INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 18, 2008 through June 19, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHD Womanspace 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 July 11, 2008.
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Plan of Correction
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709.32(c)(4) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
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Observations
Based on a review of medication policies and procedures and medication administration records, the facility failed to document complete medication records. The medication records were blank on numerous days in June 2008. Documentation was missing to indicate whether or not a client received their medication, if a client refused their medication or whether the medication was discontinued.
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Plan of Correction
Staff Nurse will review recent medication records to identify specific issues related to failure to document medication receipt, refusal and discontinued medications. Staff Nurse will develop a detailed written protocol for proper medication monitoring and documentation, as well as for ordering, receiving and logging new and discontinued prescriptions. Staff Nurse will provide an all staff training scheduled on or about July 30, 2008, at which time all staff will be trained on all medication protocol and will be reminded of the urgency of prioritizing medication policy and procedure. Staff Nurse and Program Director will create a medication training DVD, which will be used to train all future employees on or before the first day of employment. Staff Nurse will review medication log monthly to ensure adherence to Medication Policy and Procedure.
Complete Date: 8.29.08 Initial Training with Ongoing Review of Medication Documentation
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document complete psychosocial evaluations in three of six records reviewed, #1, 2, and 6. Psychosocial evaluations were historical rather than an assessment of the client's assets and strengths, support systems, coping mechanisms , negative factors that my inhibit treatment and counselors conclusions/impressions of the client.
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Plan of Correction
Program Director and Director of Credentials and Licensing will conduct an initial training for clinical staff on completion of Psychosocial Evaluation on or before 8.29.08, which will emphasize the importance of clinical assessment; including but not limited to client assets and strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and clinical impressions and conclusions about the client. Clinical staff will have monthly peer supervision meetings for ongoing assessment of Psychosocial Evaluations and continued development of clinical assessment skills. Program Director will review clinical charts monthly to ensure continued emphasis on clinical assessments.
Complete Date: 8.29.08 Initial Training with ongoing monthly training updates and monthly review of clinical documentation.
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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
Based on a review of client records, the facility failed to document a complete treatment plan updates in four of eight client records reviewed, #1, 2, 7 and 8. Treatment plan updates did not include an assessment of the client's progress in relationship to the stated goals of the treatment plan.
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Plan of Correction
Program Director and Director of Credentials and Licensing will conduct an initial training for clinical staff on completion of Updated TX Plans on or before 8.29.08, which will emphasize the importance of assessing and documenting client's progress in relationship to goals on current TX Plan. Clinical staff will have monthly peer supervision meetings for ongoing assessment of Updated TX Plans and continued development of clinical assessment skills with regards to client progress. Program Director and will review clinical charts monthly to ensure clinical team is meeting standards with regards to tracking client progress on Updated TX Plans.
Complete Date: 8.29.08 Initial Training with ongoing monthly training updates and monthly review of clinical documentation.
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