INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 25-26, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, RHD Lower Merion Counseling 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:
|
Plan of Correction
|
704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
|
Observations
The facility failed to provide a complete and accurate plan documenting the qualifications and training of staff to the Department licensing representatives at the time of the project's site visit. The Staffing Requirements Summary Report (SRFSR) for provided at the onsite inspection had inaccurate information relative to the listed project director. The facility was given an opportunity to correct the document and provide new information at the time of the onsite inspection, but, were unable to do so. The facility was then permitted to update the document and forward it to the Department which they di d on March 22, 2019. However the document had conflicting dates regarding the position date for the listed Project Director. The SRFSR listed the date for the current position as July 1, 2019; however, a letter dated February 20, 2018 indicated that the individual was put in the position of Project Director on February 20, 2018.
|
Plan of Correction
RHD/Lower Merion Counseling & Mobile Crisis Services (LMCMS) developed the following Plan of Correction in response to the deficiencies found during the on-site licensure renewal inspection conducted on
February 25-26, 2019.
The Quality Assurance Manager will update the Staffing Requirements Facility Summary Report (SRFSR) to reflect the appropriate start date for the Project Director.
The Facility Director will submit the new SRFSR form to DDAP by 4/19/2019.
To ensure that this doesn't reoccur the Facility Director will make sure that the Project Director's Employee Training Record is delivered to the Program prior to the onsite licensure visit. The Project Director's Employee Training Record is maintained at the Corporate Office not the Program Site.
|
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) form the facility failed to develop individual training plans for staff for the 2019 training year.The facility self reported on the SRFSR that employees #1-5 did not have individual training plans for the 2019 training year. Additionally the SRFSR listed the last individual trainng plans for support staff had not been completed since "18- Feb".
|
Plan of Correction
Individual training plans were completed for employees #1 through 5 that included input from both the employee and supervisor between February 19 and March 4, 2019.
To ensure that this doesn't reoccur the Clinical Supervisor will audit employee training records bi-annually in May and December to make sure that an individual training plan is developed for each employee.
The Clinical Supervisor will also monitor and send out notifications and alerts to employees and managers when required training are due prior to the expiration or due date of training.
|
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of personnel records, and interview with facility staff, the facilty failed to ensure that all staff completed the mandatory HIV/AIDS and TB/STD trainings within the regulatory timeframes.Employee #3 was hired as a counselor on June 5, 2017 and should have completed the required 4 hours of HIV/AIDS and 6 hours of TB/STD and other health related topics using a Department approved curriculum no later than June 5, 2018. The employee completed the 6 hours of HIV/AIDS training on June 12, 2018 and had not completed the required 4 hours TB/STD and other health related topics per the Department approved curriculum.Employee #6 was hired on May 31, 2016 as a Medical Assistant and should have completed the required 4 hours of HIV/AIDS and 6 hours of TB/STD and other health related topics using a Department approved curriculum no later than May 31, 2018. The employee had not yet completed the 6 hours of HIV/AIDS training and had not completed the required 4 hours TB/STD and other health related topics per the Department approved curriculum.This was discussed with facility staff at the time of the inspection.This is a repeat citation. The facility was previously cited for noncompliance with this standard during the February 21, 2018 Licensing Inspection.
|
Plan of Correction
Employee #3 and #6 will remain in their current position.
They will be scheduled to attend the approved DDAP HIV/AIDS, TB, STD and other health related training by June 30, 2019.
All personnel records will be reviewed by the D&A Coordinator to determine if any other employee needs to attend the required communicable disease training and schedule them accordingly before the end of the training year by June 30, 2019.
To ensure that this doesn't reoccur, the Clinical Supervisor will audit employee training records annually to make sure all staff complete training within the first 2 years of employment.
