INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 9-10, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on August 9, 2007.
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Plan of Correction
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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
The facility failed to instruct employees #6 and #8 in the use of the fire extinguisher within seven days from the date of employment.
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Plan of Correction
Effective immediately, Tech Supervisor will be responible to ensure that all fire safety training is completed for new hires within the expected timeframe of 7 days. Campus Director will monitor compliance through random audits for 3 months. |
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
The facility failed to train employees #6 and #8 to perform assigned tasks during emergencies within seven days from the date of employment.
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Plan of Correction
Effective immediately, Tech Supervisor will be responible to ensure that all new hires are trained in emergency procedures, within the expected timeframe of 7 days. Campus Director will monitor compliance through random audits for 3 months. |
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
The project failed to obtain a consent to release information form for a letter that was sent to the District Magistrate contained in client record #3. In addition, one consent to release information form failed to include what information was to be released in client record #3, who is releasing the information in client record #4 and who is to receive the information in client record #4.
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Plan of Correction
Clinical Supervisor will review confidentialy regulations and expections during clinical staff meeting by 8/20/2007. All new hires will continue to be trained on importance of following confidentiality laws and documentation guidelines to maintain confidentilality. Clinical supervisor will audit 10 percent of active charts to monitor compliance for 3 months. |
709.62(c)(3)(ii) LICENSURE D & A History
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
The drug and alcohol histories failed to include lengths and patterns pertaining to the progression of use in 4 of 4 client records reviewed, specifically client records #1, 2, 3 and 4. In addition, documentation of the client's prior treatment history failed to address all treatment experiences, outcomes and how long the client remained abstinent in 2 of 4 client records reviewed, specifically #2 and 3.
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Plan of Correction
The Nursing Assessment will be discussed at the Forms Committee meeting on August 8, 2007 and will be developed by the Nursing Leadership Committee on August 29, 2007. The Forms Committee Chairperson will present the revised form to Senior Quality Leadership Committee on September 11, 2007 for review and approval. Approved form will be distributed by September 17, 2007. Trainings by Director of Nursing or designee will be provided to clinical staff with full implementation by October 1, 2007. |
709.62(c)(3)(iii) LICENSURE Personal history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
The facility failed to provide for complete personal histories. The personal history, which is the nursing assessment, failed to document military and sexual history in 4 of 4 client records reviewed, specifically client records #1, 2, 3 and 4.
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Plan of Correction
The addition of the military and sexual history to the Nursing Assessment will be discussed at the Forms Committee meeting on August 8, 2007 and will be developed by the Nursing Leadership Committee on August 29, 2007. The Forms Committee Chairperson will present the revised form to Senior Quality Leadership Committee on September 11, 2007 for review and approval. Approved form will be distributed by September 17, 2007. Trainings by Director of Nursing or designee will be provided to clinical staff with full implementation by October 1, 2007. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
The facility failed to document a composite picture in the psychosocial evaluation, which is the nursing assessment summary, that included impressions regarding the client's current situation in 4 of 4 client records reviewed, specifically client records #1, 2, 3 and 4.
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Plan of Correction
Additional trainings will be conducted before August 31, 2007 by Nursing Leadership with all nursing staff regarding writing an evaluative summary using their impressions about the patients current situation. Monthly audits will be completed by Lead Nurse for a minimum of 3 months with submission of findings to The Quality Improvement Department. |
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
The facility failed to provide for a drug and history that included lengths and patterns of use in order to determine the client's progression of use in 4 of 4 client records reviewed, specifically client records #2, 3, 5 and 6. In addition, the client's prior treatment history failed to include details regarding the type of discharge and how long the client remained abstinent in 4 of 4 client records reviewed, specifically client records #2, 3, 5 and 6.
