minimum qualifications, they will not be hired for that position. The director will monitor this process at time of hire, and monthly thereafter. |
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 of personnel records, the facility failed to ensure one of one counselor met the qualifications for this position, #3. Employee #3 did not have one year of clinical experience.
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Plan of Correction
The Unit Director of the Womanspace Program assumes full responsibility for this project not being in compliance with the standard provided by state laws. This Unit Director is no longer an employee of Resources for Human Development or the Womanspace Philadelphia program. The prior director had incorrectly calculated Employee #3's years as case manager as meeting requirement of clinical experience. On 2/13/08 employee #3 was re-assigned as a Counselor Assistant, and signed a job description, allowing her to carry 2 clients thus satisfying the client / counselor ratio of 8 to 1. On 2/ 26/08, employee # 3 signed a new training plan that specifically addressed a plan to achieve counseling competency with respect to chemical dependency issues. Employee #3 is also scheduled to receive weekly 1hour supervision sessions starting on 2/29/08. By 4/1/08 the Director will include a minimum qualification check off sheet in the hiring packet of supervisory employees, which allows for an applicants qualifications to be checked against state regulations. If an applicant does not meet the minimum qualifications, they will not be hired for that position. The director will monitor this process at time of hire, and monthly thereafter. |
704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop a comprehensive staff development program. The facility policy did not include who is responsible and the time frames for completing an assessment of staff training needs, an overall training plan, feedback information and an annual evaluation of the overall training plan.
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Plan of Correction
704.11(a)
The Unit Director of the Womanspace Program assumes full responsibility for this project not being in compliance with the standard provided by state laws. This Unit Director is no longer an employee of Resources for Human Development or the Womanspace Philadelphia program. By 3/24/08 the Director or Interim Director will establish a comprehensive staff development program. The director will be responsible for completing assessments of staff training needs and participate in the completion of the overall training plan. The director will provide feedback in an annual evaluation of the overall training plan. The Director will monitor on a quarterly basis, for compliance.
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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 a review of facility policy and training records, the facility failed to document a complete individual training plan in thirteen of fifteen records reviewed, #1, 2, 3, 4, 6, 8, 9, 10, 11, 12, 13, 14 and 15. Training plans were not documented in three records reviewed, #1, 13 and 15. Training plans were not documented within the time frame stated in the facility's policy and procedure in ten records reviewed, 2, 3, 4, 6, 8, 9, 10, 11, 12 and 14. The facility's policy stated that training plans were to be completed every August or within 30 days of hire.
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Plan of Correction
The Unit Director of the Womanspace Program assumes full responsibility for this project not being in compliance with the standard provided by state laws. This Unit Director is no longer an employee of Resources for Human Development or the Womanspace Philadelphia program. By 3/28/08 a complete individual training plan will be completed for every employee of Womanspace program. All subsequent training plans will be documented by the end of July, or within 30 days of hire. The Director will monitor on a quarterly basis, for compliance. |
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 training records, the facility failed to document HIV/AIDS and TB/STD training in one of fifteen records reviewed, #9. Employee #9 was hired 7/11/01.
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Plan of Correction
The Unit Director of the Womanspace Program assumes full responsibility for this project not being in compliance with the standard provided by state laws. This Unit Director is no longer an employee of Resources for Human Development or the Womanspace Philadelphia program. By 2/26/08 all staff members will be scheduled for HIV / AIDS and TB/STD training to meet the general training requirements. By 11/08 all staff will have completed the training and have present in file a current training certificate for the aforementioned health related subjects. The Director will monitor on a monthly basis, for compliance. |
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 training records and a four week work schedule, the facility failed to provide a sufficient number of persons certified in CPR on 1/19/08, 1/27/08 and 2/2/08, 2/9/08 and 2/10/08. Employee #6 and #15 did not have documentation of CPR certification. The work schedule showed that employee #6 worked alone on 1/19/08, 1/27/08 and 2/9/08 and employee #15 worked alone on 2/2/08 and 2/10/08.
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Plan of Correction
The Unit Director of the Womanspace Program assumes full responsibility for this project not being in compliance with the standard provided by state laws. This Unit Director is no longer an employee of Resources for Human Development or the Womanspace Philadelphia program. By 4/10/08 all staff will have a documented CPR/ First Aid certification in their respective employee file. If there is a new staff member who has not taken the training, they will be scheduled with someone who is certified, so that at any given time there will be a staff member on duty who is CPR / First Aid certified. The Director will ensure all staff members are scheduled for the training upon hire, and will follow up monthly on staff trainings. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document fire extinguisher training within the required time frame in five of seven records reviewed, #2, 3, 5, 6 and 7.
