INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 29, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Men and Women for Human Excellence 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:
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Plan of Correction
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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 a review of personnel records, CPR certification cards and an interview with the project/facility director conducted on June 29, 2016, the facility failed to ensure that a sufficient number of staff persons were trained in CPR so that at least one person trained in these skills is onsite during the project's hours of operation.
This facility operates in 2 locations (2600 & 2603 Cecil B. Moore Ave. Phila Pa) under the same license number, so at least (1) staff would need to be CPR certified in each building during hours of operation.
Facility failed to submit valid CPR cards during presubmission and was unable to produce enough valid CPR cards, and a four-week schedule during the licensing inspection.
This information was reviewed with facility staff.
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Plan of Correction
The Program Director will instruct all staff to bring in copies of their CPR Certifications to be placed in their records ASAP, as some were not available at the time of the inspection. The Training Coordinator will schedule a CPR Training for all staff on 08/29/2016,and an additional CPR Training within 6 months for any new staff. The Program Director will monitor the scheduling of each program to ensure a sufficient number of CPR trained staff are on duty at all times. The Program Director and Human Resource Manager will conduct monthly reviews of personnel records to ensure that there is always a sufficient number of staff CPR trained to cover all facilities and shifts.
Persons Responsible:
Program Director / Human Resource Manager |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of employee records conducted on June 29, 2016, the facility failed to ensure that employee #4 obtained the required 25 hours of training. The training year reviewed was January 1, 2015 through December 31, 2015. Employee #4 only obtained 16 hours of training for the 2015 training year.
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Plan of Correction
The Clinical Supervisor will meet with employee #4, review DDAP findings and obtain a signed agreement of the employee's commitment to comply with DDAP training requirements. During weekly supervision sessions the Clinical Supervisor will monitor each Counselor's progress on achieving 25 hours of annual clinical training. |
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.
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Observations
A physical plant inspection, conducted on June 29, 2016 at approximately 1:30pm, as well as a discussion with the facility staff revealed that the facility failed to keep the grounds of the facility clean, safe, sanitary at all times.
An unidentified, unattended urine specimen was found on a shelf in the 3rd floor, front counseling office at 2603 Cecil B. Moore Ave. Facility staff admitted the specimen was not identifiable and there was no way to determine when it had been placed there.
This information was reviewed with facilty staff.
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Plan of Correction
The Program Director and Clinical Supervisor will address this issue at the next scheduled staff meeting. The urine sample discovered was flushed in the toilet and new urine samples were taken on all clients receiving services the morning of the inspection since upon investigation by the Clinical Supervisor it was verified that the urine sample was left there that same morning . The Clinical Supervisor will provide training to all clinical staff on the proper procedures for collecting and storing urine drug samples. All newly hired staff will also be trained on these procedures by the Clinical Supervisor during their new employee orientation.
Persons Responsible:
Clinical Supervisor |
705.23 (2) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
A physical plant inspection was conducted on June 29, 2016 at approximately 1:30 pm. Based on an observation the chair on the third floor in the front counseling office had a chair that was worn out with torn fabric on the seat.
This information was reviewed with facilty staff.
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Plan of Correction
The maintenance staff will remove the torn chair and replace it with a chair that's in good repair. Also, the maintenance dept. will take an inventory of all the chairs in the facility and replace any that are torn or damaged.
Persons Responsible:
Maintenance Supervisor / Program Director |
705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential 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.
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Observations
Based on the physical plant inspection conducted on June 29, 2016, the facility failed to provide paper towels in the restroom at the end of the middle hallway in the main building.
This information was reviewed with facility staff.
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Plan of Correction
The Housekeeping staff will conduct hourly rounds to identify and replace any missing paper towels and/or toilet tissue during their work shift. The Maintenance Supervisor will monitor the Housekeeping staff activities to ensure that this procedure is followed.
Persons Responsible:
Housekeeping Staff / Maintenance Supervisor |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The physical plant inspection was conducted on June 29, 2016. During the inspection of the facility restrooms the hot water temperature in the lobby restroom at the 2603 Cecil B. Moore Ave. building was measured at 145 degrees F.
These findings were reviewed with facility staff.
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Plan of Correction
The Maintenance Supervisor will reset the water valve to ensure that the hot water temperature in the lobby restroom is measured below 120 degrees F. The Maintenance staff will conduct periodic checks to ensure that the hot water temperature does not exceed 120 degrees F.