The Clinical Supervisor and Facility Director will also work with RHD's Learning & Development Director to ensure that DDAP approved communicable disease training training is available for employees by June 30, 2019.
|
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 upon a review of facility staff with current CPR certificaiton and First Aid training employed by the Drug and Alcohol portion of the facility, and discussion with facility staff, the facilty was unable to verify that at least one person trained in those skills was onsite during the hours of operation.The facility's hours of operation are as follows:Monday through Thursday 9:00 AM - 9:00 PMFriday 9:00 AM - 5:00 PM Saturdays 9:00 AM - 2:00 PMThe facility was only able to provide documentation of CPR certification and First Aid training for four employees of the D&A facility, a receptionist hired on February 3, 2018, a Therapeutic Liaison hired on October 16, 2017 and employee #6, the Medical Assistant who completed the CPR and First Aid trainings on February 8, 2019 and one of the psychiatrists hired on July 13, 2018. The facility confirmed that these four individuals did not cover all hours that the facility was open.The agency has other individuals certified in CPR and trained in First Aid, that work for the Mental Health (MH) portion of the agency; however, documentation verifying the exact number and certifications as well as documentation that management for the D&A program could mandate MH staff to cover for D&A staff in their absence was not provided.This was discussed with he facility director at the time of the inspection.
|
Plan of Correction
By June 30, 2019 all Administrative/ Reception, Therapist and D&A staff will participate in CPR Certification and First Aide Training. The completion of this training by staff will ensure that at least one person trained in these skills will be on-site during office hours of operation.
To ensure that this doesn't reoccur the D&A Coordinator, Office Coordinator, Billing Coordinator, and Clinical Supervisor will monitor expiration dates of individual CPR and First Aide Certification and send out notices to employees that need re-certification in CPR and First Aide Training prior to expiration date.
|
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) form and an interview with facility staff, the facility failed to ensure the Project Director, employee #1 and Facility Director Employee #2 each completed 12 hours of annual training.The facility self reported on the SRFSR that employees #1 & 2 did not complete any trainng hours for the 2018 annual training year.
|
Plan of Correction
Employee #1 Project Director will remain in her current position.
Employee #2 Interim Facility Director will be replaced by the Facility Director effective 4/15/2019.
Employee 1 and 2 will complete the required 12 hours of annual training for the year 2019.
The Clinical Supervisor will be responsible for monitoring, scheduling and notifying the Project Director and Facility Director that required training is due prior to due date.
|
705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential 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 observation on February 26, 2019 the facility failed to ensure all trash, garbage and rubbish were stored in noncombustible, covered containers that prevent the penetration of insects and rodents. The facility's dumpsters (recycling and trash) had lids that were unable to be closed in a manner that would prevent the penetration of rodents and/or insects. The lids were damaged/warped. This was discussed with he facility director at the time of the inspection.
|
Plan of Correction
The Property Manager contacted the Landlord on April 4, 2019 to notify him of the issue with the dumpsters.
Going forward to prevent penetration of rodents and insects, all tenants using the dumpsters will be notified that large boxes must be broken down prior to disposal to ensure that the lids close properly.
Additionally, a request was submitted to the landlord to have more frequent checks at the dumpster site to ensure that all debris is cleared from around the dumpsters.
Time frame for Completion: May 31, 2019.
|
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.
|
Observations
Based on observation on February 26, 2019, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.The two bathrooms located in the main hallway adjacent to the waiting area had wallpaper pulling away from the walls and the one had some visible signs of mold along the baseboard. This was discussed with he facility director at the time of the inspection.
|
Plan of Correction
The Property Manager will remove the damaged wallpaper in the two bathrooms located in the main hallway adjacent to the waiting area by May 31, 2019.
Both bathrooms will be inspected for mold, cleaned and painted by the Property Manager by May 31, 2019.
To ensure that the bathrooms are maintained appropriately the Office Manager will complete quarterly plant inspections with the Property Manager to ensure that the office facilities are functional, clean and sanitary
|
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of the facility fire drill log on February 25, 2019, and a conversation with facility staff, the facility failed to ensure that a fire drill was conducted at least once a month.There was no documentation of a fire drill for the month of January 2019 in the fire drill log. When asked, facility staff confirmed that no drill had been conducted during that month.This was discussed with he facility director at the time of the inspection.
|
Plan of Correction
On April 11, 2019 the Operations Manager and the Quality Assurance Manager amended the Fire Drill Policy to clarify staff roles and responsibilities. The amended Fire Drill Policy includes
guidelines for scheduling and conducting fire drills.