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Plan of Correction
The Unit Director of the Womanspace Program assumes full responsibility for this project not being in compliance with the standard provided by state laws. This Unit Director is no longer an employee of Resources for Human Development or the Womanspace Philadelphia program. By 3/28/08, all personnel records will include fire safety training for each staff member with documentation confirming their knowledge of the use and location of all emergency fire exits, use and location of fire extinguishers, and substantiation of their viewing of "Fire Safety: Plan To Get Out Alive". This training will be held within the required time as stated in the policy and procedures manual. The Director will ensure all staff members are scheduled for this training within allotted time frame upon hire, and will monitor this monthly. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 a review of personnel records, the facility failed to perform assigned tasks during emergencies within the required time frame in five of seven records reviewed, #3, 2, 5, 6 and 7.
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Plan of Correction
The Unit Director of the Womanspace Program assumes full responsibility for this project not being in compliance with the standard provided by state laws. This Unit Director is no longer an employee of Resources for Human Development or the Womanspace Philadelphia program. By 4/25/08 all personnel records will include fire drill training for each staff member with documentation confirming their knowledge of how to conduct a fire drill and who is responsible for specific tasks during emergencies. This training will be held within the required time as stated in the policy and procedures manual. The Director will ensure all staff members are scheduled for this training within allotted time frame upon hire, and will monitor this monthly. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the fire drill record, the facility failed to document problems encountered during fire drills conducted from September 2007 through February 2008.
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Plan of Correction
The Unit Director of the Womanspace Program assumes full responsibility for this project not being in compliance with the standard provided by state laws. This Unit Director is no longer an employee of Resources for Human Development or the Womanspace Philadelphia program. On 3/11/08 a Fire Drill Report form was developed to document the pertinent details of a fire drill, including problems and how they were and will be addressed. By 4/18/08 all staff will be trained on the use of the Fire Drill Report. This training will be documented by 4/25/08. The Director will ensure all staff members are scheduled for this training within allotted time frame upon hire, and will monitor this monthly. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill record, the facility failed to set off a fire alarm or smoke detector during each fire drill from September 2007 through February 2008.
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Plan of Correction
The Unit Director of the Womanspace Program assumes full responsibility for this project not being in compliance with the standard provided by state laws. This Unit Director is no longer an employee of Resources for Human Development or the Womanspace Philadelphia program. By 3/19/08 monthly fire drills will be conducted as scheduled by the Director. The staff member leading the drill will use the smoke detector or the fire alarm to begin the drill. This information will be documented in the Fire Drill Report and reviewed by Director monthly. |
709.22(e)(2) 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:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the annual report, the facility failed to include a financial statement of income and expenses for the 2006/2007 fiscal year.
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Plan of Correction
The Unit Director of the Womanspace Program assumes full responsibility for this project not being in compliance with the standard provided by state laws. This Unit Director is no longer an employee of Resources for Human Development or the Womanspace Philadelphia program. On 2/14/08 the Director included a financial statement of income and expenses for the 2006 / 2007 fiscal year in the policy and procedures manual. This statement will be updated annually and will be made available to the public. The Director will ensure this requirement is met annually. |
709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
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Observations
Based on a physical plant inspection conducted on January 13, 2008, the facility failed to post a service fee schedule in a prominent place. A fee schedule was not posted.
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Plan of Correction
The Unit Director of the Womanspace Program assumes full responsibility for this project not being in compliance with the standard provided by state laws. This Unit Director is no longer an employee of Resources for Human Development or the Womanspace Philadelphia program. By 3/11/08 the director will post a service fee schedule in the entryway area and the administrative office both of which are prominent areas in the program and areas of high visibility. The Director will monitor this monthly. |
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 client records, the facility failed to obtain an informed and voluntary consent in four of four records reviewed, #1, 2, 3 and 4. Information was released to the Department of Public Welfare (DPW) without a signed consent by the client in one record, #1. Documentation in the client record indicated a phone call was made to the "welfare office" without a signed consent from the client. Information was released to the Department of Public Welfare (DPW) and a dentist office without signed consents by the client in one record reviewed, #2. Documentation in the client record indicated a phone call was made to the "welfare office" and dentist office without a signed consent from the client. Information was released to the client's family, parole office, Forensic Intensive Recovery Program (FIR) and a friend of the client without signed consents by the client in one record, #4. Documentation in the client record indicated that phone calls were made to the client's family, parole office, Forensic Intensive Recovery Program (FIR) and a friend of the client without a signed consent from the client. The facility used one consent to release form for different purposed to multiple agencies, the Forensic Intensive Recovery Program (FIR), parole and probation office and medical offices, in three of four records reviewed, #2, 3 and 4.
