INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 13, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Nuestra Clinica Rehabilitacion 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of employee # 6's counselor assistant supervision notes, the facility failed to provide documentation of supervision weekly for the first 6 months in this position with a bachelor's degree and to also include direct observation.
Employee # 6 was hired as counselor assistant on July 30, 2021 and was still in this position at the time of the inspection. Supervision notes indicate no supervision the weeks of November 29-December 3, 6-10, 13-17, 20-24, 27-31, 2021 and January 3-7, 2022. Also, there was no documentation of direct observation August 23-November 3, 2021.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Lead Counselor has been assigned to provide counselor assistant with direct supervision for the next 3 months and then weekly supervision for the following 3 months. This will be monitored by lead counselor signing off on notes for three months then providing documentation to support the following 3 months. Information will be audited by the facility manager.
Going forward a supervision plan will be established prior to start of employment for counselor assistants. |
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.
|
Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #7, #8 and #9 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #7 was hired as a support staff on September 21, 2019 and was still in this position at the time of the inspection. Employee # 7 was due to have the communicable disease trainings no later than September 21, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #8 was hired as a driver on November 22, 2012 and was still in this position at the time of the inspection. Employee # 9 was due to have the communicable disease trainings no later than November 22, 2014. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #9 was hired as a driver on November 22, 2011 and was still in this position at the time of the inspection. Employee # 9 was due to have the communicable disease trainings no later than November 22, 2013. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 22, 2020 and January 7, 2020 annual inspection.
|
Plan of Correction
Lead Counselor will schedule training and ensure the three staff members attend within the next 3 months. If not available on DDAP a trainer will be obtained and brought in house to complete training by May 1, 2022
going forward all new staff will attend training within the 90-day probationary period upon employment. The director will review monthly for compliance |
705.5 (b) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(b) Each shared bedroom shall have at least 60 square feet of floor space per resident measured wall to wall, including space occupied by furniture. When bunk beds are used, each bedroom shall have at least 50 square feet of floor space per resident measured wall to wall. Bunk beds shall afford enough space in between each bed and the ceiling to allow a resident to sit up in bed. Bunk beds shall be equipped with a securely attached ladder capable of supporting a resident. Bunk beds shall be equipped with securely attached railings on each open side and open end of the bunk. The use of bunk beds shall be prohibited in detoxification programs. Each single bedroom shall have at least 70 square feet of floor space per resident measured wall to wall, including space occupied by furniture.
|
Observations
Based on a physical plant inspection, the facility failed to ensure bunk beds to be equipped with securely attached railings on each open side and open end of the bunk and equipped with a securely attached ladder capable of supporting a resident.
A bunk bed on a second floor bedroom did not have a ladder or railings.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The director has ordered new bunk beds with ladders for the second floor bedroom.
For future compliance there will be a weekly walk though by house managers to identify and report any bed issues for immediate repair replacements. The operation manager will be responsible for the oversight of this report weekly to director |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
|
Observations
Based on a physical plant inspection, the facility failed to provide an operable soap dispenser or paper towels on the second and third floor bathrooms.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
All bathrooms were inspected and soap dispensers and paper towels repaired or replaced and effective 2/1/2022 all are operable. Maintenance will review the bathrooms weekly to ensure proper operations of dispensers and paper towel racks and report compliance to Lead Counselor |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
|
Observations
Based on a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. The first floor resident bathroom shower head was broken and not attached to the shower.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Shower head was replaced and now functioning. The bathrooms will be checked during the maintenance weekly walk through and reported to Lead Counselor for follow up and repair. |
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.
|
Observations
Based on a physical plant inspection, the facility failed to ensure that exits from rooms and from the residential facility are unobstructed. The fire exit door on the third floor was blocked from the outside and unable to be opened.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
New Fire door was ordered. The plastic blocking the exit was removed and door is now operable. The maintenance department will review doors weekly and maintenance supervisor will be advised of any issues he will repair within 7 days. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of the facility 2021 fire drill log, the facility failed to provide documentation of unannounced fire drills being conducted at least once a month. The fire drill log indicates that a fire drill was not conducted the months of April, May, November, and December 2021.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 22, 2020 annual inspection.
|
Plan of Correction
the operations manager was discharged and the Project Director will complete fire drills monthly documenting the process for compliance immediately. |
709.28 (c) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
|
Observations
Based on six of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the name of the person, agency or organization to whom the disclosure is being made.
Client # 1 was admitted on November 17, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated November 17, 2021 to a "Health Insurance Company" did not provide the name of the person, agency or organization to whom the disclosure is being made. Also, another informed and voluntary consent from the client for the disclosure of information signed dated November 17, 2021 did not provide the name of the person, agency or organization to whom the disclosure is being made.
