INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 3-4, 2019 of Gaudenzia New Destiny by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Gaudenzia New Destiny 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(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
|
Observations
The facility failed to document a written semiannual performance evaluation on counselor assistants for employee # 4 and # 5.
Employee # 4 was hired on October 22, 2018 as a counselor assistant and was still employed as a counselor assistant at time of the inspection. Employee # 4 personnel record failed to contain a semiannual performance review that was due to be completed on April 22, 2019.
Employee # 5 was hired on November 19, 2018 as a counselor assistant and was still employed as a counselor assistant at the time of the inspection. Employee # 5 personnel record failed to contain a semiannual performance review that was due to be completed on May 19, 2019.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will conduct a supervisory session wit the Clinical Supervisor by 9/1/2019 to review regulation 704.9(b). Employee #4 and Employee #5 received their semiannual evaluations on June 10, 2019 by the Clinical Supervisor and are located in their personnel file. The Program Director will ensure future compliance with this regulation by reviewing with the Clinical Supervisor any upcoming staff evaluation due dates at the weekly Administrative Meeting. |
704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
|
Observations
Based on a review of the policy and procedure manual, the facility failed to follow their policy in regard to completion of the assessment of staff training needs. The Plan for Assessing Staff Training Needs policy stated, "The training plan shall be ready for implementation effective Jan. 31st of each year." The overall training plan for the project was not completed until May 16th, 2019.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The relevant Gaudenzia Policy has been revised to state that, "Program-level training needs assessments are due to the Training department by the end of January of each year. Upon receipt of the program-level annual assessments of staff training needs, the Director of Training and Education, in collaboration with the Project Director, will review the assessments in detail and develop a plan to address the training needs of the agency. The annual agency-wide training plan shall be ready for implementation no later than April 30th of each year." The Gaudenzia Director of Training and Education will ensure that this is completed within the designated time frame each year. |
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.
|
Observations
Based on a review of CPR certifications for all staff and four weeks of staff schedules it was determined that the facility was without at least one person trained in CPR on May 11th, 12th, 15th, 16th, 17th, 25th, 26th and 30th 2019.
The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will conduct a supervisory session with the Administrative Assistant by 9/1/19 to review Regulation 704.11(c)(2). The Administrative Assistant will develop a CPR tracking system to ensure that all CPR certifications are kept current. To ensure compliance with this regulation the administrative assistant will review the system with the Program Director at the weekly Administrative Meeting. |
705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
|
Observations
Based on a physical plant inspection on June 3, 2019, the facility failed to ensure all structures were free from any danger to health and safety.
The cabinets in the kitchen under the sink were rotted causing one of the cabinets to have a hole in the bottom where plumbing could in the floor below. It was noted that children ' s toys were located in this hole under the sink.
The second-floor group room had exposed wires located above an electrical outlet.
The air conditioning/heating unit's coverings did not close properly exposing the electrical unit and wires.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The kitchen cabinets have already been repaired and child safety locks have been placed on the cabinet doors so children do not have access to that area.
The exposed wires above the electrical outlet in the second floor group room have been covered and the electrical outlet was replaced.
