INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 28, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Resources for Human Development 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 the staffing records, the facility failed to ensure that a sufficient number of staff persons were trained in CPR onsite during the project ' s hours of operation.
Reviewed staffing schedules from May 2023 and the following shifts did not have CPR coverage May 7, 2023 from 11:15 pm to 7 am; May 15, 2023 from 11 pm to 7 am; May 21, 2023 from 11 pm to 7 am; and May 28, 2023 from 11 pm to 7 am.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, Office manager will schedule new hires for CPR training through the American Red Cross within the first month of hire to ensure all staff are CPR certified during their onboarding to the program. Office manager will schedule bi-annual onsite training for existing staff to recertify CPR certification. Office manager will utilize a spreadsheet to track CPR certification for all staff and review the spreadsheet quarterly to ensure all staff members have an up to date CPR certification.
Each shift will be staffed with at least one person certified in CPR. |
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.
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Observations
Based on a review of the staffing records, the facility failed to ensure that all staff were instructed in the use of fire extinguishers upon employment in one of four staff records.
Staff #5 was hired as a counselor on March 20, 2023 and still a current employee. There was no documentation of fire extinguisher training at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, Office Manager will complete onboarding that includes fire extinguisher training with all new employees within the first 7 days of hire. Program Director will review new staff files monthly to ensure fire extinguisher training is completed in a timely manner.
Employee #5 will be provided fire extinguisher training by 8/31/2023. |
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.
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Observations
Based on a review of the staffing records, the facility failed to ensure that all personnel were trained to perform assigned tasks during emergencies in one of four personnel records.
Staff #5 was hired as a counselor on March 20, 2023 and still a current employee. There was no documentation of emergency training at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, Office Manager will complete onboarding that includes emergency training with all new employees within the first 7 days of hire. Program Director will review new staff files monthly to ensure fire extinguisher training is completed in a timely manner.
Employee #5 will be provided emergency training by 8/31/2023.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill records, the facility failed to maintain a fire drill record which included all of the required components.
The fire drills were reviewed for the period of July 2022 to June 2023. All of the fire drills documented for the period reviewed did not include the amount of time for evacuation, exit route used, number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm / smoke detector was operable.
In addition, the time of the fire drill was not documented on the March 2023 fire drill log.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and Office Manager will provide training on July 12, 2023 to all staff on how to complete the updated fire drill record report which includes date, time, amount of time it took for evacuation, exit route used, number of persons in the facility at the time of the drill, problems encountered, and whether the fire alarm or smoke detector was operative. Program Director will conduct a monthly review of the fire drill log book to ensure accurate completion of the monthly report. Program Director will also collaborate with the building property manager to ensure leadership is notified of any unscheduled fire drills to ensure all fire drills are appropriately documented. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill records, the facility failed to prepare alternate exit routes to be used during fire drills.
Fire drill logs reviewed from July 2022 through June 2023. There was no evidence of which exit routes were used during fire drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director/ Office Manager will provide training to staff on July 12, 2023 on the requirement to use alternate routes of egress during fire drills. Program Director will conduct monthly reviews of the fire drill report log to ensure alternate exit routes are being utilized during fire drills. |
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 obtain an informed and voluntary consent for the disclosure of information in one of seven client records reviewed.
Client #7 was admitted on August 23, 2022 and discharged on December 3, 2022. There was no signed and voluntary consent for the funding source while the client was admitted to the facility. It was confirmed with facility staff that services are being billed to the funding source for client #7.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Effective immediately, Clinical Manager or clinical staff will complete consents with all intakes as the first item during the intake process to ensure all necessary consents are completed. Clinical Manager will be updating an excel spreadsheet weekly to ensure documentation is completed in a timely manner. Clinical Manager will conduct a training with all clinical staff on September 5, 2023 on completion of consents. Clinical Manager will complete weekly chart reviews to ensure consents are completed accurately. A weekly clinical review will be sent to the Director and monthly chart audits will be conducted by Regional Director. |
709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom disclosure is made in one of seven records.