Client # 2 was admitted on December 14, 2021 and was still active at the time of the inspection. Eight informed and voluntary consent from the client for the disclosure of information signed and dated December 14, 2021 did not provide the name of the person, agency or organization to whom the disclosure is being made.
Client # 3 was admitted on December 3, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated December 3, 2021 to a "Health Insurance Company" did not provide the name of the person, agency or organization to whom the disclosure is being made. Also, another informed and voluntary consent from the client for the disclosure of information signed dated December 3, 2021 did not provide the name of the person, agency or organization to whom the disclosure is being made.
Client # 5 was admitted on August 18, 2021 and was discharged on September 15, 2021. An informed and voluntary consent from the client for the disclosure of information dated August 18, 2021 to a "Health Insurance Company" did not provide the name of the person, agency or organization to whom the disclosure is being made. Also, seven additional informed and voluntary consent from the client for the disclosure of information signed and dated August 18, 2021 did not provide the name of the person, agency or organization to whom the disclosure is being made.
Client # 6 was admitted on August 23, 2021 and was discharged on November 17, 2021. An informed and voluntary consent from the client for the disclosure of information dated August 23, 2021 to a "Health Insurance Company" did not provide the name of the person, agency or organization to whom the disclosure is being made. Also, seven additional informed and voluntary consent from the client for the disclosure of information signed and dated August 23, 2021 did not provide the name of the person, agency or organization to whom the disclosure is being made.
Client # 7 was admitted on October 4, 2021 and was discharged on December 20, 2021. An informed and voluntary consent from the client for the disclosure of information dated September 11, 2021 to a "Health Insurance Company" did not provide the name of the person, agency or organization to whom the disclosure is being made.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 22, 2020 and January 7, 2020 annual inspection.
|
Plan of Correction
New intake coordinator has been hired. For clients still in treatment consents were redone with client approval. The lead counselor will audit charts weekly to ensure compliance. Biannual renewal training for consents/confidentiality will be held by clinical supervisor for clinical and intake personnel. |
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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
|
Observations
Based on three of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed.
Client # 2 was admitted on December 14, 2021 and was still active at the time of the inspection. Eight informed and voluntary consent from the client for the disclosure of information signed and dated December 14, 2021 did not provide the specific information disclosed.
Client # 3 was admitted on December 3, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated December 3, 2021 to a government agency did not provide the specific information disclosed.
Client # 4 was admitted on November 29, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated December 5, 2021 to a funding source and dated December 10, 2021 to an outreach/follow up, primary care physician, hospital, pharmacy, and two government agencies did not provide the specific information disclosed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 22, 2020 and January 7, 2020 and February 8, 2019 annual inspection.
|
Plan of Correction
New intake coordinator has been hired. For clients still in treatment consents were redone with client approval. The lead counselor will audit charts weekly to ensure compliance. Biannual renewal training for consents/confidentiality will be held by clinical supervisor for clinical and intake personnel. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
|
Observations
Based on five of seven client records reviewed, the facility failed to document a completed informed and voluntary consent from the client for the disclosure of information to include the purpose of the disclosure.
Client # 2 was admitted on December 14, 2021 and was still active at the time of the inspection. Eight informed and voluntary consent from the client for the disclosure of information signed and dated December 14, 2021 did not provide the purpose of the disclosure.
Client # 3 was admitted on December 3, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated December 3, 2021 to a "government agency" did not provide the purpose of the disclosure.
Client # 4 was admitted on November 29, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated December 5, 2021 to a funding source did not provide the purpose of disclosure. An informed and voluntary consent signed and dated December 10, 2021 to outreach/follow up, primary care physician, hospital, pharmacy, and two government agencies did not provide the purpose of the disclosure.
Client # 5 was admitted on August 18, 2021 and was discharged on September 15, 2021. An informed and voluntary consent from the client for the disclosure of information dated August 18, 2021 to an emergency contact, health insurance company, and four government agencies, did not provide the purpose of the disclosure.
Client # 6 was admitted on August 23, 2021 and was discharged on November 17, 2021. An informed and voluntary consent from the client for the disclosure of information dated August 23, 2021 to a Health Insurance Company, hospital, and four government agencies did not provide the purpose of the disclosure. Also, seven other informed and voluntary consent from the client for the disclosure of information dated August 23, 2021 did not provide the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 22, 2020 and January 7, 2020 annual inspection.
|
Plan of Correction
New intake coordinator has been hired. For clients still in treatment consents were redone with client approval. The lead counselor will audit charts weekly to ensure compliance. Biannual renewal training for consents/confidentiality will be held by clinical supervisor for clinical and intake personnel. |
709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
|
Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the dated signature of client.
