INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 17, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Homing 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 December 28, 2010.
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Plan of Correction
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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 November 17, 2010. A discharge summary was required to be completed in two client records, specifically P.H. records # 6 and 7. In accordance with the facility policy, discharge summaries are to be completed within seven days of discharge.
P.H. Client record #6 - Client was admitted on August 9, 2010 and discharged on October 29, 2010. The discharge summary was due by November 5, 2010. The discharge summary had not documented as of the date of inspection.
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Plan of Correction
The Clinical Services Manager will maintain a listing of all individuals in D&A programming that are to be discharged and will review all charts within 5 business days of discharge to ensure that all required documentation is complete and in the discharge chart.
Any individuals to be discharged will be reviewed at D&A weekly team meetings. |
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 three of four client records
The findings include:
Five Outpatient (O.P.) client records were reviewed on November 17, 2010. Per agency policy, case consultations shall be completed every 60 days. Case consultations were required in four O.P. client records. The facility did not document a case consultation within the 60 day time frame in O.P. client records #2, 3, 4, and 5.
1. O.P. Client # 2 was admitted on June 23, 2010 and discharged on October 13, 2010. A case consultation had been completed on October 7, 2010. A case consultation was due by August 23, 2010.
2. O.P. Client #3 was admitted on June 23, 2010 and discharged on October 6, 2010. Case consultations had been completed on July 3, 2010 and October 6, 2010. A case consultation was due by September 3, 2010.
3. O.P. Client # 4 was admitted on July 15, 2010 and discharged on October 19, 2010. A case consultation was due by September 15, 2010. No case consultation had been completed as of the date of inspection.
4. O.P. Client # 5 was admitted on June 15, 2010 and discharged on October 6, 2010. Case consultations were completed on June 28, 2010 and October 6, 2010. A case consultation was due by August 28, 2010. .
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Plan of Correction
On the D&A listing of individuals in outpatient services, the date of their opening in services will be listed along with the first due date of the case consultation (at 60 days).
This listing will be reviewed at the weekly D&A team meetings to ensure that D&A counselors are aware of when case consultations are due.
The Clinical Services Manager will review the client listing regularly to update case consultation due dates. |