Client #3 admitted on November 23, 2022 and discharged on March 6, 2023. Client #3 signed release to Probation but did not specify an organization or individuals name in which disclose can occur to.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Effective immediately, the consent template for has been updated to reflect the appropriate agency listed. Clinical Manager will conduct a training with all clinical staff on September 5, 2023 on completion of consents. Clinical Manager will complete weekly chart reviews to ensure consents are completed accurately. A weekly clinical review will be sent to the Director and monthly chart audits will be conducted by Regional Director |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document specific information to be disclosed on a signed consent to release information in two of seven records reviewed.
Client #1 admitted on February 7, 2023 and discharged on June 2, 2023. A release of information was signed on February 7, 2023 to the funding source with no specific information to be disclosed.
Client #6 admitted on February 10, 2023 and still a client at the time of the inspection. A release of information was signed on February 16, 2023 to the funding source with no specific information to be disclosed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director has obtained an updated consent template from Service Line Director that includes specific information disclosed. This template has been added to the intake packet effective immediately. Clinical Manager will conduct a training with all clinical staff on September 5, 2023 on completion of consents. Clinical Manager will complete weekly chart reviews to ensure consents are completed accurately. A weekly clinical review will be sent to the Director and Regional Director will conduct monthly chart audits |
709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of disclosure on an informed and voluntary consent in three of seven client records.
Client #1 was admitted on February 7, 2023 and discharged on June 2, 2023. A release was signed on February 7, 2023 to an agency with no purpose of disclosure included.
Client #2 was admitted on February 15, 2023 and discharged on June 22, 2023. A release was signed on February 23, 2023 to an emergency contact with no purpose of disclosure included.
Client #3 was admitted on November 23, 2022 and discharged on March 6, 2023. A release was signed on March 6, 2023 to an agency with no purpose of disclosure included.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director has obtained an updated consent template from Service Line Director that includes purpose of disclosure. This template has been added to the intake packet effective immediately. Clinical Manager will conduct a training with all clinical staff on September 5, 2023 on completion of consents. Clinical Manager will complete weekly chart reviews to ensure consents are completed accurately. A weekly clinical review will be sent to the Director and Regional Director will conduct monthly chart audits |
709.28 (c) (6) 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. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event, or condition upon which the consent will expire in two of seven client records.
Client #1 was admitted on February 7, 2023 and discharged on June 2, 2023. A release was signed on February 7, 2023 to an agency which did not include an expiration date. A second release signed on February 16, 2023 to an agency which did not include an expiration date.
Client #5 was admitted on April 28, 2023 and still a current client during the time of inspection. A release was signed on May 3, 2023 to the funding source which did not include an expiration date.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Manager and Office Manager will provide training to all staff to make certain that date, event, or condition upon which the consent will expire is documented on all consent forms. Clinical Manager will conduct a training with all clinical staff on September 5, 2023 on completion of consents. Clinical Manager will complete weekly chart reviews to ensure consents are completed accurately. A weekly clinical review will be sent to the Director and Regional Director will conduct monthly chart audits |
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, the facility failed to offer a copy of a client consent to the client in four of seven client records.
Client #1 was admitted on February 7, 2023 and discharged on June 2, 2023. A release was signed on February 7, 2023 to the funding source which did not include whether a copy was offered to the client.
Client #3 was admitted on November 23, 2022 and discharged on March 6, 2023. A release was signed on November 30, 2022 to an agency which did not include whether a copy was offered to the client.
Client #5 was admitted on April 28, 2023 and still a current client during the time of inspection. A release was signed on May 3, 2023 to the funding source which did not include whether a copy was offered to the client.
