INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on 2/8-2/11/21 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, Libertae Family House Libertae, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility
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Plan of Correction
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirement Facility Summary Report on February 8, 2021 through February 11, 2021, the facility failed to comply with the FTE counselor caseload ratio for staff # 4.Employee #4's caseload ratio calculation was 72:1The finding was reviewed with facility staff.
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Plan of Correction
The deficiency has been corrected. The deficiency was the result of miscalculating the FTE counselor caseload ratio. According to DDAP Licensing Alert 01-14 of September 2014, "Some long-term active clients are receiving regular and predetermined direct counseling services but at a frequency of less than twice per month. These long-term active clients who are not receiving direct counseling services at least twice per month will not be included in the counselor caseload computations..."
The project will adhere to the above directive in that any client who is not receiving direct counseling services on a regular basis at least twice per month will not be included as a client on a counselor's caseload. The project will still consider the client to be active according to the licensing department's approved capacity, and include that same client on a listing of active clients at any given. However, the maximum caseload for a full-time equivalent/(FTE) counselor for counseling in the outpatient programs will not exceed 35 clients.
To ensure that the deficiency does not reoccur, the manager of the outpatient program will review attendance of each client at the end of every month. The assignment of new clients to each counselor will be made in accordance with the mandated ratio. Outpatient utilization will be reviewed monthly at Quality Assurance Committee meetings. |
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
A physical plant inspection was conducted on February 8, 2021, the facility failed to ensure that there were no portable space heaters located throughout the facility. 3 portable space heaters were located in the following areas:1st floor therapist offices on the right side of the hallway across from the conference room.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency has been corrected. All portable space heaters have been removed and discarded.
The correction will be maintained by taking the following action steps:
1. The Facility Director will disseminate the Building and Grounds Policy and Procedures and review procedures with operations department personnel, to include the need to ensure that no portable space heaters are located throughout the facility.
2. All staff will be directed to enter a work order in the facility management system should they identify any area of the buildings and grounds that need attention, including findings issues with heating and cooling systems.
3. It is the responsibility of maintenance personnel to respond to all work orders in the facilities management system in a timely manner.
4. All grounds of the facility will be inspected monthly by maintenance personnel who are to ensure that the heating and cooling system is functional.
5. The Director of Operations or the Facility Director shall review with maintenance personnel all work orders entered into the facility management system and the resolution of same on a monthly basis.
6. The management team of the facility will develop and implement written standard work procedures for maintenance services that are organized to include all areas for improvement that have been identified by this inspection.
7. The Facility Director will generate and disseminate data reports that demonstrate improvements in the area of physical plant. |
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 on February 8, 2021 through February 11, 2021, the facility failed to document fire extinguisher training in 1 of 3 records.Employee #1, hired 10/15/2020The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency has been corrected. Employee #1, hired on 10/15/2020 received fire extinguisher training. This instruction was documented by the facility in the personnel record of Employee #1.
In order to ensure that the deficiency does not reoccur, the Administrative Assistant is responsible to monitor the compliance of all staff with use of the fire extinguishers training upon employment, and documenting same in the personnel files. Oversight of the compliance with the required trainings is the responsibility of the supervisor of the Administrative Assistant of the project. The supervisor shall review all personnel records on a quarterly basis for completeness of documentation. Any deficiencies noted shall be addressed with the employee. |
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 on February 8, 2021 through February 11, 2021, the facility failed to document training on assigned tasks during emergencies in 1 of 3 records.Employee #1, hired 10/15/2020The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
This deficiency has been corrected. All staff, including Employee #1, hired 10/15/2020, have been instructed to perform assigned tasks during emergencies, and the required training has been documented in their personnel files.
The corrective action will be maintained by the facility, by following the standard work procedures which were developed and implemented for personnel hiring.
This includes the orientation of new staff to performing assigned tasks during emergencies by the operations personnel, who then signs off on the training form and returns it to the office manager for inclusion in the staff's personnel file.
It is the responsibility of the Finance Director, to then review the personnel files quarterly for completeness. |
709.32 (c) (6) LICENSURE Medication control
§ 709.32. Medication control.
