INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on by staff from the Division of Drug and Alcohol Program Licensure on April 5, 2010 through April 7, 2010. Based on the findings of the on-site inspection, Home Nursing Agency Community Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on May 11, 2010.
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Plan of Correction
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709.81(b)(3)(i) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of client records, and an interview with the clinical supervisor, the facility failed to document medical histories in three of four client records.
The findings include:
Four Partial Hospitalization (P.H.) records were reviewed on April 6, 2010. A medical history was to be completed in four client records. An interview was conducted with the clinical supervisor on April 6, 2010 around 11:20 am. The clinical supervisor advised that the medical history form was to be given to the client to complete at intake and should be returned to the record.
P.H. Client #1, was admitted on January 20, 2010, P.H. client record #1 did not include a medical history as of the date of inspection.
P.H. Client #3, was admitted on August 13, 2009, P.H.client record #3 did not include a medical history as of the date of inspection.
P.H. Client #2, was admitted on December 16, 2009, P.H. client record #2 did include a faxed copy of a medical history from another facility, however there was no verification that this history had been reviewed with the client.
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Plan of Correction
Individuals entering D&A services will be required to complete the medical history at the time of assessment. The assessment counselor will be responsible to confirm that the medical history is completed and the assigned primary counselor will
re-confirm that the completed medical history is present upon development of initial treatment plan.
By June 1, 2010 an admission chart checklist will be conducted on all individuals entering our D&A services by the medical records staff.
Monthly random chart audits will be completed and reviewed by the D&A Clincial Services Manager. |
709.83(a)(10) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document discharge summaries in one of the two records reviewed.
The findings include:
Four Partial Hospitalization (P.H.) records were reviewed on April 6, 2010. A discharged summary was required to be completed in two client records, specifically P.H. records # 3 and 4. In accordance with the facility policy, discharge summaries are to be completed within seven days of discharge.
P.H. Client record #4 - Client was admitted on October 21, 2009 and discharged on November 30, 2009. The discharge summary was due by December 7, 2009. The discharge summary had not documented as of the date of inspection.
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Plan of Correction
The Department Assistant will keep all paperwork relating to the discharge of an individual and will remind staff of what papework must be completed and turned in for discharge. She will not remove the individual from active client list until all paperwork is completed and turned in.
A discharge chart checklist will be completed by the medical records staff and results will be reviewed with the D&A Clincial Services Manager on a regular basis. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of client records, and an interview with the clinical supervisor, the facility failed to document medical histories in three of six client records.
The findings include:
Six Outpatient (O.P.)records were reviewed on April 6, 2010. A medical history was to be completed in six client records.
O.P. Client #2, was admitted on January 14, 2010, O.P. client record #2 did not include a medical history as of the date of inspection.
O.P. Client #3, was admitted on July 16, 2009, O.P. client record #3 did not include a medical history as of the date of inspection.
O.P. Client #4, was admitted on September 23, 2009, O.P. client record #4 did not include a medical history as of the date of inspection.
An interview with the clinical supervisor on April 6, 2010 around 11:20 am confirmed the medical history form was to be given to the client to complete at intake and should be returned to the record.
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Plan of Correction
Individuals entering D&A services will be required to complete the medical history at the time of assessment. The assessment counselor will be responsible to confirm that the medical history is completed and the assigned primary counselor will
re-confirm that the completed medical history is present upon development of initial treatment plan. By June 1, 2010 an admission chart checklist will be conducted on all individuals entering our D&A services by the medical records staff. Monthly random chart audits will be completed and reviewed by the D&A Clinical Services Manager. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on the review of client records, the facility failed to develop an individualized treatment and rehabilitation plan based off of a biopsychosocial evaluation in one out of four client records.
The findings include:
Four Outpatient (O.P.) client records were reviewed on April 6, 2010. One out of four failed to have a treatment and rehabilitation plan based off of the biopsychosocial evaluation. O.P. Client record # 4 contained a comprehensive treatment plan dated October 9, 2009 and as of the date of inspection, April 7, 2010, the facility lacked a biopsychosocial evaluation in O.P. client record # 4.
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Plan of Correction
All individuals entering D&A services will have the biopsychosocial evaluation completed at time of assessment. The assigned primary counselor will ensure that this is completed and present at the time of initial treatment plan development.
The admission chart checklist will be completed by the medical records staff to re-confirm that the completed biopsychosocial evaluation is present.