Client #6 admitted on February 10, 2023 and still a client at the time of the inspection. A release was signed on February 16, 2023 to the funding source which did not include whether a copy was offered to the client.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director has obtained an updated consent template from Service Line Director that includes verification that the client was offered a copy of the consent. This template has been added to the intake packet effective immediately. Clinical Manager will conduct a training with all clinical staff on September 5, 2023 on completion of consents. Clinical Manager will complete weekly chart reviews to ensure consents are completed accurately. A weekly clinical review will be sent to the Director and Regional Director will conduct monthly chart audits |
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.
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Observations
Based on a review of client records, the facility failed to have written documentation that included the project may not discriminate in the provision of services on the basis of marital status, in all records reviewed.
The findings were discussed with project staff during the licensing process.
This is a repeat citation from the July 19, 2022 annual licensing inspection.
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Plan of Correction
Effective immediately the client rights document will be updated and staff will be trained on the procedures for client rights by September 5, 2023. Clinical Manager will conduct weekly chart reviews to ensure the proper client rights document is completed in each chart. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of client records, the facility failed to provide client medications, as prescribed, in five of six client records.
Client #1 was admitted on February 7, 2023 and discharged on June 2, 2023.
Medication #1 was prescribed for 3 tablets by mouth once per day. Medication #1 was not administered as prescribed on March 22, 23, 24 & 29, 2023. Also, May 11, 19, 20, 21, 22, 24, 25, 26, 27, 28, 30 and 31, 2023.
Medication #2 was prescribed for 2 tablets by mouth twice a day for seven days. Medication #2 was not administered as prescribed on February 23, 24, 25, 26, 27 and 28, 2023.
Medication #3 was prescribed for one tablet by mouth twice per day for seven days. Medication #3 was not administered as prescribed on February 23, 24, 25, 26 and 27, 2023.
Client #3 was admitted on November 23, 2022 and discharged on March 6, 2023.
Medication #1 was prescribed for one tablet by mouth twice per day for fourteen days. Medication #1 was not administered as prescribed on January 18, 19, 23, 26, 27, 28, 29, 30 and 31, 2023.
Medication #2 was prescribed for one tablet by mouth at bedtime. Medication #2 was not administered as prescribed on January 15, 16, 18, and 26, 2023.
Medication #3 was prescribed for two tablets by mouth twice per day for fourteen days. Medication #3 was not administered as prescribed on January 18, 19, 22, 23, 26, 27, 28, 29, 30 and 31, 2023.
Medication #4 was prescribed for two capsules by mouth at bedtime. Medication #4 was not administered as prescribed on January 15, 16, 18 & 26, 2023.
Client #5 was admitted on April 28, 2023 and is currently an active client.
Medication #1 was prescribed for two tablets by mouth per day. Medication #1 was not administered as prescribed on May 1, 2 and 29, 2023.
Medication #2 was prescribed for one capsule per mouth once per day. Medication #2 was not administered as prescribed on May 21, 2023.
Medication #3 was prescribed for one tablet by mouth once per day. Medication #3 was not administered as prescribed on June 20, 21, 22, 23, 24, 25, 26, 27 and 28, 2023.
Client #6 was admitted on February 10, 2023 and is currently an active client.
Medication #1 was prescribed for one capsule per mouth twice per day. Medication #1 was not administered as prescribed on May 23, 24, 25 and 26, 2023.
Medication #2 was prescribed for one tablet per mouth once per day. Medication #2 was not administered as prescribed on May 11, 12, 13, 14, 15, 16, 17, 19, 20, 21, 23, 24, 25, 26, 27, 28, 29 & 31 and June 1, 2, 3, 4, 5, 6, 7 & 8, 2023.
Client #7 was admitted on August 23, 2022 and discharged on December 3, 2022.