(6) Medication errors and drug reactions shall be recorded in the client record. This may be the medical record if a separate medical record is maintained for all clients.
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Observations
Based on a review of the facility's policy and procedure manual on February 8, 2021 through February 11, 2021, the facility failed to include in their policy, procedures pertaining to documenting medication errors and drug reactions in the client record. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency has been corrected. The facility has developed and implemented an updated policy and procedure, to include procedures pertaining to documenting medication errors and drug reactions in the client record.
The updated policy shall be distributed to all staff. Ongoing monitoring of the corrective action plan will occur at the monthly Quality Assurance Committee meetings where the facility's medication incident log is reviewed for compliance with policies and procedures.
In order to ensure that the deficiency does not recur, the project director will perform an annual review of all DDAP licensing alerts to ascertain the need to revise any policies and procedures to include any updates, accordingly.
The project director is responsible for updating and/or revising policies and procedures, per regulation 709.23, which states, "Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures."
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709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Based on a review of the facility's policy and procedure manual on February 8, 2021 through February 11, 2021, the facility failed to include in their policy, procedures pertaining to physical assaults or sexual assault by staff or a client.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency has been corrected. The facility has developed and implemented an updated policy and procedure according to the Licensing Alert 02-2018 "Reporting of Unusual Incidents", to include procedures pertaining to physical assaults or sexual assault by staff or a client.
The updated policy shall be distributed to all staff. Ongoing monitoring of the corrective action plan will occur at the monthly Quality Assurance Committee meetings where the facility incident log is reviewed for compliance with policies and procedures.
In order to ensure that the deficiency does not recur, the project director will perform an annual review of all DDAP licensing alerts to ascertain the need to revise any policies and procedures to include any updates, accordingly.
The project director is responsible for updating and/or revising policies and procedures, per regulation 709.23, which states, "Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures." |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on a review of the facility's policy and procedure manual on February 8, 2021 through February 11, 2021, the facility failed to include in their policy, procedures pertaining to the selling or use of illicit drugs on the premises.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency has been corrected. The facility has developed and implemented an updated policy and procedure according to the Licensing Alert 02-2018 "Reporting of Unusual Incidents", to include procedures pertaining to the selling or use of illicit drugs on the premises.
The updated policy shall be distributed to all staff. Ongoing monitoring of the corrective action plan will occur at the monthly Quality Assurance Committee meetings where the facility incident log is reviewed for compliance with policies and procedures.
In order to ensure that the deficiency does not recur, the project director will perform an annual review of all DDAP licensing alerts to ascertain the need to revise any policies and procedures to include any updates, accordingly.
The project director is responsible for updating and/or revising policies and procedures, per regulation 709.23, which states, "Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures." |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
Based on a review of the facility's policy and procedure manual on February 8, 2021 through February 11, 2021, the facility failed to include in their policy, procedures pertaining to death or serious injury due to trauma, suicide, medication error or unusual circumstances.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency has been corrected. The facility has developed and implemented an updated policy and procedure according to the Licensing Alert 02-2018 "Reporting of Unusual Incidents", to include procedures pertaining to death or serious injury due to trauma, suicide, medication error or unusual circumstances.
The updated policy shall be distributed to all staff. Ongoing monitoring of the corrective action plan will occur at the monthly Quality Assurance Committee meetings where the facility incident log is reviewed for compliance with policies and procedures.
In order to ensure that the deficiency does not recur, the project director will perform an annual review of all DDAP licensing alerts to ascertain the need to revise any policies and procedures to include any updates, accordingly.
The project director is responsible for updating and/or revising policies and procedures, per regulation 709.23, which states, "Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures." |
709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
Based on a review of the facility's policy and procedure manual on February 8, 2021 through February 11, 2021, the facility failed to include in their policy, procedures pertaining to a significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency has been corrected. The facility has developed and implemented an updated policy and procedure according to the Licensing Alert 02-2018 "Reporting of Unusual Incidents", to include procedures pertaining to a significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than one (1) day.
The updated policy shall be distributed to all staff. Ongoing monitoring of the corrective action plan will occur at the monthly Quality Assurance Committee meetings where the facility incident log is reviewed for compliance with policies and procedures.