Persons Responsible:
The Maintenance Supervisor / Housekeeping Staff |
705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection conducted on June 29, 2016, the facility failed to maintain each bathroom in a functional, clean and sanitary manner . The restroom at the end of the middle hallway in the 2600 Cecil B. Moore building had a baseboard heating unit that was severely damaged.
This information was reviewed with facility staff.
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Plan of Correction
The Maintenance Supervisor will replace
the damaged baseboard heater unit, and conduct weekly inspections of the building/restrooms to identify and repair any damaged equipment. The Program Director will provide oversight of these procedures.
Persons Responsible:
Maintenance Supervisor Program Director |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on observation during the physical plant inspection conducted on June 29, 2016, the facility failed to ensure that exits from the facility were unobstructed.
The alleyway leading from the rear emergency exit to the street at the 2603 Cecil B. Moore Ave. building was cluttered with trash and debris. The gate to the sidewalk was secured with a clasp and staff would have to reach over to the door to open the clasp. This exit was not able to be opened from the inside.
Additionally, the alleyway leading from the rear emergency exit to the street at the 2600 Cecil B. Moore Ave. building was obstructed with discarded bedding and the concrete walkway was in disrepair creating a potential tripping hazard.
These results were reviewed with facility staff.
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Plan of Correction
The Program Director will arrange for the clasp on the emergency exit door to be removed and replace with an inside latch that is accessible to persons existing the building. Additionally, the Maintenance Supervisor will have all debris/trash removed from the rear exit. Also, the Maintenance Supervisor will remove the bedding from the rear emergency exit at 2600 Cecil B. Moore Ave. building, and re-cement the walkway to eliminate any hazards. The Maintenance Supervisor will make daily inspections of all emergency exists to ensure that they remain free of any trash and/or other obstructions. The Program Director will provide supervision of these projects and provide training to maintenance staff to ensure that they understand the importance of complying with DDAP Fire Safety regulations.
Persons Responsible:
Maintenance Supervisor / Program Director |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a discussion with the Facility Director conducted on June 29, 2016, the 2015 financial audit was not availble for review at the time of the licensing inspection site visit.
These results were reviewed with facility staff.
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Plan of Correction
The Executive Director will submit a completed 2015 financial audit to DDAP by September 30, 2016. Going forward the Executive Director will establish a contract with an Independent CPA that ensures that a annual financial audit is prepared and made available no later than March 31st of each year.
Persons Responsible:
Executive Director / Accountant |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
During a physical plant inspection conducted on June 28, 2016 is was observed that the facility was storing client charts on top of filing cabinets, on tables and on the floor. Some of these records were in boxes that could not be locked and some were stored loosely throughout the office.
This information was reviewed with the facility staff.
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Plan of Correction
The Program Director and Clinical Supervisor will conduct a full inspection of the client record room identify any client records on top of filing cabinets, client records in unlocked boxes, and client records loosely stored in the office. Based on our findings, the Program Director and Clinical Supervisor will direct staff to place all current client records in the locked file cabinets, and ensure that all outdated client records are placed in our locked storage room with no access other than the record room workers and management staff. The Clinical Supervisor will provide training on confidentiality, and the proper filing and storage of confidential records. The Clinical Supervisor will monitor the record room daily to ensure compliance with this confidentiality regulation.
Persons Responsible:
Program Director / Clinical Supervisor/ Record Room Staff |
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.
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Observations
Based on a review of client records, the facility failed to document a valid consent form in nine of twelve records.
Client #2 was admitted on 1/16/16 and was still an active client on the date of the inspection. A consent form dated 1/16/16 to an outside agency did not contain the purpose of the disclosure.
Client #3 was admitted on 12/22/15 and was still an active client on the date of the inspection. Two consent forms dated 12/22/15 one to a funding source and the other to an outside agency did not contain the purpose of the disclosures.
Client #4 was admitted on 2/23/16 and was still an active client on the date of the inspection. A consent form dated 2/23/16 to government agency did not contain the specific name of the agency.
Client #5 was admitted on 1/14/16 and was discharged 4/19/16. A consent form dated 1/14/16 to a funding source allowed for the release of funding which is beyond the limits imposed 4 Pa. code 255.5
Client #6 was admitted on 10/16/15 and was discharged 5/9/16. A consent form dated 10/16/15 to an outside agency did not contain the purpose of the disclosure.