The Facility Plant Manager has already spoken with the facility air conditioning vendor (Trane) and new air conditioner lids have been ordered fro the units which require them. The air conditioning vendor will contact the facility when the order comes in to schedule a date for installation. Expected date for completion is 9/15/2019. Until installation can occur all broken lids will be taped down on 8/14/2019 to prevent anyone from placing a finger, hand, etc into the area. In addition, house managers will visibly check those areas during their routine house runs to ensure the lids are still closed. The Clinical Supervisor will ensure compliance with this by reviewing the daily house run sheets and discuss any issues with compliance with the Program Director at the weekly administrative meeting. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
|
Observations
Based on a physical plant inspection on June 3, 2019, the facility failed to ensure that the grounds are kept in good repair at all times. This was demonstrated by multiple holes in the walls and ceilings, paint chipping off the walls and multiple stains on the ceiling caused by leaks.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facility Plant Manager has already begun work on multiple areas of the facility ie: providing spackle, replacing damaged ceiling tiles, and repainting affected areas. The expected date of completion for all of the above work is 9/30/2019. The Program Director will ensure compliance with this regulation by speaking with the Facility Plant Manager weekly regarding the status of the repairs. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
|
Observations
Based on a physical plan inspection, it was observed that the facility failed to maintain trash dumpsters in a manner to prevent the penetration of insects and rodents. The lids to the dumpsters were observed open.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor will hold a mandatory staff meeting on August 29, 2019 to discuss the proper maintenance of the trash dumpsters and review regulation 705.2(4). In addition, the trash dumpster area will also be added to both the client and staff house run sheet to ensure that the area is secure. A supervisory note will be placed in each personnel file documenting awareness and understanding of the regulation. The Clinical Supervisor will ensure compliance of this regulation by reviewing the house run sheets weekly. |
705.5 (a) (3) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(3) A storage area for clothing.
|
Observations
Based on a physical plant inspection on June 3, 2019, the facility failed to ensure each resident had a storage area for clothing as the dresser in room 301 was missing a drawer.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 6/10/2019 every resident has an intact, functional dresser. In addition, hangers and a plastic storage bin were provided for each resident to use to have additional storage. The staff on duty will visibly check these areas during their daily house runs to ensure the items are present and orderly. The Program Director will ensure compliance with this regulation by reviewing the house run sheets at the weekly Administrative Meeting. |
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 conducted on June 3, 2019, the facility failed to ensure that the 3rd floor bathroom had paper towels at all times.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Paper towels were replenished in the 3rd floor bathroom following discovery of them being absent. To ensure compliance with this regulation, the staff on duty will visibly check the paper towel dispenser during every house run and replenish as needed. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
|
Observations
Based on a physical plant inspection conducted on June 3, 2019, the facility failed to provide privacy in the bathroom. In room 301, the shower did not have a shower curtain.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 6/4/2019 every shower has a shower curtain and liner to ensure privacy. To ensure compliance with this regulation the staff on duty will visibly check the shower areas during each daily house run. The Program Director will ensure compliance with this regulation by reviewing the house run sheets at the weekly Administrative Meeting. |
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 conducted on June 3, 2019 the facility failed to ensure each bathroom was maintained in a functional, clean and sanitary manner at all times.
The third-floor bathroom handicap toilet was blocked off and "out of order" for an unknown amount of time. The sink pipe was not connected and poured water onto the floor upon testing water temperature. A shower head was missing in the first shower stall and there were exposed pipes through a hole in the wall.
The bathroom in room 7A had a sink that was clogged as well as a sign that stated, "Still clogged". The bathroom in 7A also had a blind that was broken and not operable over the bathroom window. The bathroom ceiling also had large brown spot caused by a leak in the ceiling.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The third floor handicap toilet was repaired and is now in working order.
The sink pipe has been repaired and connected and is now in working order.
The shower head has been replaced and is in working order. The hole in the wall in the third floor bathroom has been taped off until a permanent repair can be completed. Expected date of completion for this repair is 8/30/2019.
The bathroom sink in room 7A has been and remains unclogged and is in working order.
The blind in bathroom 7A has been replaced.
The leak in the ceiling in bathroom 7A has been repaired and the ceiling tile has been replaced.
A mandatory staff meeting will be held on 8/29/2019 and the Program Director will review with all staff how to properly complete facility work orders and discuss the importance on following up on submitted work orders with the Facility Plant Manager. A supervisory note will be place in each employee personnel file documenting this. The Program Director will ensure compliance with this regulation by reviewing the work order binder at the weekly Administrative Meeting and assigning staff follow up when necessary.
|
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
|
Observations
Based on a physical plant inspection conducted on June 3, 2019, The facility failed to ensure that all fire extinguishers indicated the date of inspection.