In order to ensure that the deficiency does not recur, the project director will perform an annual review of all DDAP licensing alerts to ascertain the need to revise any policies and procedures to include any updates, accordingly.
The project director is responsible for updating and/or revising policies and procedures, per regulation 709.23, which states, "Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures." |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on a review of the facility's policy and procedure manual on February 8, 2021 through February 11, 2021, the facility failed to include in their policy, procedures pertaining to theft, burglary, break-in or similar incident at the facility.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency has been corrected. The facility has developed and implemented an updated policy and procedure according to the Licensing Alert 02-2018 "Reporting of Unusual Incidents", to include procedures pertaining to theft, burglary, break-in or similar incident at the facility.
The updated policy shall be distributed to all staff. Ongoing monitoring of the corrective action plan will occur at the monthly Quality Assurance Committee meetings where the facility incident log is reviewed for compliance with policies and procedures.
In order to ensure that the deficiency does not recur, the project director will perform an annual review of all DDAP licensing alerts to ascertain the need to revise any policies and procedures to include any updates, accordingly.
The project director is responsible for updating and/or revising policies and procedures, per regulation 709.23, which states, "Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures." |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's policy and procedure manual on February 8, 2021 through February 11, 2021, the facility failed to include in their policy, procedures pertaining to an event requiring the presence of police, fire or ambulance personnel.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency has been corrected. The facility has developed and implemented an updated policy and procedure according to the Licensing Alert 02-2018 "Reporting of Unusual Incidents", to include procedures pertaining to an event requiring the presence of police, fire or ambulance personnel.
The updated policy shall be distributed to all staff. Ongoing monitoring of the corrective action plan will occur at the monthly Quality Assurance Committee meetings where the facility incident log is reviewed for compliance with policies and procedures.
In order to ensure that the deficiency does not recur, the project director will perform an annual review of all DDAP licensing alerts to ascertain the need to revise any policies and procedures to include any updates, accordingly.
The project director is responsible for updating and/or revising policies and procedures, per regulation 709.23, which states, "Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures." |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
Based on a review of the facility's policy and procedure manual on February 8, 2021 through February 11, 2021, the facility failed to include in their policy, procedures pertaining to fire or structural damage to the facility.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency has been corrected. The facility has developed and implemented an updated policy and procedure according to the Licensing Alert 02-2018 "Reporting of Unusual Incidents", to include procedures pertaining to fire or structural damage to the facility.
The updated policy shall be distributed to all staff. Ongoing monitoring of the corrective action plan will occur at the monthly Quality Assurance Committee meetings where the facility incident log is reviewed for compliance with policies and procedures.
In order to ensure that the deficiency does not recur, the project director will perform an annual review of all DDAP licensing alerts to ascertain the need to revise any policies and procedures to include any updates, accordingly.
The project director is responsible for updating and/or revising policies and procedures, per regulation 709.23, which states, "Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures." |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
Based on a review of the facility's policy and procedure manual on February 8, 2021 through February 11, 2021, the facility failed to include in their policy, procedures pertaining to an outbreak of a contagious disease requiring Centers for Disease Control notification.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency has been corrected. The facility has developed and implemented an updated policy and procedure according to the Licensing Alert 02-2018 "Reporting of Unusual Incidents", to include procedures pertaining to an outbreak of a contagious disease requiring Centers for Disease Control notification.
The updated policy shall be distributed to all staff. Ongoing monitoring of the corrective action plan will occur at the monthly Quality Assurance Committee meetings where the facility incident log is reviewed for compliance with policies and procedures.
In order to ensure that the deficiency does not recur, the project director will perform an annual review of all DDAP licensing alerts to ascertain the need to revise any policies and procedures to include any updates, accordingly.
The project director is responsible for updating and/or revising policies and procedures, per regulation 709.23, which states, "Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures." |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
Based on a review of the facility's policy and procedure manual on February 8, 2021 through February 11, 2021, the facility failed to include in their policy, procedures pertaining to the implementation of a timely and appropriate corrective action plan.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency has been corrected. The facility has developed and implemented an updated policy and procedure according to the Licensing Alert 02-2018 "Reporting of Unusual Incidents", to include procedures pertaining to the implementation of a timely and appropriate corrective action plan.