To ensure that this doesn't reoccur the Quality Assurance Manager and the Office Manager will schedule fire drills in advance and monthly. To date, monthly drills have been scheduled for 2019.
All employees will receive a copy of the new Fire Drill Policy by 4/19/2019. Employees will be required to sign and date the new policy to acknowledge receipt.
|
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
|
Observations
Based upon a review of the facility's Policies and Procedure manual on February 25, 2019, the Project Director failed to prepare, annually update and sign a written manual delineating project policies and procedures.The last documented update of the policy and procedure manual was July 1, 2017 and signed by the General Counsel Corporate Secretary rather than the Project Director. This was discussed with facility staff at the time of the inspection.
|
Plan of Correction
The Project Director will prepare, amend and sign the updated Program Policy and Procedures Manual by May 31, 2019.
The following Policies and Procedures need to be amended and incorporated in the Manual:
1.Fire Drill Procedures
2.Client Rights and Responsibilities
3.Consent to Release Information Forms
4.Reporting Unusual Incidents
5.Client Notification of Termination
The Project Director will submit amended Policies and Procedures along with a signed attestation form to DDAP by May 31, 2019.
|
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.
|
Observations
Based on a review of seven client records the facility failed to obtain voluntary consent to release information forms complying 42 CFR and 4 Pa. Code 255.5(b) and released information exceeding the limitations of 4 Pa. Code 255.5(b) in seven of seven records reviewed. Consent forms also state to"to release and receive information".4 pa. Code 255.5(b) restricts information released to judges, probation or parole officers, insurance company health or hospital plan or governmental officials to the following:(1) Whether the client is or is not in treatment. (2) The prognosis of the client. (3) The nature of the project. (4) A brief description of the progress of the client. (5) A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse. Client records #1 through 7 contained consents to release information allowing for the release of information to governmental officials and third party payors exceeding the above permitted information. The client records had documentation showing tha the information had been released.Client record #6 had a signed and witnessed consent to release information form dated May 23, 2018 allowing for the release of Psychiatric Evaluation, Diagnosis, Treatment Summary, Medication/Emergency Info, Medical History/Evaluation; however, the form did not indicate who the information was to be released to, what form the information would be in, what the purpose of th e release was for, and the effective and expiration dates were left blank.Consent forms labeled "CONSENT FOR RELEASE OF INFORMATION" only allowed for verbal revocation in the event the individual was physically unable to provide a signature. Revocations may be made verbally and a client may not be mandated to make the revocation to a specified individual.Consent forms labeled "Authorization for Release of Records" had a section labeled "Recipient Information" with a line stating "Please indicate the information or types of information to be disclosed"; however, there was a section labeled "Patient Consent" that stated "Specifically, I consent to disclosure of the following information., as applicable, and to the fullest extent allowed under federal and state law information regarding drug and alcohol abuse, mental illness, acquired immune deficiency syndrome (AIDS), Human immunodeficiency virus (HIV), sexually transmitted disease, tuberculosis and genetics. With respect to drug and alcohol abuse information, I consent to disclosure of the following information in accordance with 71 P.S. 1690.108(b) and 4 Pa. Code 255.5(b) treatment, my prognosis, the nature of the program that is treating me, a brief description of my progress and a short statement regarding whether I have relapsed into drug or alcohol abuse." The consent to release form is not clear as to what exactly the client is allowing to be released as it is written.The consent form labeled "Authorization for Release of Records" also requires that a revocation must be in writing and addressed to counsel for Resources in Human Development, Inc. c/o 4700 Wissahickon Avenue, Suite 129, Philadelphia, PA 19144. attn: Legal Department. This is in violation of 42 CFR. Revocations may be made verbally and a client may not be mandated to make the revocation to a specified individual.This was discussed with the facility staff at the time of the inspection.
|
Plan of Correction
The D&A Coordinator and the Facility
Director will review and amend the current Release of Information Forms to ensure that all elements of the Confidentiality Standards are incorporated in the consent to release information forms.
