INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 18 - 21, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Penn Foundation for Mental Health, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
|
Observations
Based on a review of personnel records, the facility failed to document the required period of close supervision for one of three counselor assistants.
The findings include:
Fifteen personnel records were reviewed on March 19, 2013. Three of the fifteen personnel records reviewed were for the position of counselor assistant. Two counselor assistant had the appropriate documentation. The counselor assistant represented in record # 11, only documented the clients reviewed and check off boxes of what was reviewed. No documentation detailing what the issues were or how this helped the counselor assistant. This employee is required to have six months of close supervision. The lack of documentation was confirmed by facility staff on March 19, 2013.
|
Plan of Correction
Supervision notes were available for review, but did not contain sufficient information and detail to satisfy the intent of this regulation. The clinical supervisor has been informed of what is expected in supervision notes for any future supervision requirements. Going forward, supervision notes will document the specific issues or problems discussed by the Counselor Assistant during the supervisory session as well as areas in which they are demonstrating competency. Director of the Recovery Center will oversee this POC. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of personnel records, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment in one of two personnel records, as required by regulation.
The findings include:
Fifteen personnel records were reviewed on March 19, 2013. Two employees were hired since the last inspection. Per regulation, the residential facility shall instruct all staff in the use of the fire extinguishers upon staff employment. The facility failed to document that fire extinguisher training was completed upon employment in employee record # 6.
Employee # 6 was hired on December 6, 2012. Fire extinguisher training was due to be completed no later than December 12, 2012. The facility did not document the completion of fire extinguisher training until December 18, 2012.
An interview with facility staff on March 19, 2013 confirmed the findings.
|
Plan of Correction
It was brought to our attention during the site visit that the fire extinguisher training for a new employee occurred one week late. The supervisor of the new employee was not aware of the regulation and therefore did not realize the importance of this training upon hire. This supervisor, as well as all other supervisors in the building has been made aware of this regulation, thus ensuring that this training will be completed in a timely manner on all future employees. Director of the Recovery Center will oversee this POC. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on a review of personnel records, the facility failed to train staff to perform assigned tasks during emergencies upon staff employment in two of two personnel record, as required by regulation.
The findings include:
Fifteen personnel records were reviewed on March 19, 2013. Two employees were hired since the last inspection. Per regulation, the residential facility shall train staff to perform assigned tasks during emergencies upon staff employment. The facility failed to document that this training was completed upon employment in employee records # 5 and 6.
Employee # 5 was hired on October 11, 2012. Emergency training was due to be completed no later than October 17, 2012. The facility did not document the completion of the emergency training until November 1, 2012.
Employee # 6 was hired on December 6, 2012. Emergency training was due to be completed no later than December 12, 2012. The facility did not document the completion of the emergency training until December 27, 2012.
An interview with facility staff on March 19, 2013 confirmed the findings.
|
Plan of Correction
It was brought to our attention during the site visit that the emergency training for two new employees occurred late. The supervisor of the new employees was not aware of the regulation and therefore did not realize the importance of this training upon hire. This supervisor, as well as all other supervisors in the building has been made aware of this regulation, thus ensuring that this training will be completed in a timely manner on all future employees. Director of the Recovery Center will oversee this POC. |
709.81(b)(6) LICENSURE Intake and admission
709.81. 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 provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in five of six partial hospitalization client records.
The findings include:
Twenty-seven client records were reviewed on March 20-21, 2013. Six of the twenty-seven client records were reviewed from the partial hospitalization activity. All records were reviewed for psychosocial evaluations.
The psychosocial evaluations in client records #13 did not include a composite picture of the client.
The psychosocial evaluations in client records #13, 14, 16 and 17 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records #13, 15 and 16 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluations in client records #13, 14, 16 and 17 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records #13, 14, 15, 16 and 17 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluations in client records # 13 did not include an evaluation of the client's attitude toward treatment and how they would impact treatment.
The psychosocial evaluations in client records #17 did not include an evaluation of the counselor conclusions/impressions of the client.
An interview with facility staff on March 21, 2013, confirmed the findings.
|
Plan of Correction
It was discovered during the site visit that counselors are not consistently documenting their clinical evaluations of the client in the client record. Counselors and assessors will need to be retrained on what is expected in a clinical evaluation to include all the above components. Recovery Center staff will research additional training opportunities for clinical documentation and these trainings will be mandatory for all staff to attend. Quality of documentation will be monitored by random weekly chart review. Outpatient Coordinator will oversee this POC. |
709.83(a)(11) 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:
(11) Follow-up information.
|
Observations
Based on client record review, the facility failed to document a follow up attempt in two of three discharge partial hospitalization client records.