The updated policy shall be distributed to all staff. Ongoing monitoring of the corrective action plan will occur at the monthly Quality Assurance Committee meetings where the facility incident log is reviewed for compliance with policies and procedures.
It is the responsibility of the project director to ensure that the corrective action is implemented.
The project director is responsible for updating and/or revising policies and procedures, per regulation 709.23, which states, "Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures." |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
Based on a review of the facility's policy and procedure manual on February 8, 2021 through February 11, 2021, the facility failed to include in their policy, procedures pertaining to the ongoing monitoring of corrective action plans.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency has been corrected. The facility has developed and implemented an updated policy and procedure according to the Licensing Alert 02-2018 "Reporting of Unusual Incidents", to include procedures pertaining to the ongoing monitoring of corrective action plans.
The updated policy shall be distributed to all staff. Ongoing monitoring of the corrective action plan will occur at the monthly Quality Assurance Committee meetings where the facility incident log is reviewed for compliance with policies and procedures.
It is the responsibility of the project director to ensure that the corrective action is implemented.
The project director is responsible for updating and/or revising policies and procedures, per regulation 709.23, which states, "Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures." |
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 client records reviewed on February 8, 2021 through February 11, 2021, the facility failed to provide documentation of a physical examination in 1 of 4 records.Client # 2- admitted on 11/23/20 to present.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency has been corrected by entering documentation of a physical examination in the client record for client #2.
The correction will be maintained by taking the following action steps:
1. The facility director, with the manager of admissions, will review, revise and update the intake and admissions policies and procedures as needed.
2. The facility director, with the manager of admissions will develop and implement written standard work procedures for admissions that include the documentation in the clinical records of a physical examination for each client within 7 days of admission.
3. The manager of admissions will ensure that documentation of a physical examination has been obtained for all clients within 7 days of admission and filed in each client's record.
The correction will be maintained by conducting a rigorous review of client records to ensure that the documentation of a physical examination is included in each client's record within 7 days of admission.
It is the responsibility of the Facility Director with the Director of Social Services and Finance Director to conduct a review of all client records every 30 days for all clients admitted the previous 30 days, to verify that each client record captures the required documentation, including this documentation of a physical examination. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on client records reviewed on February 8, 2021 through February 11, 2021, the facility failed to document treatment plan updates in 1 of 4 records.Client # 1- admitted on 11/26/19 to present.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency has been corrected.
A treatment plan update has been completed and documented in the client record for client #1, admitted on 11/26/19.
Treatment and rehabilitation plans shall be reviewed and updated at least every sixty (60) days. The treatment plan update shall include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records.
The Project Director will review the policy and procedures with all agency treatment providers by December 16, 2020.
Client records will be reviewed at regularly scheduled supervision meetings with the Clinical Supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records, per month of the previous month.
Adherence to the requirements regarding client records will be verified and any problems will be reported and reviewed by the Project Director for corrective action. |
709.93(a)(5) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Progress notes.
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Observations
Based on client records reviewed on February 8, 2021 through February 11, 2021, the facility failed to provide in the progress note a plan for the client in 3 of 4 records. Client # 1- admitted on 11/26/19 and still an active client. The following notes failed to have the required information; 11/10/20, 12/2/20, 12/8/20, 12/22/20, 1/5/21 and 1/19/21.Client # 2- admitted on 8/29/19 and discharged 12/18/20. The following notes failed to have the required information; 10/28/20 and 11/4/20.Client # 3- admitted on 10/24/19 and still an active client. The following notes failed to have the required information; 11/3/20,12/29/20 and 2/8/21.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency shall be corrected by updating the client records to include a plan for the client in the progress notes for Client #1 and Client #2 on the dates cited. The therapist of record is the responsible party for curing the deficiency.
The issue will be corrected by 3/29/21.
Each client's progress shall be reviewed at least quarterly, and more frequently if needed, at a case conference attended by a multidisciplinary team.
Documentation of the case consultation shall be noted in the client's record by the counselor rendering treatment services.