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Plan of Correction
The Unit Director of the Womanspace Program assumes full responsibility for this project not being in compliance with the standard provided by state laws. This Unit Director is no longer an employee of Resources for Human Development or the Womanspace Philadelphia program. By 3/17/08 the Director will develop the informed and voluntary consent form and ensure that one is obtained from each client that comes into treatment. Also, consent to release information and consent to accept information forms will be developed and utilized for each contact the program may make on the client's behalf. The Director will train all staff of the proper use of consents and how to fill them out by 3/28/08. The Director will review training schedules quarterly. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to obtain informed and voluntary consent to release information in three of four records reviewed, #1, 2 and 4. Consent to release information forms for Community Behavioral Health (CBH) exceeded the limitations imposed at 4 Pa. Code 255.5 stating that the facility can release "specific information", without further clarification, to be disclosed in four of four records reviewed, #1, 2, 3 and 4.
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Plan of Correction
The Unit Director of the Womanspace Program assumes full responsibility for this project not being in compliance with the standard provided by state laws. This Unit Director is no longer an employee of Resources for Human Development or the Womanspace Philadelphia program. The Consents to Release Information to Community Behavioral Health (CBH) will be re-formed as not to exceed the limitations imposed at 4 PA Code 255.5 by 4/11/08. The Director will ensure this requirement is met monthly. |
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 records.
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Observations
Based on a review of client records, the facility failed to document that clients were offered a copy of the consent to release forms (medical) in four of four records reviewed, #1, 2, 3 and 4.
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Plan of Correction
The Unit Director of the Womanspace Program assumes full responsibility for this project not being in compliance with the standard provided by state laws. This Unit Director is no longer an employee of Resources for Human Development or the Womanspace Philadelphia program. All consents to release information forms will have a demarcation of accepted and rejected included on the form to document that each client will be offered a copy of the forms. This will be completed by 3/28/08 and will be monitored by monthly follow up supervision conducted by the director. |
709.32(c)(4) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
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Observations
Based on a review of the medication policies and procedures and medication administration records, the facility failed to document complete medication records. The medication records were blank on numerous days in February 2008. Documentation was missing to indicate whether or not a client received their medication, if a client refused their medication or whether the medication was discontinued.
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Plan of Correction
The Unit Director of the Womanspace Program assumes full responsibility for this project not being in compliance with the standard provided by state laws. This Unit Director is no longer an employee of Resources for Human Development or the Womanspace Philadelphia program. By 4/1/08 the Director or designee will conduct a quarterly medication monitoring training for all staff members. The training will concentrate on the importance of medication monitoring, documentation and procedures. The Director or designee will monitor the completeness of the medication log on a monthly basis and will discuss this in monthly staff meetings. The monthly discussion will reinforce the information disseminated in the training. |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. 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 client records, the facility failed to document a complete drug and alcohol history in three of three records reviewed, #1, 2 and 4. The lengths and patterns of use were not documented.
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Plan of Correction
The Unit Director of the Womanspace Program assumes full responsibility for this project not being in compliance with the standard provided by state laws. This Unit Director is no longer an employee of Resources for Human Development or the Womanspace Philadelphia program. By 4/12/08 the Womanspace intake and admission documentation process will be comprised of a more comprehensive drug and alcohol history that will include length and patterns of use. The Director will reconfigure the bio-psychosocial to emphasize this information by 4/12/08. The Director will then review each drug and alcohol history monthly, to ensure that the lengths and patterns of use are documented properly. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document complete physical examinations in three of three records reviewed, 1, 2 and 4. The physical examination did not include the client's general appearance, a review of their organ systems and the physician impressions.