Client # 4 was admitted on November 29, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated December 5, 2021 to a funding source and dated December 10, 2021 to an outreach/follow up, primary care physician, hospital, pharmacy, "government agency" , and "government agency" did not provide the dated signature of the client but was signed and dated by the witness.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
New intake coordinator has been hired. For clients still in treatment consents were redone with client approval. The lead counselor will audit charts weekly to ensure compliance. Biannual renewal training for consents/confidentiality will be held by clinical supervisor for clinical and intake personnel. |
709.28 (c) (5) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(5) Dated signature of witness.
|
Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the dated signature of witness.
Client # 2 was admitted on December 14, 2021 and was still active at the time of the inspection. Eight informed and voluntary consent from the client for the disclosure of information signed and dated December 14, 2021 did not provide the dated signature of witness.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
New intake coordinator has been hired. For clients still in treatment consents were redone with client approval. The lead counselor will audit charts weekly to ensure compliance. Biannual renewal training for consents/confidentiality will be held by clinical supervisor for clinical and intake personnel. |
709.28 (c) (6) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
|
Observations
Based on four of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the name of the date, event or condition upon which the consent will expire.
Client # 2 was admitted on December 14, 2021 and was still active at the time of the inspection. Eight informed and voluntary consent from the client for the disclosure of information signed and dated December 14, 2021 did not provide the date, event or condition upon which the consent will expire.
Client # 4 was admitted on November 29, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated December 14, 2021 to a "government agency" did not provide the date, event or condition upon which the consent will expire.
Client # 5 was admitted on August 18, 2021 and was discharged on September 15, 2021. An informed and voluntary consent from the client for the disclosure of information dated August 18, 2021 to seven different agencies did not provide the date, event or condition upon which the consent will expire.
Client # 6 was admitted on August 23, 2021 and was discharged on November 17, 2021. An informed and voluntary consent from the client for the disclosure of information dated August 23, 2021 to seven different agencies did not provide the date, event or condition upon which the consent will expire.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
New intake coordinator has been hired. For clients still in treatment consents were redone with client approval. The lead counselor will audit charts weekly to ensure compliance. Biannual renewal training for consents/confidentiality will be held by clinical supervisor for clinical and intake personnel. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
|
Observations
Based on three of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include documentation that a copy of the consent was offered to the client.
Client # 2 was admitted on December 14, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated December 14, 2021 to eight separate agencies did not provide documentation that a copy of the consent was offered to the client.
Client # 5 was admitted on August 18, 2021 and was discharged on September 15, 2021. An informed and voluntary consent from the client for the disclosure of information signed and dated August 18, 2021 to seven separate agencies did not provide documentation that a copy of the consent was offered to the client.
Client # 6 was admitted on August 23, 2021 and was discharged on November 17, 2021. An informed and voluntary consent from the client for the disclosure of information signed and dated August 23, 2021 to eight separate agencies did not provide documentation that a copy of the consent was offered to the client.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
New intake coordinator has been hired. For clients still in treatment consents were redone with client approval. The lead counselor will audit charts weekly to ensure compliance. Biannual renewal training for consents/confidentiality will be held by clinical supervisor for clinical and intake personnel. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
|
Observations
Based on five of five applicable client records reviewed, the facility failed to provide documentation of the administration of medication according to the facility policy and procedure manual. The policy and procedure manual indicates that both the client and staff will initial the medication administration record for documenting medication.
Client # 1 was admitted on November 17, 2021 and was still active at the time of the inspection.
A medication prescribed to be taken three times daily was not documented, by initial from staff and client, on the medication administration record for December 1-4, 6, 10-12, 15, 17-20, 22-25, 27-29, January 1, 2, and 4-11.
A medication prescribed to be taken one time daily was not documented, by initial from staff and client, on the medication administration record for December 5, 17, 26, 27, 29, 21 and January 5, 8, and 9.
Two medications prescribed to be taken at bedtime was not documented, by initial from staff and client, on the medication administration record for December 4, 5, 8, 9, and 11.
Client # 3 was admitted on December 3, 2021 and was still active at the time of the inspection. A medication prescribed to be taken two times daily was not documented, by initial from staff and client, on the medication administration record for December 1-7, 11, 12, and 14-31, 2021.