Staff who render treatment services are required to adhere to the program's policy and procedures regarding the completion of client records.
The Project Director will review the policy with all agency treatment providers by March 30, 2021.
Client records will be reviewed at regularly scheduled supervision meetings with the clinical supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records.
Adherence to the requirements regarding client records will be verified and any problems will be reported and addressed by the Project Director for corrective action. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on client records reviewed on February 8,2021 through February 11, 2021, the facility failed to provide documentation for case consultations in 2 of 4 records. Client # 1- admitted on 11/26/19 to presentClient # 3 -admitted on 10/24/19 to presentThese findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency shall be corrected by providing documentation for case consultations in the records for Client #1 and Client #3. It is the responsibility of the therapist of record to enter the documentation into the client charts.
The issue will be corrected by 3/29/21. The therapist will enter documentation for case consultations in the client records.
Each client's progress shall be reviewed at least quarterly, and more frequently if needed, at a case conference attended by a multidisciplinary team.
Documentation of the case consultation shall be noted in the client's record by the counselor rendering treatment services.
Staff who render treatment services are required to adhere to the program's policy and procedures regarding the completion of client records.
The Project Director will review the policy with all agency treatment providers by March 30, 2021.
Client records will be reviewed at regularly scheduled supervision meetings with the clinical supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records.
Adherence to the requirements regarding client records will be verified and any problems will be reported and addressed by the Project Director for corrective action. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on client records reviewed on February 8, 2021 through February 11, 2021, the facility failed to provide documentation of an aftercare plan in 2 of 4 records.Client # 2- admitted 8/19/19 and discharged 12/18/20Client # 4 -admitted on 8/15/19 and discharged 12/18/20These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency shall be corrected by entering an aftercare plan into each client record for Client #2 and Client #4. It is the responsibility of the therapist of record to provide documentation of an aftercare plan in these records.
The issue will be corrected by 3/29/21. The therapist will enter documentation of an aftercare plan in the two records by this date.
The facility shall maintain a complete client record for every individual in treatment, including an aftercare plan, if applicable.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records.
The Project Director will review the policy and procedures with all agency treatment providers by March 30, 2021.
Client records will be reviewed at regularly scheduled supervision meetings with the Clinical Supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records, plus 100% of all discharged client records for the previous month.
Adherence to the requirements regarding client records will be verified and any problems will be reported to the Project Director for corrective action. |
709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on client records reviewed on February 8, 2021 through February 11, 2021, the facility failed to provide documentation of a discharge summary in 1 of 4 records.Client # 4 - admitted on 8/15/19 and discharged 12/18/20The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency has been corrected. A discharge summary has been documented in the record of Client #4.
Within a week after discharge, the treatment provider shall enter into the client's record a discharge summary describing the reasons for treatment, services offered, response to treatment and client's status or condition upon discharge.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records.
The Project Director will review the policy and procedures with all agency treatment providers by March 30, 2021.
Client records will be reviewed at regularly scheduled supervision meetings with the Clinical Supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records, plus 100% of all discharged client records for the previous month.
Adherence to the requirements regarding client records will be verified and any problems will be reported to the Project Director for corrective action. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on client records reviewed on February 8, 2021 through February 11, 2021, the facility failed to provide documentation of follow up information for 2 of 4 records.Client # 2- admitted on 8/29/19 and discharged 12/18/20Client # 4- admitted on 8/15/19 and discharged 12/18/20These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency has been corrected. Documentation of follow up information for Client #2 and Client #4 has been entered into the client records.
The client record shall contain follow-up information. When a client has been discharged the project shall, with the written consent of the client and within one week from the day the the client has discharged, attempt to contact the client to determine her disposition at one-week post-discharge. Once the attempt has been made and documented, the project shall consider its obligation to the individual fulfilled.
Staff who render treatment services are required to adhere to the program's policy and procedures regarding the completion of client records.
The Project Director will review the policy and procedures with all agency treatment providers by March 30, 2021.
Client records will be reviewed at regularly scheduled supervision meetings with the clinical supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records and 100% of discharged clients for the previous month.
Adherence to the requirements regarding client records will be verified and any problems will be reported by the Project Director for corrective action. |