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Plan of Correction
The Unit Director of the Womanspace Program assumes full responsibility for this project not being in compliance with the standard provided by state laws. This Unit Director is no longer an employee of Resources for Human Development or the Womanspace Philadelphia program. By 4/13/08 the Womanspace intake and admission documentation process will be comprised of a more comprehensive physical examination segment that will include a clients' general appearance, a review of their organ systems, and a physician's impression. The amended Client Physical Examination Form will be completed by 4/13/08 by the Director or a designee. The Director will maintain quarterly follow up supervisions to ensure that the amended forms are completed. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document complete psychosocial evaluations in three of three records reviewed, #1, 2 and 4. Psychosocial evaluations were historical rather than an assessment of the client's assets and strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and counselors conclusions/impressions of the client.
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Plan of Correction
The Unit Director of the Womanspace Program assumes full responsibility for this project not being in compliance with the standard provided by state laws. This Unit Director is no longer an employee of Resources for Human Development or the Womanspace Philadelphia program. By 4/1/08 the Director will conduct a documentation training for clinicians that will entail an explanation of how to conduct an assessment that evaluates a client's assets, strengths, support systems, coping mechanisms, and negative factors that may inhibit treatment. By 4/14/08 assessments will emphasize counselors conclusions and impressions of the client as required by regulations. By 4/25/08 the Director will review psychosocial evaluations monthly to ensure compliance. The Director will repeat documentation training annually. |
709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
Based on a review of client records, the facility failed to document an individual treatment plan in one of three records reviewed, #4. The treatment plan was missing.
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Plan of Correction
The Unit Director of the Womanspace Program assumes full responsibility for this project not being in compliance with the standard provided by state laws. This Unit Director is no longer an employee of Resources for Human Development or the Womanspace Philadelphia program. By 3/28/08, a documentation flow chart will be created that monitors timely bio-psychosocial histories, comprehensive treatment plans, updated treatment plans, 90-day review submissions. This flow chart will be reviewed weekly by clinical staff and monitored monthly by program Director. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document a complete treatment plan in three of three client records reviewed, #1, 2 and 4. Treatment plan updates did not include the client's progress in relationship to the stated goals of the treatment plan, but rather stated generalized comments that were not specific to each client's progress in treatment.
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Plan of Correction
The Unit Director of the Womanspace Program assumes full responsibility for this project not being in compliance with the standard provided by state laws. This Unit Director is no longer an employee of Resources for Human Development or the Womanspace Philadelphia program. By 4/1/08 the Director will conduct documentation training for clinicians that will entail an explanation of time requirements for treatment plan updates, and how an updated treatment plan should include a client's progress in relationship to the stated goal. The Director will repeat documentation training annually. |
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 on a review of client records, the facility failed to document complete progress notes in three of three records reviewed, #1, 2 and 4. Group progress notes did not include the counselor's assessment of the client.
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Plan of Correction
The Unit Director of the Womanspace Program assumes full responsibility for this project not being in compliance with the standard provided by state laws. This Unit Director is no longer an employee of Resources for Human Development or the Womanspace Philadelphia program. By 4/1/08 the Director will conduct documentation training for clinicians that will entail an explanation of how to write complete progress notes utilizing D-A-P notes. Specific emphasis will be placed on documenting the assessment segment of the progress notes. The Director will repeat documentation training annually. |
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 document complete discharge summaries in two of two records reviewed, #3 and 4. The discharge summary was not completed in one record, #3. The discharge summary was documented in client record #4, but did not have a date to verify when it was completed.
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Plan of Correction
The Unit Director of the Womanspace Program assumes full responsibility for this project not being in compliance with the standard provided by state laws. This Unit Director is no longer an employee of Resources for Human Development or the Womanspace Philadelphia program. By 4/1/08 the Director will conduct documentation training for clinicians that will entail an explanation of how to complete a discharge summary. The Director will repeat documentation training annually. |
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 document follow-up information in two of two records reviewed, #3 and 4.
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Plan of Correction
The Unit Director of the Womanspace Program assumes full responsibility for this project not being in compliance with the standard provided by state laws. This Unit Director is no longer an employee of Resources for Human Development or the Womanspace Philadelphia program. By 4/1/08 the Director will conduct documentation training for clinicians that will entail an explanation of how and when to document client follow up information. The Director will repeat documentation training annually. |