The findings include:
Twenty-seven client records were reviewed on March 20-21, 2013. Six of the twenty-seven client records were reviewed from the partial hospitalization activity. Three of the six were discharge clients, #16, 17 and 18 and a follow up attempt was required in three of the client records. The facility did not document a follow up in two client record, #16. The facility policy stated that follow up will be attempted within seven days for referrals, a letter will be mailed out on the day of discharge. An interview with facility staff on March 20, 2013 confirmed the findings.
Client #16 was admitted on August 17, 2012 and discharged on October 24, 2012. There was no follow-up attempt documented in client record #16.
|
Plan of Correction
It was discovered at the site visit that follow ups were not being done consistently in Partial Hospital Program. Coordinator of Outpatient services will meet with clinicians and support staff, who are responsible for doing the follow ups, to distribute and discuss our policy and procedure for follow ups. Staff will be made aware of the fact that these follow ups are a priority. Chart check, an internal system we use to ensure all necessary paperwork is done, will be utilized to ensure this does not re-occur. Chart check is to be completed within 7 days of discharge, so we will be immediately aware if follow up calls were not placed. Coordinator of Outpatient Services will oversee the implementation of this POC. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in four of six inpatient nonhospital short term detox client records.
The findings include:
Twenty-seven client records were reviewed on March 20-21, 2013. Six of the twenty-seven client records were reviewed from the inpatient nonhospital short term detox activity. All records were reviewed for psychosocial evaluations.
The psychosocial evaluations in client records #1, 2, 3 and 6 did not include a composite picture of the client.
The psychosocial evaluations in client records #6 did not include an evaluation of the client's problems/needs and how they would impact treatment.
The psychosocial evaluations in client records #1, 2, 3 and 6 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records #1, 2, 3 and 6 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluations in client records #1, 2, 3 and 6 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records #1, 2, 3 and 6 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluations in client records # 6 did not include an evaluation of the client's attitude toward treatment and how they would impact treatment.
The psychosocial evaluations in client records #1 and 6 did not include an evaluation of the counselor conclusions/impressions of the client.
An interview with facility staff on March 21, 2013, confirmed the findings.
|
Plan of Correction
It was discovered during the site visit that counselors are not consistently documenting their clinical evaluations of the client in the client record. Counselors and assessors will need to be retrained on what is expected in a clinical evaluation to include all the above components. Recovery Center staff will research additional training opportunities for clinical documentation and these trainings will be mandatory for all staff to attend. Quality of documentation will be monitored by random weekly chart review. Inpatient Director will oversee this POC. |
709.63(a)(6) LICENSURE Aftercare plan
709.63. 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:
(6) Aftercare plans, if applicable.
|
Observations
Based on a review of client records, the facility failed to include all the components in the aftercare plan in two of three discharge inpatient nonhospital short term detox client records.
The findings include:
Twenty-seven clients records were reviewed on March 20-21, 2013. Six of the twenty-seven client records were reviewed from the inpatient nonhospital short term detox activity. Three of the six were discharge clients, #4, 5 and 6. Aftercare plans are to include the clients goals with time frames, support services, contact person and reentry process. Also, aftercare plans are to be documented prior to the clients discharge date.
Client #4 was admitted on September 19, 2012 and discharged on September 29, 2012. The aftercare plan was due prior to client # 4's discharge date. Client # 4's aftercare plan was not documented in record reviewed.
Client #6 was admitted on November 20, 2012 and discharged on November 27, 2012. The aftercare plan was documented on November 26, 2012. The aftercare plan was missing the time frames, the contact person and reentry process.
An interview with facility staff on March 21, 2013 confirmed the findings.
|
Plan of Correction
It was discovered during the site visit that some records contained an older version of our aftercare plan, one that did not contain time frames, contact person and reentry process. All copies of the former aftercare plan have been destroyed and staff has been instructed to only use the newly developed aftercare plan that contains all required information. Special Projects Coordinator will oversee this POC. |
709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
|
Observations
Based on a review of client records, the facility failed to include components in the discharge summary.
The findings include:
Twenty-seven client records were reviewed on March 20-21, 2013. Six of the twenty-seven client records were reviewed from the inpatient nonhospital short term detox activity. Three of the six were discharge clients, #4, 5 and 6. The following components are required to be documented on the discharge summary; reason for treatment, services offered, respond to treatment and client status. The facility failed to include reason for treatment on the discharge summary for client's #4 and 5.