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Plan of Correction
The Nursing Assessment will be discussed at the Forms Committee meeting on August 8, 2007 and will be developed by the Nursing Leadership Committee on August 29, 2007. The Forms Committee Chairperson will present the revised form to Senior Quality Leadership Committee on September 11, 2007 for review and approval. Approved form will be distributed by September 17, 2007. Trainings by Director of Nursing or designee will be provided to clinical staff with full implementation by October 1, 2007. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
The personal history failed to include details regarding family issues and relationships, employment history including job skills and sexual history that includes significant relationships and abuse in 4 of 4 client records reviewed, specifically client records #2, 3, 5 and 6. In addition, questions often contained one word answers with no further details documented.
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Plan of Correction
Individual supervision will occur with all clinical staff on completion of biopsychosicial summaries, obtaining detailed information and completion of evaluative summaries by 8/20/07. Clinical Supervisor will audit 10 percent of admissions for the next three months to monitor compliance and provide supervision as needed. |
709.52(a)(1) LICENSURE Short/Long term TX Goals
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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
The facility failed to provide individualized short and long-term goals in the individual treatment plan for each client in 2 of 2 client records reviewed, specifically client records #2 and 6. In addition, the actions steps for the short and long-term goals were identical.
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Plan of Correction
Clinical Supervisor will provide onsite training on treatment planning, by 8/20/07. Supervisor will audit and initial ten percent of treatment plans for each clinician for 3 months, effective immediately to monitor compliance and provide supervision as needed. |
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
The facility failed to ensure that the treatment plan update included the client's progress as it relates to the goals identified on the individual treatment plan, but rather included generalized comments that were not specific to each client in 1 of 2 client records reviewed, specifically client record #6. In addition, the treatment plan update was missing in 1 of 2 client records reviewed, specifically client record #3.
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Plan of Correction
Clinical Supervisor will provide on-site training on treatment plan updates that document the patient's progress as it relates to the treatment plan goals by 8/24/07. Supervisor will audit and intial 10% of treatment plan updates for each clinician for three months begining 8/27/07 to monitor compliance and provide supervison as needed. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
The facility failed to provide documentation or verification that work performed by the client was an integral part of the client's treatment plan in 3 of 3 client records reviewed, specifically client records #2, 3 and 6.
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Plan of Correction
Clinical Supervisor will meet with Lancaster's Clinical Supervisor by 8/20/2007. He will then train his clinical team on integration of work therapy by 9/1/07. He will then audit 10 percent of charts for 3 months to monitor compliance and provide individual supervision as needed. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The facility failed to provide for psychosocial evaluations that included clinical opinions and impressions in 1 of 4 client records reviewed, specifically client record #7. The psychosocial evaluation was historical rather than evaluative and relied on statements made by the client rather than the counselor's clinical impressions. In addition, the psychosocial evaluation was missing in 1 of 4 client records reviewed, specifically client record #8.
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Plan of Correction
The Outpatient Clinical Supervisor will train counseling staff members in writing clinically evaluative diagnostic summaries by 8/31/07. The Clinical Supervisor will monitor compliance to the POC through random chart audits, ensuring that a minimum of three charts are monitored monthly for no less than three months. The diagnostic summaries will include all of the components required under the regulation. |
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
The failed to ensure that treatment plans were consistently completed. The treatment plan update was missing in 1 of 1 client record reviewed, specifically client record #8.
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Plan of Correction
Clinical Supervisor will provide onsite training on treatment planning, to include time frames for completion of treatment plans by 8/20/07. Supervisor will audit and initial ten percent of treatment plans for each clinician for 3 months, effective immediately to monitor compliance and provide supervision as needed. Facility will "trial" adding a monthly administrative day for clinicians to review, consult and audit records to ensure ongoing compliance. |
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
The facility failed to ensure that case consultations were consistently completed. The case consultation note was missing in 1 of 1 client record reviewed, specifically client record #8.
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Plan of Correction
Clinical Supervisor will provide onsite training on case consults, to include policy review by 8/20/07. Supervisor will audit 10 percent for each clinician for 3 months, effective immediately to monitor compliance and provide supervision as needed. Facility will "trial" adding a monthly administrative day for clinicians to review, consult and audit records to ensure ongoing compliance. |