These finding were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The Program Director will hold a mandatory staff meeting on 8/29/2019 to review regulation 705.10(c)(3). A supervisory note will be placed in each staff personnel file documenting the awareness and understanding of this regulation. To ensure compliance of this regulation a staff member will be assigned to physically check each fire extinguisher and report back to the Program Director completion of this task by the last day of each month. |
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.
|
Observations
Based on a review of personnel files, employee #1 and #5 was not trained in the use of fire extinguishers upon employment.
Employee #1 was hired on March 19, 2019 and was still employed at the time of the inspection. There was no documentation that he employee received the training as of the date of this inspection June 3rd, 2019.
Employee #5 was hired November 19, 2018 and was still employed at the time of the inspection. There was no documentation that he employee received the training as of the date of this inspection June 3rd, 2019.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director completed this training on 6/7/19 and documentation of this has been placed in his file. All relevant staff within the HR and Training departments will review the DDAP 705.10(c)(4)-705.28(c)(4) regulations by 7/31/19, and as the head of the Training department, the Director of Training and Education will be ultimately responsible for ensuring that all staff (to include administrative staff) receive required fire extinguisher training upon hire. Training department staff will review all staff files during the orientation process to ensure that this training is completed.
Employee #5 actually received the training on 5/16/19; however, the documentation could not be located and presented during the time of the audit. It has since been located and has been put into the employee file. To ensure compliance with this regulation, the Training Department staff, as well as, New Destiny's Clinical Supervisor, will review all staff files during the Orientation process to ensure the training is completed. |
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.
|
Observations
Based on a review of personnel files, employee #1 and #5 were not trained to perform assigned tasks during emergencies.
Employee #1 was hired on March 19, 2019 and was still employed at the time of the inspection. There was no documentation that the employee received the training as of the date of this inspection June 3rd, 2019.
Employee #5 was hired on November 19, 2018 and was still employed at the time of inspection. There was no documentation that he employee received the training as of the date of this inspection June 3rd, 2019.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director completed this training on 6/7/19 and documentation of this has been placed in his file. All relevant staff within the HR and Training departments will review the DDAP 705.10(d)(3) regulations by 7/31/19, and as the head of the Training department, the Director of Training and Education will be ultimately responsible for ensuring that all staff (to include administrative staff) receive required emergency procedure training upon hire. Training department staff will review all staff files during the orientation process to ensure that this training is completed.
Employee #5 actually received the training on 5/16/19; however, the documentation could not be located and presented during the time of the audit. It has since been located and has been put into the employee file. To ensure compliance with this regulation, the Training Department staff, as well as, New Destiny's Clinical Supervisor, will review all staff files during the Orientation process to ensure the training is completed. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a review of the facility ' s fire drill log, the facility failed to ensure that alternate routes are used during the fire drills. The only exit used was "DC".
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will hold a mandatory staff meeting on 8/29/2019 to review regulation 705.10(d)(6). A supervisory note will be placed in each staff personnel file documenting awareness and understanding of the regulation. To ensure compliance with this regulation the Program Director will review the fire drill log at each weekly Administrative Meeting to ensure alternative routes are being utilized. |
705.11 (2) (ii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(ii) Maintain security screens or safety locks for all operable windows.
|
Observations
Based on a physical plant inspection on June 3, 2019 it was observed that the facility failed to maintain security screens or safety locks for all operable windows.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 6/12/2019 all window screens were intact and secure in the facility. To ensure compliance with this regulation the staff on duty will visibly check the window during their daily house runs and document on the house run sheets that they are secure. The Program Director will ensure compliance with this regulation by reviewing the daily house run sheets at the weekly Administrative Meeting. |
705.11 (2) (iii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iii) Maintain protective caps over each electrical outlet.
|
Observations
Based on a physical plant inspection on June 3 2019, the facility failed to maintain protective caps over each electrical outlet including electrical outlets used for stoves.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
All electrical outlets had the necessary protective caps including those used for stoves. The staff on duty will ensure compliance with this regulation by visibly checking the outlets during their daily house runs. The Program Director will ensure compliance with this regulation by reviewing the daily house run sheets at the weekly Administrative Meeting. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
|
Observations
Based on a review of seven client records, the facility's client rights documentation, included in the orientation packet, failed to include all the required client rights. The facility failed to include that:
Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
Clients have the right to appeal a decision limiting access to their records to the director.
Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Continuous Quality Improvement Director has revised the Gaudenzia Client Bill of Rights to accurately reflect the DDAP 709.30 regulations regarding a client's right to inspect their own record and actions they may take in this regard. The document now states that, "The following rights are affirmed...The right to examine one's own record within the guidelines approved by the agency in accordance with Federal regulations 42 CFR, and rebut any information in their record by inserting a counter statement of clarification or correction. The agency may temporarily remove portions of the record prior to inspection if the Director determines that the information may be detrimental if presented to the client. Reasons for removal of sections will be documented in the record. Clients have the right to appeal a decision limiting access to their records to the Director. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records." This revised Bill of Rights document will be distributed to all programs by 7/26/19. The Program Director will review it with all staff and it will be incorporated into the client orientation manuals and signed by all active clients by 8/2/19. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process, the current version of the Client Bill of Rights is being completed. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
|
Observations
The project ' s data collection and recordkeeping system failed to efficiently retrieve data needed to measure the project performance in relationship to its stated goals and objectives.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will meet with the Clinical Supervisor and the Administrative Assistant to discuss regulation 709.31a by 9/13/2019. A supervisory note will be placed in each staff personnel file. The Administrative Assistant will develop a tracking and organizational system to improve overall record keeping ie: staff training certificates, new hire paperwork, employee evaluations etc.and efficiency of data retrieval. The Program Director will ensure compliance of this regulation by reviewing the tracking system with the Administrative Assistant at the weekly Administrative Meeting. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
|
Observations
The facility failed to provide documentation of the removal and disposal of outdated drugs following their last log entry of April 27, 2018.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will hold a mandatory staff meeting on 8/29/2019 to review regulation 709.32(c)(3). A supervisory will be placed in each staff personnel file documenting awareness and understanding of the regulation. A binder was created containing necessary medication disposal paperwork as well as instructions on the proper way to dispose of the medications. In addition the Clinical Supervisor will check the medication storage area the first week of each month and assign a senior house manager to assist with the disposal of the medication if necessary. The Program Director will ensure compliance of this regulation by discussing medication disposal with the Clinical Supervisor at the weekly Administrative Meeting. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
|
Observations
The facility failed to document a medication record with staff and client acknowledging the medication was taken or documentation for the reason why the client did not receive the medication in seven out of seven client records.
These finding were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will hold a mandatory staff meeting by 9/13/2019 to review regulation 709.32(c)(4). The Regional Nurse Coordinator will attend this meeting and conduct an in-service with all staff to review the proper way to document whether a client received medication or not. A supervisory note will be placed in each staff personnel file documenting awareness and understanding of this regulation. The Clinical Supervisor will ensure compliance with this regulation by conducting weekly audits of the client medication administration record and will schedule one on one training with the Regional Nurse Coordinator when necessary. The Program Director will ensure compliance of the regulation by reviewing the client medication administration record with the Clinical Supervisor at the weekly Administrative Meeting. |
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 a review of seven client records, the facility failed to document treatment and rehabilitation plan updates within the regulatory timeframe in three records reviewed.
Client #1 was admitted on March 11, 2019 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on April 14, 2019 and the next update was due no later than May 14, 2019; however, there was no update documented in the record at the time of the inspection.
Client #2 was admitted on March 12, 2019 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on April 13, 2019 and the next update was due no later than May 13, 2019; however, there was no update documented in the record at the time of the inspection.