Also, discharge summaries are to be completed within 7 days after the clients discharge date. Client #6 was admitted on November 20, 2012 and discharged on November 27, 2012. The discharge summary was to be documented by December 4, 2012. The discharge summary documented in client record #6 did not have the date when it was completed and it was unable to be determined when the summary had been completed..
An interview with facility staff on March 21, 2013, confirmed the findings.
|
Plan of Correction
It was discovered that discharge summaries are not being consistently completed within 7 days on discharged detox clients. It is the expectation that a discharge summary is completed on all clients within seven (7) days of discharge. Inpatient Director will meet with counselors to discuss the importance of timely completion and including reason for treatment on all discharge summaries. Chart check and EHR "tickler" system will be used to monitor compliance with this regulation. Inpatient Director will oversee this POC. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) Follow-up information.
|
Observations
Based on client record review, the facility failed to document a follow up attempt in two of three discharge inpatient nonhospital short term detox client records.
The findings include:
Twenty-seven client records were reviewed on March 20-21, 2013. Six of the twenty-seven client records were reviewed from the inpatient nonhospital short term detox activity. Three of the six were discharge clients, #4, 5 and 6. A follow up attempt is required in three of the client records. The facility did not document a follow up in two client records, #4 and 5. The facility policy states that follow up will be attempted within seven days for referrals, a letter will be mailed out on the day of discharge. An interview with facility staff on March 21, 2013 confirmed the findings.
Client #4 was admitted on September 19, 2012 and discharged on September 29, 2012. There was no follow-up attempt documented in client record #4.
Client #5 was admitted on October 21, 2012 and discharged on October 22, 2012. There was no follow-up attempt documented in client record #5.
|
Plan of Correction
It was discovered during the site visit that follow ups were not being done consistently in Detox. Inpatient Director will meet with clinicians and support staff, who are responsible for doing the follow ups, to distribute and discuss our policy and procedure for follow ups. Staff will be made aware of the fact that these follow ups are a priority. Chart check, an internal system we use to ensure all necessary paperwork is done, will be utilized to ensure this does not re-occur. Chart check is to be completed within 7 days of discharge, so we will be immediately aware if follow up calls were not placed. Inpatient Director will oversee the implementation of this POC. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. 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 provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in six of six inpatient nonhospital client records.
The findings include:
Twenty-seven client records were reviewed on March 20-21, 2013. Six of the twenty-seven client records were reviewed from the inpatient nonhospital activity. All records were reviewed for psychosocial evaluations.
The psychosocial evaluations in client records #7, 8, 9, 10 and 12 did not include a composite picture of the client.
The psychosocial evaluations in client records #7, 8 and 9 did not include an evaluation of the client's problems/needs and how they would impact treatment.
The psychosocial evaluations in client records #7, 8, 10, 11 and 12 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records #7, 8, 10, 11 and 12 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluations in client records #7, 8, 10, 11 and 12 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records #7, 8, 9, 10, 11 and 12 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluations in client records #7, 8, 10, 11 and 12 did not include an evaluation of the client's attitude toward treatment and how they would impact treatment.
The psychosocial evaluations in client records #7, 8 and 10 did not include an evaluation of the counselor conclusions/impressions of the client.
An interview with facility staff on March 21, 2013, confirmed the findings.
|
Plan of Correction
It was discovered during the site visit that counselors are not consistently documenting their clinical evaluations of the client in the client record. Counselors and assessors will need to be retrained on what is expected in a clinical evaluation to include all the above components. Recovery Center staff will research additional training opportunities for clinical documentation and these trainings will be mandatory for all staff to attend. Quality of documentation will be monitored by random weekly chart review. Inpatient Director will oversee this POC. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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.
|
Observations
Based on a review of client records, the facility failed to document a complete case consultation in six of six inpatient residential client records.
The findings include:
Twenty-seven client records were reviewed on March 20-21, 2013. Six of the twenty-seven client records were reviewed from the inpatient nonhospital activity. Per the Standards case consultations are to include the date/signature, summary and disposition. During the review of the client records six of the six did not document the disposition on each case consultation, #7, 8, 9, 10, 11 and 12.
Client #7 was admitted on February 27, 2013 and their case consultation was documented on March 6, 2013. The March 6, 2013 failed to include the disposition on the case consultation.
Client #8 was admitted on March 5, 2013 and their case consultation was documented on March 12, 2013. The March 12, 2013 failed to include the disposition on the case consultation.