Client #7 was admitted on 8/21/15 and was and was discharged 4/5/16. A consent form dated 8/21/15 to funding source did not contain an expiration date.
Client #8 was admitted on 7/8/15 and was and was discharged 3/14/15. A consent form dated 9/15/15 to a person did not contain the purpose of the disclosure. Additionally, a consent form dated 7/8/15 to an outside agency did not contain the purpose of the disclosure.
Client #11 was admitted on 9/25/15 and was and was discharged 1/5/16. A consent form dated 9/25/15 to a funding source allowed for the release of UDS (urinalysis) results which is beyond the limits imposed 4 Pa. code 255.5
Client #12 was admitted on 9/25/15 and was and was discharged 1/5/16. A consent form dated 10/23/15 to a person did not contain the purpose of the disclosure.
This information was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will direct all Counselors to obtain State approved training on Confidentiality within the next three months. Also, the Program DIrector and Clinical Supervisor will conduct an inservice training on procedures for accurately completing the organization's Consent to Release Confidential Information Form. The CLinical Supervisor will review the records of client #2, client #3, client #4 with the identified Counselors and make immediate corrections to the consent forms. The Clinical Supervisor will review the records of client #5, client #6, client #7, client #8, client #11, and client #12 with the identified Counselors and provide targeted training. Also, the Clinical Supervisor will review all active client records with Counselors during weekly supervision sessions to ensure that consent forms are completed correctly. All corrected consent to release forms will be reviewed with and initialed by the appropriate clients.
Persons Responsible:
Program Director / Clinical Supervisor |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records on June 29, 2016, the facility failed to document whether the client was offered a copy of the consent in two of eleven records.
Client #7 was admitted on 8/21/15 and was discharged 4/5/16. A consent form dated 8/21/15 to a funding source did not contain indication as to whether the client was offered a copy of the consent.
Client #9 was admitted on 9/8/15 and was and was discharged 3/29/16. A consent form dated 9/16/15 to an individual did not contain indication as to whether the client was offered a copy of the consent.
This information was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will direct all Counselors to obtain State approved Confidentiality Training within three months. Also, the Program DIrector and Clinical Supervisor will conduct a training on the accurate procedures for completing Client Consent to Release Confidential Information Forms. Additionally, the Clinical Supervisor will conduct reviews of client case records during weekly clinical supervision sessions to ensure compliance with this regulation.
Persons Responsible:
Clinical Supervisor / Program Director |
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.
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Observations
During an on-site licensing renewal inspection conducted on June 29, 2016, the facility failed to provide the requested client files in a timely manner.
At approximately 10:30 am the licensing specialist requested 12 client records for review. At 11:05 am none of the requested client records had been delivered and an inquiry was made by licensing specialist as to the nature of the delay. At that time (2) discharged client files were handed to the licensing specialist. At 11:23 am more files were brought, however (2) charts were not accounted for and one of the files that was delivered was not among the client files requested.
At 11:35 am the remaining charts were delivered.
This information was reviewed with facility staff.
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Plan of Correction
The Program Director and Clinical Supervisor will conduct a training with record room staff on how to prepare for a DDAP inspection, including procedures for making active and discharge records easily accessible to DDAP staff. The Program Director will recruit and hire an Office Manager who will be responsible for managing record room staff.
Persons Responsible:
PRogram DIrector, CLinical SUpervisor |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Hummel, Gregg
The facility's Policy and Procedure manual was reviewed during the licening inspection on June 29, 2016 and was found not to be in compliance with State regulation 709.34 Reporting of unusual incidents.
Facility policy failed to include the reporting of the unusual incidents as per 709.34, subsection (c): To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day.
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
(5) Outbreak of a contagious disease requiring CDC notification.
This information was reviewed with facility staff.
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Plan of Correction
The Program Director will revise the current reporting of unusual incidents policy / procedures to include , "the project shall file a written unusual incident report with DDAP within 3 business days following an unusuall incident".
Persons Responsible:
Program Director |
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 a review of client records the facility did not document a complete medical history on each client.
Client #4 was admitted on 2/23/16 and was still an active client at the time of the inspection. Facility failed to document a medical history in the client chart.
Client #10 was admitted on 2/10/16 and was and was discharged 5/19/16. Facility failed to document a medical history in the client chart.