Chart audits will be conducted monthly on a random sampling of D&A charts to ensure compliance with regulations. |
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 a review of client records, the facility failed to document treatment plan review and updates within sixty days, in two out of four client records.
The findings include:
Six Outpatient (O.P.) client records were reviewed on April 6, 2010. Four client records required treatment plan review and updates, specifically O.P. records # 1,2,3, and 4. Per the facility policy, treatment plan review and updates are required to be completed at least once, every sixty days. The facility failed to document treatment plan review and updates within sixty days, in O.P. client records # 1 and 3.
O.P. Client # 1 was admitted on January 4, 2010. The comprehensive treatment plan was completed on January 18, 2010. The first treatment plan update was due no later than March 19, 2010 and had not yet been completed at the date of inspection.
O.P. Client # 3 was admitted into outpatient treatment on July 16, 2009. The comprehensive treatment plan was completed on May 7, 2009. The only treatment plan update in the O.P. client # 3's record had been completed on July 16, 2009. Another treatment plan update was due no later than September 16, 2009 and had not yet been completed at the date of inspection on April 7, 2010.
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Plan of Correction
The Clinical Services Manager will ensure that D&A charts are audited on a montly basis by staff to ensure compliance with regulations and that the completed treatment plan review and updates are present in the chart.
At monthly staff meetings, the Clincial Services Manager will review with staff what individuals are due for treatment plan review and updates. |
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 the review of client records, the facility failed to document case consultations within the 60 day time frame in two of four client records
The findings include:
Six Outpatient (O.P.) client records were reviewed on April 6, 2010. Per agency policy, case consultations shall be completed every 60 days. Case consultations were required in four O.P. client records, specifically O.P. client records # 1,2,3, and 4. The facility did not document a case consultation within the 60 day time frame in O.P. client records # 3 and 4.
O.P. Client # 3 was admitted on July 16, 2009. A case consultation had been completed on August 19, 2009. A case consultation was due by October 19, 2009. There had not been an additional case consultation completed as of the date of this inspection.
O.P. Client # 4 was admitted on September 23, 2009. The case consultation was due by November 23, 2009. There had not been a case consultation completed as of the date of this inspection.
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Plan of Correction
The Clinical Services Manager will ensure that monthly chart audits are completed on individuals in the D&A program to ensure compliance with regulations and that case consultations are documented and present in the chart.
At monthly staff meetins, the Clinical Services Manager will review with staff what individuals need the case consultations to be completed. |
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 the review of client records, and an interview with the clinical supervisor, the facility failed to document a follow-up in one of two client records.
The findings include:
Six Outpatient (O.P.) client records were reviewed on April 6, 2010. Follow-up information was required in two client records, specifically O.P. records # 5 and 6.
O.P. Record # 5 was admitted on June 24, 2009 and discharged on September 17, 2009. The follow up attempt was due by October 17, 2009. As of the date of inspection a follow-up had not been documented.
An interview was conducted with the clinical supervisor on April 6, 2010; when asked when the follow-ups were due for non-successful discharges, the inspector was advised within 30 days of discharge.
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Plan of Correction
A discharge chart checklist will be completed by the medical records staff to ensure that necessary paperwork is completed and filed to ensure comliance with regulations. The medical records staff will also ensure that an after-care letter is mailed to the individual and a copy is kept for the chart.
The Clinical Services Manager will be notified by medical records staff is a chart is 'tore down' and there is no after care letter present. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on an interview with the Clinical Supervisor and a review of facility staff CPR documentation, the facility failed to ensure that a sufficient number of staff persons trained in CPR skills are present during the project's hours of operation.
The findings include:
On April 5th, 2010 the facility presented the Staffing Requirement Facility Summary Report to the licensing specialist and there was only one current CPR certification card attached, the referenced employee works Monday through Thursday, 9am-4pm. On April 6th, 2010 a CPR Certification Course sign in sheet dated 3/29/2010 was presented, however there was no way to determine if the staff members had passed the CPR course. The facility failed to provide verification of staff trained in CPR skills during their hours of operation, Monday through Thursday, 4:00-7:30pm.
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Plan of Correction
On May 10, 2010, the Clinical Services Manager and two D&A Counselors will receive CPR training and become CPR certified. This will ensure that a staff person who is trained in CPR and First Aid is present during the operating hours of the program.
The Clincial Services Manager will keep a calendar of the expiration dates for CPR and First Aid for staff and schedule trainings accordingly so that we continue to remain in compliance with regulation. |