Client #9 was admitted on February 28, 2013 and their case consultation was documented on March 7, 2013. The March 7, 2013 failed to include the disposition on the case consultation.
Client #10 was admitted on September 7, 2013 and their case consultation was documented on September 14, 2012. The September 14, 2012 failed to include the disposition on the case consultation.
Client #11 was admitted on October 10, 2012 and their case consultation was documented on October 19, 2012. The October 19, 2012 failed to include the disposition on the case consultation.
Client #12 was admitted on December 17, 2012 and their case consultation was documented on December 27, 2012. The December 27, 2012 failed to include the disposition on the case consultation.
An interview with facility staff on March 21, 2013 confirmed the findings.
|
Plan of Correction
During the site visit it was discovered that the case consultations did not include disposition. Inpatient Director will meet with Inpatient Treatment Team to discuss all elements that are required in a case consultation. In addition, we will modify our Case Consultation form to include an area designated for disposition to ensure it is included in every case consultation. Quality control chart audits will be conducted to ensure that case consultations are being completed thoroughly. Inpatient Director will oversee this POC. |
709.53(a)(9) LICENSURE Aftercare plans
709.53. 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:
(9) Aftercare plan, if applicable.
|
Observations
Based on a review of client records, the facility failed to include all the components in the aftercare plan one of three discharge inpatient client records.
The findings include:
Twenty-seven client's records were reviewed on March 20-21, 2013. Six of the twenty-seven client records were reviewed from the inpatient nonhospital activity. Three of the six were discharge clients, #10, 11 and 12. Aftercare plans are to include the clients goals with time frames, support services, contact person and reentry process.
Client #11 was admitted on October 10, 2012 and discharged on October 22, 2012. The aftercare plan was documented on October 22, 2012. The aftercare plan was missing the time frames, the contact person and reentry process.
An interview with facility staff on March 21, 2013 confirmed the findings.
|
Plan of Correction
It was discovered during the site visit that some records contained an older version of our aftercare plan, one that did not contain time frames, contact person and reentry process. All copies of the former aftercare plan have been destroyed and staff has been instructed to only use the newly developed aftercare plan that contains all required information. Special Projects Coordinator will oversee this POC. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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 include components in the discharge summary.
The findings include:
Twenty-seven client records were reviewed on March 20-21, 2013. Six of the twenty-seven client records were reviewed from the inpatient nonhospital activity. Three of the six were discharge clients, #10, 11 and 12. The following components are required to be documented on the discharge summary; reason for treatment, services offered, respond to treatment and client status. The facility failed to include reason for treatment on the discharge summaries for clients #10 and 11.
An interview with facility staff on March 21, 2013 confirmed the findings.
|
Plan of Correction
It was discovered that discharge summaries are not being consistently completed within 7 days on discharged detox clients. It is the expectation that a discharge summary is completed on all clients within seven (7) days of discharge. Inpatient Director will meet with counselors to discuss the importance of timely completion and including reason for treatment on all discharge summaries. Clinicians will be expected to utilize the EHR "tickler" system to ensure timely completion of the Discharge Summary. Chart check and Administrative EHR "tickler" system will be used to monitor compliance with this regulation. Inpatient Director will oversee this POC. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 client record review, the facility failed to document a follow up attempt in two of three discharge inpatient client records.
The findings include:
Twenty-seven client records were reviewed on March 20-21, 2013. Six of the twenty-seven client records were reviewed from the inpatient nonhospital activity. Three of the six were discharge clients, #10, 11 and 12. A follow up attempt is required in three of the client records. The facility did not document a follow up in two client records, #10 and 11. The facility policy states that follow up will be attempted within seven days for referrals, a letter will be mailed out on the day of discharge. An interview with facility staff on March 21, 2013 confirmed the findings.
Client #10 was admitted on September 9, 2012 and discharged on September 15, 2012. There was no follow-up attempt documented in client record #10.
Client #11 was admitted on October 10, 2012 and discharged on October 22, 2012. There was no follow-up attempt documented in client record #11.
|
Plan of Correction
It was discovered during the site visit that follow ups were not being done consistently in Residential Treatment. Inpatient Director will meet with support staff, who are responsible for doing the follow ups, to retrain. Staff will be made aware of the fact that these follow ups are a priority. Chart check, an internal system we use to ensure all necessary paperwork is done, will be utilized to ensure this does not re-occur. Chart check is to be completed within 7 days of discharge, so we will be immediately aware if follow up calls were not placed. Inpatient Director will oversee the implementation of this POC. |
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 provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in seven of nine outpatient client records.