Client #12 was admitted on 9/25/15 and was and was discharged 1/5/16. Facility failed to document a medical history in the client chart.
This information was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Program Director and Clinical Supervisor will conduct a training on the procedures for obtaining and documenting a complete medical history in each client record. The Clinical Supervisor will review the records of client # 4, Client # 10, and client # 12 with the responsible Counselors and provide targeted training. Also, the Clinical Supervisor will review all active client case records with the Counselors during weekly clinical supervision sessions to ensure full compliance with this regulation. The Program Director will also conduct random reviews of client case records to assist the Clinical SUpervisoe with ensuring compliance.
Persons Responsible:
Program Director / Clinical SUpervisor
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709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. 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
Based on a review of client records the facility did not document a complete drug and alcohol history on each client.
Client #4 was admitted on 2/23/16 and was still an active client at the time of the inspection. Facility failed to document a drug and alcohol history in the client chart.
Client #10 was admitted on 2/10/16 and was and was discharged 5/19/16. Facility failed to document a drug and alcohol history in the client chart.
Client #12 was admitted on 9/25/15 and was and was discharged 1/5/16. Facility failed to document a drug and alcohol history in the client chart.
This information was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will conduct a training on the accurate procedures for obtaining and documenting drug / alcohol histories on each client. The Clinical Supervisor will review records of client # 4,with the identified counselor and instruct the counselor to make the appropriate corrections to the record. The Clinical Supervisor will review the records of client # 10, and client #12 with the identified Counselor to provide targeted training. Also, the Clinical Supervisor will review all active client case records with Counselors during weekly supervision sessions to ensure compliance with this regulation. The Program Director will conduct random envies of client records to assist the Clinical Supervisor with ensuring compliance.
Persons Responsible:
Program Director / Clinical SUpervisor |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records the facility did not document a complete personal history on each client.
Client #4 was admitted on 2/23/16 and was still an active client at the time of the inspection. Facility failed to document a personal history in the client chart.
Client #10 was admitted on 2/10/16 and was and was discharged 5/19/16. Facility failed to document a personal history in the client chart.
Client #12 was admitted on 9/25/15 and was and was discharged 1/5/16. Facility failed to document a personal history in the client chart.
This information was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will conduct a training with Counselors on the accurate procedures for obtaining and documenting complete personal histories on all client case records. The Clinical Supervisor will review the case records of client #4 with the identified Counselors to ensure appropriate corrections to the record. The Clinical Supervisor will review the records of client #10 and client # 12 with the identified Counselor and provide targeted training. Also, the Clinical Supervisor will review all active client case records with Counselors during weekly supervision sessions to ensure compliance with this regulation. The Program DIrector will conduct random reviews of client case records to assist the Clinical Supervisor with ensuring compliance with this regulation.
Persons Responsible:
Program Director / Clinical Supervisor |
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
Based on a review of client records the facility did not document a complete psychosocial evaluation on each client.
Client #4 was admitted on 2/23/16 and was still an active client at the time of the inspection. Facility failed to document a complete psychosocial evaluation in the client chart.
Client #7 was admitted on 8/21/15 and and was discharged 4/5/16. Facility failed to document a complete psychosocial evaluation in the client chart.
Client #10 was admitted on 2/10/16 and was and was discharged 5/19/16. Facility failed to document a complete psychosocial evaluation in the client chart.
Client #12 was admitted on 9/25/15 and was and was discharged 1/5/16. Facility failed to document a complete psychosocial evaluation in the client chart.
This information was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will conduct a training for Counselors on accurate procedures for obtaining and documenting psychosocial evaluations in client case records. The Clinical Supervisor will review the records of Client # 4 with the identified Counselors to ensure appropriate corrections to the record. The Clinical Supervisor will review the records of client # 7, client # 10, and client #12 with the identified Counselors and provide targeted training. Also, the Clinical Supervisor will conduct record reviews of all active clients during weekly clinical supervision sessions to ensure compliance with this regulation. The Program Director will conduct random record reviews to assist the Clinical Supervisor with ensuring compliance.
Persons Responsible:
Program Director / Clinical Supervisor |
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 conducted on June 29, 2016, the facility failed to document an update of the treatment and rehabilitation plan, at least every sixty days, in six of ten client records.