A medication prescribed to be taken every morning was not documented on the medication administration record, by initial from staff and client, on the medication administration record for December 1-31, 2021 and January 1- 13, 2022.
A medication prescribed to be taken at bedtime was not documented on the medication administration record, by initial from staff and client, on the medication administration record for December 1-7, 11, 12, and 14-31, 2021.
Client # 4 was admitted on November 29, 2021 and was still active at the time of the inspection. A medication prescribed to be taken at bedtime was not documented on the medication administration record, by initial from staff and client, for December 11, 21, 22, and 28, 2021.
Client # 6 was admitted on August 23, 2021 and discharged on November 17, 2021. A medication prescribed to be taken one time daily was not documented on the medication administration record, by initial from staff and client, for November 7, 10-13, and 17, 2021.
Client # 7 was admitted on October 4, 2021 and discharged on December 20, 2021.
A medication prescribed to be taken one time in the AM was not documented on the medication administration record, , by initial from staff and client, for October 7, 8, and 13, 2021. A medication prescribed to be taken at bedtime was not documented on the medication administration record, by initial from staff and client, for November 6 and 21, 2021.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The staff were retrained on medication policy and procedure, including documenting non-compliance by refused or rejected for doctor follow up. Nurse will review MAR daily for compliance.
New medication sheets were placed in MAR to ensure compliance
Director will review audit sheets weekly for compliance |
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.
|
Observations
Based on four of five applicable client records reviewed, the facility failed to provide documentation of treatment and rehabilitation plans being reviewed and updated at least every 30 days in client record # 1, 3, 4, and 6.
Client # 1 was admitted on November 17, 2021 and was still active at the time of the inspection. A treatment plan was developed on November 20, 2021. The treatment plan update was due to occur on December 20, 2021 however, there was no treatment plan update in the client record.
Client # 3 was admitted on December 3, 2021 and was still active at the time of the inspection. A treatment plan was developed on December 9, 2021. The treatment plan update was due to occur on January 9, 2022 however, there was no treatment plan update in the client record.
Client # 4 was admitted on November 29, 2021 and was still active at the time of the inspection. A treatment plan was developed on December 5, 2021. The treatment plan update was due to to occur on January 5, 2022 however, there was no treatment plan update in the client record.
Client # 6 was admitted on August 23, 2020 and was discharged on November 17, 2021. A treatment plan update occurred on September 23, 2021. The next treatment plan update was due to occur on October 23, 2021 however, there was no other treatment plan update in the client record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinical team was retrained on policy of treatment plan and updates by director. All treatment plans were updated that were not in compliance. Lead Counselor will audit charts weekly to ensure compliance. Audit charts will be reviewed by clinical supervisor/director biweekly |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on three of seven client records reviewed, the facility failed to assure counseling services are provided according to the individual treatment and rehabilitation plan in client records # 1, 3, and 5.
Client # 1 was admitted on November 17, 2021 and was still active at the time of the inspection. A treatment plan developed on November 20, 2021 indicated individual sessions to occur weekly. A review of progress notes and record of service indicate no individual sessions occurred the weeks of November 21-27, 2021, November 28-December 4, 2021, December 19-25, 2021, December 26, 2021-January 1, 2022 and January 2-8, 2022.
Client # 3 was admitted on December 3, 2021 and was still active at the time of the inspection. A treatment plan developed on December 9, 2021 indicated individual sessions to occur weekly. A review of progress notes and record of service indicate no individual sessions occurred the weeks of December 5-11, 2021, and December 19-25, 2021.
Client # 5 was admitted on August 18, 2021 and was discharged on September 15, 2021. A treatment plan developed on August 25, 2021 indicated individual sessions to occur weekly. A review of progress notes and record of service indicate no individual sessions occurred the weeks of September 5-11, 2021.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Lead counselor retrained clinical staff on documentation or record of service with each activity. Additionally trained to file notes immediately after session for assured presence. Lead counselor will audit charts weekly for 6 months then biweekly after July, 2022.
Audit sheets will be reviewed monthly by director/clinical supervisor for compliance |
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.
|
Observations
Based on two of two applicable client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to the client occur within 30 days by letter.
Client # 5 was admitted on August 18, 2021 and discharged on September 15, 2021. There was no follow-up information documented in the client record.
Client # 6 was admitted on August 23, 2021 and discharged on November 17, 2021. There was no follow-up information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
New intake coordinator was hired and follow up letters were sent to the two individuals from audit. Intake coordinator will mail letters going forward on day 30. The Lead counselor will audit charts weekly for 6 months then biweekly after July, 2022.
Audit sheets will be reviewed monthly by director/clinical supervisor for compliance |