A record keeping retraining to include a review of the confidentiality standards will be facilitated on May 31, 2019 to ensure that staff adhere to the DDAP Licensure Standards per 709.28 ( c )Confidentiality Standards.
All Release of Information Forms will be reviewed and monitored by the D&A Coordinator to ensure adherence to confidentiality standards going forward.
The D&A Coordinator and the Clinical Supervisor will be responsible for ensuring these standards are adhered to going forward.
Time frame for Completion: May 31, 2019
|
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
|
Observations
Based on a review of seven client records, and an interview with facility staff, the facility failed to document that the clients were informed of all their rights in seven of seven client records reviewed.Based on an interview with facility staff, clients receive a packet of information that they must sign for to acknowledge that they received the packet. The packet contains a document named "RIGHTS AND RESPONSIBILITIES" which lists client rights. The document did not include the following: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. 2. A client may not be discriminated against based on ethnicity.3. 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. 4. Clients have the right to appeal a decision limiting access to their records to the director. 5. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. 6. Clients have the right to submit rebuttal data or memoranda to their own records.This was discussed with the facility staff at the time of the inspection.
|
Plan of Correction
Plan of Correction:
The D&A Coordinator and the Facility
Director will review and amend the current Intake Package to ensure that the intake forms incorporate the following information regarding client rights:
1. Civil Rights and liberties while receiving treatment.
2. A client may not be discriminated against based on age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion
3. Access to inspect their own records.
4. Clients have the right to appeal a decision limiting access to their records to the director.
5. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
6. Clients have the right to submit rebuttal data or memoranda to their own
A record keeping retraining to include a review of Client Rights Standards will be facilitated on May 31, 2019 to ensure that staff adhere to the DDAP Licensure Standards per 709.30 (1) Client Rights.
Client Charts will be reviewed and monitored by the D&A Coordinator and Clinical Supervisor monthly to ensure program compliance to DDAP Standard 709.30 (1).
The D&A Coordinator and the Clinical Supervisor will be responsible for ensuring these standards are adhered to going forward.
Time frame for Completion: May 31, 2019
|
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
|
Observations
Based on a review of one client record where the client was terminated from treatment services, the facility failed to inform the client that they have the right to request reconsideration of a decision terminating treatment.Client #3 was terminated from treatment; however, the termination letter did not inform the client of the right to request reconsideration of a decision terminating treatment. Nor was there anything in the client record demonstrating that they were made aware of this during intake/orientation. .
|
Plan of Correction
Client #3 will be informed of their right to request reconsideration of a decision terminating treatment.
A record keeping retraining to include a review of Notification of Termination Standards will be facilitated by May 31, 2019 to ensure that staff adhere to the DDAP Licensure Standards per 709.33(b) Notification of Termination.
Client Charts will be reviewed and monitored by the D&A Coordinator and Clinical Supervisor monthly to ensure program compliance to DDAP Standard 709.30 (1).
The D&A Coordinator and the Clinical Supervisor will be responsible for ensuring these standards are adhered to going forward.
Time frame for Completion: May 31, 2019
|
709.34 (c) (2) 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:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
|
Observations
Based on a review of facility incident reports, the facility failed to notify the Department within three business days of the death of a client.An incident report dated September 4, 2018 regarding the death of a client occurring on August 31, 2018 was faxed to CCBH on September 5, 2018. The facility had no documentation that an incident report had been sent to the Department of Drug and Alcohol Programs.
|
Plan of Correction
Plan of Correction:
On April 11, 2019 the Operations Manager and the Quality Assurance Manager revised and amended the Incident Reporting Procedures to include DDAP Incident Reporting Standards.
To ensure that this doesn't reoccur an annual review of the Incident Reporting Procedures will be facilitated to ensure that staff adhere to the DDAP Licensure Standards per 709.34 ( c )(2) Reporting of Unusual Incidents.
All employees will receive a copy of the amended Incident Reporting Guidelines along with the weblink to the DDAP Incident Reporting Form by April 30, 2019.