Client #3 was admitted on December 22, 2015 and was still an active client at the time of the licensing inspection. The last treatment update reviewed was dated for April 22, 2016. The next treatment plan update was due to be completed by June 22, 2016. As of the date of the licensing inspection the treatment plan update was not documented.
Client #6 was admitted on October 16, 2015 and was discharged May 19, 2016. The last treatment update reviewed was dated for February 29, 2016. The next treatment plan update was due to be completed by April 29, 2016. As of the date of the licensing inspection the treatment plan update was not documented.
Client #7 was admitted on August 21, 2015 and was discharged April 5, 2016. The last treatment update reviewed was dated for November 13, 2015. The next treatment plan update was due to be completed by January 13, 2016. As of the date of the licensing inspection the treatment plan update was not documented.
Client #9 was admitted on September 8, 2015 and was discharged March 29, 2016. The individualized treatment and rehabilitation plan was completed on 10/7/15. The treatment plan update was due by December, 7, 2015. As of the date of the licensing inspection the treatment plan update was not documented.
Client #10 was admitted on February 10, 2016 and was discharged May 19, 2016. The last treatment update reviewed was dated for March 15, 2016. The next treatment plan update was due to be completed by March 15, 2016. As of the date of the licensing inspection the treatment plan update was not documented.
Client #11 was admitted on September 25, 2015 and was discharged January 5, 2016. The last treatment update reviewed was dated for September 25, 2015. The next treatment plan update was due to be completed by November 25, 2015. As of the date of the licensing inspection the treatment plan update was not documented.
This information was reviewed with facility staff.
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Plan of Correction
The Clinical Supervisor and Program Director will conduct a training on developing and updating treatment plans, including time frames for completion, goals and interventions. The Clinical Supervisor will also review the client case record of client # 3 with the identified Counselor to ensure appropriate corrections to the record. The Clinical Supervisor will review the records of client #6, client #7, client #9,client #10,and client #11 with the identified Counselors and provide targeted training. Also, the Clinical Supervisor will review all active client records with Counselors during weekly clinical supervision session to ensure compliance with this regulation. The Program DIrector will do random reviews of client records to assist the Clinical Supervisor with ensuring compliance.
Persons Responsible:
Program Director / Clinical Supervisor |
709.93(a) 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:
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Observations
Based on a review of client records conducted on June 29, 2016, the facility failed to ensure that there was a complete client record in nine of ten client records.
Client #5 was admitted on 1/14/16 and was discharged 3/14/16. Facility failed to provide documentation of any attempt to follow up with client after discharge.
Client #8 was admitted on 7/8/15 and was discharged 3/14/16. Facility failed to provide documentation of any attempt to follow up with client after discharge.
Client #9 was admitted on 9/8/15 and was discharged 3/29/16. Facility failed to document a case consult as of the date of the licensing inspection.
Client #10 was admitted on 2/10/16 and was discharged 5/19/16. Facility failed to document a case consult as of the date of the licensing inspection. Additionally, facility failed to provide documentation of any attempt to follow up with client after discharge.
Client #11 was admitted on 9/25/15 and was discharged 1/5/16. Facility failed to document a case consult as of the date of the licensing inspection or any attempt to follow-up with the client. Additionally, a progress note for an individual session, dated 10/9/15, was not documented on the record of service and two entries on the record of service (individual session 9/9/15 and group session 9/25/15) had no corresponding progress notes documented in the chart.
Client #12 was admitted on 9/25/15 and was discharged 1/5/16. Facility failed to document a case consult as of the date of the licensing inspection or any attempt to follow-up with the client. Additionally, an entry on the record of service (group session dated 10/9/15) had no corresponding progress note documented in the chart.
This information was reviewed with facility staff.
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Plan of Correction
The Clinical Supervisor will conduct a training with Counselors on documenting a complete client case record, including documenting progress notes, documenting case consults, and documenting follow-up attempts in client case records. Also, the Clinical Supervisor will conduct record reviews of client #5, client #8, client #9, client #10, client #11, and client #12 with identified Counselors and provide targeted training on required documentation. Also, the Clinical Supervisor will conduct reviews of all active client records during weekly clinical supervision sessions to ensure follow up information, progress notes and corresponding service entries are documented in all records. The Program Director will conduct random record reviews to assist the Clinical Supervisor with ensuring compliance with this regulation.
Persons Resonsible:
Program Director / Clinical Supervisor |