Client #5 was admitted on September 16, 2018 and was discharged on January 24, 2019. A treatment and rehabilitation plan update was completed on October 31, 20198 and the next update was due no later than November 30, 2018; however, there was no update documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will hold a clinical meeting with the Clinical Supervisor and all counselors to review regulation 709.25(b) and will obtain written notification that regulation is understood by 8/15/2019. A supervisory note will also be placed in each counselor personnel file documenting awareness and understanding of this regulation. The Clinical Supervisor will ensure compliance with this regulation by holding a weekly clinical meeting to review what treatment plans are due for the following week. In addition, The Clinical Supervisor will do weekly checks in the Electronic Health Care system to ensure treatment plan reviews were completed, signed, and submitted. The Program Director will ensure compliance of this regulation by reviewing what treatment plan needs an update with the Clinical Supervisor at the weekly Administrative Meeting. |
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 a review of seven client records, there was no documentation that the clients received counseling services according to their individual comprehensive treatment and rehabilitation plan in three charts reviewed.
Client # 1 was admitted March 11, 2019 and was still active at the time of inspection. The comprehensive treatment and rehabilitation plan dated March 13, 2019 indicated two individual sessions per month. The chart's record of service and progress notes indicated that the client did not receive two individual sessions a month in March and May.
Client # 2 was admitted January 8, 2019 and was still active at the time of inspection. The comprehensive treatment and rehabilitation plan dated February 10, 2019 indicated one individual session per week and one group session per week. The chart's record of service and progress notes indicated that the client did not receive weekly individual and group sessions for the month of March.
Client # 5 was admitted September 16, 2018 and was discharged on January 24, 2019. The comprehensive treatment and rehabilitation plan dated October 31, 2018 indicated two individual sessions per month. The chart's record of service and progress notes indicated that the client did not receive an individual session from November 23, 2018 until the time of discharge.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will hold a meeting with the Clinical Supervisor and all counselors to review regulation 709.52(c) by 8/15/19 and will obtain written notification that the regulation is understood. The clinicians will document via a clinical note in the Electronic Health System for what reason a client was not able to attend a group or individual session. The Clinical Supervisor will ensure compliance with this regulation by conducting monthly CQI chart audits and discussing client services with the counseling staff at the weekly Clinical Meeting. The Program Director will ensure compliance with this regulation by discussing client services with the Clinical Supervisor at the weekly Administrative Meeting. |
709.53(a) LICENSURE Complete Client Record
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:
|
Observations
Based on a review of client records, the facility failed to provide a complete client record in client records #'s 1, 2, 3, 4, 5, 6, and 7.
Client #1 was admitted on March 11, 2019 and was active at the time of inspection. The client record did not contain documentation of verification that work done by the client at the facility is an integral part of their treatment and rehabilitation plan.
Client #2 was admitted on March 12, 2019 and was active at the time of inspection. The client record did not contain documentation of verification that work done by the client at the facility is an integral part of their treatment and rehabilitation plan.
Client #3 was admitted on January 8, 2019 and was active at the time of inspection. The client record did not contain documentation of verification that work done by the client at the facility is an integral part of their treatment and rehabilitation plan.
Client #4 was admitted on January 9, 2019 and was active at the time of inspection. The client record did not contain documentation of verification that work done by the client at the facility is an integral part of their treatment and rehabilitation plan.
Client #5 was admitted on September 16, 2018 and was discharged on January 24, 2019. The client record did not contain documentation of verification that work done by the client at the facility is an integral part of their treatment and rehabilitation plan and follow up information.
Client #6 was admitted on December 6, 2019 and was discharged on March 3, 2019. The client record did not contain documentation of verification that work done by the client at the facility is an integral part of their treatment and rehabilitation plan and follow up information.
Client #7 was admitted on February 11, 2019 and was active at the time of inspection. The client record did not contain documentation of verification that work done by the client at the facility is an integral part of their treatment and rehabilitation plan
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director and Clinical Supervisor will meet with all clinical staff to review regulation 709.53(a) on August 15, 2019. The clinicians will be instructed to utilize more therapeutic language in their clinical documentation; in particular when documenting the assignment of the client therapeutic work chore and what therapeutic goal is hoped to be accomplished ie: independent living skills, etc. A supervisory note will be placed in each clinician personnel file documenting awareness and understanding of the regulation. The Clinical Supervisor will ensure compliance with this regulation by conducting monthly CQI chart audits and discussing any noncompliance issues with the Program Director at the weekly Administrative Meeting. |