The Quality Assurance Manager and the Clinical Supervisor will monitor monthly unusual incidents.
|
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to document psychosocial evaluations that were evaluative in five of seven client records reviewed.Client records # 2, 3, 4, & 5 failed to provide a composite picture of the individual inrelationship to the collected historical information in order to identify possiblerelationships, conditions and causes leading to the client ' s current situation. There was no indication based on the histories as to any potential or available support system the client might have, what strengths assets the client might have or other factors that can contribute to the resolution of identified problems. There was no mention as to what might be barriers to treatment, client needs or problems that can/cannot be addressed in treatment,client coping mechanisms.Psychosocial evaluations in client records #2 & 3 simply stated: Client is seeking therapy to maintain sobriety. Recommend treatment. The psychosocial evaluation in client record #4 did not address the D&A issues, but, was more about the Mental Helath issues.The section for the psychosocial evaluation in client record #5 was blank.This was discussed with staff at the time of the licensing inspection.
|
Plan of Correction
The Operations Manager and the Quality Assurance Manager will review Client Records # 2, 3, 4, & 5 by April 30, 2019 (*if key is received by 4/16/19).
All Therapists will be trained in completing a comprehensive psychosocial evaluation in accordance with DDAP Licensure Standards.
This training will be facilitated by RHD Corporate Clinical Director and documented in the employee record. All new Therapists will be trained on completing the comprehensive psychosocial evaluation as part of their onboarding and documented in their employee record.
Random chart audits of all Therapists will be completed quarterly by the D&A Coordinator and the Clinical Supervisor to review the psychosocial evaluation. This review will ensure that Therapist are completing the psychosocial evaluation in accordance with DDAP Standards.
The Quality Assurance Manager will track the chart audits.
All Therapist will be trained by May 31, 2019.
|
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of client records, the facility failed to document the type and/or frequency of services in three of seven client records reviewed.Treatment plans in client records #1, 4 & 5, lacked the type and/or frequency of treatment services.This was discussed with facilty staff at the time of the inspections.
|
Plan of Correction
Treatment plan updates that include type and frequency of treatment and rehabilitation services will be completed for Clients #1, 4, and 5 by May 31, 2019.
All Clinical staff will be trained in completing a treatment plan in accordance with DDAP Licensure Standards by May 31, 2019.
The Clinical Supervisor will be responsible for ongoing monitoring of the client's Treatment Plan for updates to be done according to policy, procedure and regulations.
|
709.93(a)(10) 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:
(10) Discharge summary.
|
Observations
Based on a review of client records, the facility failed to document a discharge summary in one of three client records reviewed. Client #2 was admitted on September 15, 2018 and discharged on January 25, 2019. The facility did not document a discharge summary in client #2's record. This was discussed with the facility staff at the time of the inspection.
|
Plan of Correction
Client #2's record will be updated with a discharge summary by 4/30/2019.
A record keeping retraining to include a review of Discharge Summary Standards will be facilitated on May 31, 2019 to ensure that staff adhere to the DDAP Licensure Standards per 709.93(a) (10) Client Records.
Client Charts will be reviewed and monitored by the D&A Coordinator monthly to ensure program compliance to DDAP Standard 709.93(a) (10).
To ensure that this doesn't reoccur Discharge Summaries will not be completed without the review and sign-off by the D&A Coordinator. Additionally, Chart Audits will be completed quarterly by the Clinical Supervisor and Quality Assurance Manager. Findings will be reviewed during individual supervision meetings.
|
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.
|
Observations
Based on a review of client records, the facility failed to document a follow-up per the facility policy in one of three client records reviewed requiring follow-up.Facility policy states that a follow-up phone call will be made 3-5 days from the discharge date.Client #2 was admitted on September 15, 2018 and discharged on January 25, 2019. The facility did not document a follow-up in client #2's record. This was discussed with the facility staff at the time of the inspection.
|
Plan of Correction
A record keeping retraining to include a review of Follow-up Standards will be facilitated by May 31, 2019 to ensure that staff adhere to the DDAP Licensure Standards per 709.93(a) (11) Client Records.
Client Charts will be reviewed and monitored by the D&A Coordinator monthly to ensure program compliance to DDAP Standard 709.93(a) (11).
To ensure that this doesn't reoccur follow-up will be completed by the D&A Coordinator within 3-5 days of Client's discharge.
|