The findings include:
Twenty-seven client records were reviewed on March 20-21, 2013. Nine of the twenty-seven client records were reviewed from the outpatient activity. All records were reviewed for psychosocial evaluations.
The psychosocial evaluations in client records #19, 20, 21, 22 and 23 did not include a composite picture of the client.
The psychosocial evaluations in client records #19, 20, 21, 22, 23, 24 and 25 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records #19, 20, 21, 22, 23, 24 and 25 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluations in client records #19, 20, 21, 22, 23, 24 and 25 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records #19, 20, 21, 22, 23, 24 and 25 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluations in client records #19, 22 and 24 did not include an evaluation of the counselor conclusions/impressions of the client.
An interview with facility staff on March 21, 2013, confirmed the findings.
|
Plan of Correction
It was discovered during the site visit that counselors are not consistently documenting their clinical evaluations of the client in the client record. Counselors and assessors will need to be retrained on what is expected in a clinical evaluation to include all the above components. Recovery Center staff will research additional training opportunities for clinical documentation and these trainings will be mandatory for all staff to attend. Quality of documentation will be monitored by random weekly chart review. Outpatient Coordinator will oversee this POC. |
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.
|
Observations
Based on a review of client records, the facility failed to document a case consultation in five of nine client records.
The findings include:
Twenty-seven client records were reviewed on March 20-12, 2013. Nine of the twenty-seven were from the outpatient activity. Five of the nine were required to have documented a case consultation, #20, 21, 23, 24 and 25. Per agency policy, case consultations shall be completed quarterly.
Client # 20 was admitted on November 15, 2012. The case consultation was due by March 15, 2013. As of the date of the inspection March 18-21, 2013 there was no documentation of Client #20's case consultation.
Client # 21 was admitted on November 15, 2012. The case consultation was due by March 15, 2013. As of the date of the inspection March 18-21, 2013 there was no documentation of Client #21's case consultation.
Client # 23 was admitted on November 5, 2012. The case consultation was due by March 5, 2013. As of the date of the inspection March 18-21, 2013 there was no documentation of Client #23's case consultation.
Client # 24 was admitted on September 19, 2012 and discharged on February 14, 2013. The case consultation was due by December 19, 2012. As of the date of the inspection March 18-21, 2013 there was no documentation of Client #24's case consultation.
Client # 25 was admitted on August 15, 2012 and discharged on January 8, 2013. The case consultation was due by November 15, 2012. As of the date of the inspection March 18-21, 2013 there was no documentation of Client #25's case consultation.
An interview with facility staff on March 21, 2013, confirmed the findings.
|
Plan of Correction
It was discovered during the site visit that Case Consultation notes are not being completed in a timely manner. At the weekly treatment team meeting for Outpatient Clinicians, the Outpatient Coordinator will discuss the need for a Case Consultation to be completed every three months on all clients. Clinicians will be expected to utilize the EHR clinical dashboard, "tickler" system to ensure timely completion of Case Consults. Clinical supervision and administrative EHR "tickler" system will be used to monitor compliance with this regulation. Outpatient Coordinator will oversee this POC. |
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 client record review, the facility failed to document a follow up attempt in two of four discharge outpatient client records.
The findings include:
Twenty-seven client records were reviewed on March 20-21, 2013. Nine of the twenty-seven client records were reviewed from the outpatient activity. Four of the nine were discharge clients, #24, 25, 26 and 27. A follow up attempt is required in four of the client records. The facility policy states that follow up will be attempted within seven days for referrals, a letter will be mailed out on the day of discharge. An interview with facility staff on March 21, 2013 confirmed the findings.
Client #24 was admitted on September 19, 2012 and discharged on February 14, 2013. The follow-up took place on February 6, 2013, 7 days before client #24's discharge date.
Client #26 was admitted on September 26, 2012 and discharged on March 12, 2013. The follow-up took place on February 11, 2013, 29 days before client #25's discharge date.
|
Plan of Correction
It was discovered at the site visit that follow ups were not being done consistently in Outpatient. Coordinator of Outpatient services will meet with support staff, who are responsible for doing the follow ups, to retrain. Staff will be made aware of the fact that these follow ups are a priority. Chart check, an internal system we use to ensure all necessary paperwork is done, will be utilized to ensure this does not re-occur. Chart check is to be completed within 7 days of discharge, so we will be immediately aware if follow up calls were not placed. Coordinator of Outpatient Services will oversee the implementation of this POC. |