Medication #1 was prescribed for one tablet by mouth two times per day from August 24 through September 6, 2022. Client #7 was administered medication #1 as prescribed through September 6, 2022; however, client #7 received additional doses on September 9, 11 and 12, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LPN will provide training to all staff on August 9, 2023 on the proper documenting procedures for if a client misses a dose or refuses a dose. The MAR includes a drop down box to document the reason for missed dose that is to be utilized in medication distribution. Quality will assist in training LPN on report functions available in the MAR by September 15, 2023 and LPN will complete weekly audits of the medication log to ensure accurate documentation. All clients medications will be administered as prescribed. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client in writing of a decision to involuntarily terminate the client ' s treatment at the project in one of one applicable client records.
Client #3 was admitted on November 23, 2022 and involuntarily terminated on March 6, 2023. There was no documentation that client #3 was provided written notification of the involuntary termination.
The findings were discussed with project staff during the licensing process.
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Plan of Correction
Prior to administrative discharge, the clinical team will convene to determine if the client in question meets criteria for involuntary termination. Once a determination has been made, the assigned counselor will meet with the resident and inform them of the intent and reasons for administrative discharge from the program. At that time, the resident will be given a written notice of termination of treatment. The client will be asked to sign the form, however if the client refuses to sign or leaves before the form is provided it will be documented in the chart and mailed to the last known address if available. Both the termination letter and discharge note will be placed in the client chart. The Program Director will ensure policy on administrative discharge is implemented by reviewing documentation before client is physically discharged from treatment when applicable. The Program Director will retrain all clinical staff on the administrative discharge process by September 5, 2023. Clinical Manager will complete weekly chart reviews to ensure the notification of termination is completed accurately. A weekly clinical review will be sent to the Director and monthly chart audits will be conducted by Regional Director |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document physical examinations in six of seven client records.
Client #1 was admitted on February 7, 2023 and discharged on June 2, 2023.
Client #2 was admitted on February 15, 2023 and discharged on June 22, 2023.
Client #3 November 23, 2022 and discharged on March 6, 2023.
Client #5 was admitted on April 28, 2023 and still a current client at the time of inspection.
Client #6 was admitted on February 10, 2023 and still a current client at the time of the inspection.
Client #7 was admitted on August 23, 2022 and discharged on December 3, 2022.
No physical examinations were documented for any of these clients.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, Program Director has added physical examination within 1 year to the referral packet to ensure intakes have received a physical prior to admission into the program. Program Physician or Urgent Care will complete a physical assessment for any referral that was unable to provide physical prior to admission during the intake process. Clinical Manager will monitor by completing weekly chart reviews to ensure physicals are completed. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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.
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Observations
Based on a review of client record, the facility failed to document the type and frequency of treatment and rehabilitation services in five of seven client records.
Client #1 was admitted on February 7, 2023 and discharged on June 2, 2023.
Client #2 was admitted on February 15, 2023 and discharged on June 22, 2023.
Client #3 November 23, 2022 and discharged on March 6, 2023.
Client #5 was admitted on April 28, 2023 and still a current client at the time of inspection.
Client #6 was admitted on February 10, 2023 and still a current client at the time of the inspection.
None of these clients had documented type and frequency of services on any of their treatment plans during their time of admission.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will provide training to all clinical staff on the accurate type and frequency of services which is to be included in the treatment plan by September 5, 2023. Clinical Manager will review all treatment plans prior to approval to verify that the correct type and frequency is documented. Clinical Manager will complete weekly chart reviews to ensure the regularity of counseling provided is completed appropriately. A weekly clinical review will be sent to the Director and Regional Director will conduct monthly chart audits |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to update treatment plans within thirty days in five of seven records reviewed.
Client #1 was admitted on February 7, 2023 and discharged on June 2, 2023. Client #1 treatment plan was completed on March 30, 2023 and update was due by April 29, 2023 but not completed until May 16, 2023.
Client #2 was admitted on February 15, 2023 and discharged on June 22, 2023. Treatment plan was completed on March 28, 2023 and an update was due by April 27, 2023 but not completed until May 8, 2023. The following treatment plan update was due by June 7, 2023 and not completed until June 14, 2023.
Client #3 was admitted on November 23, 2022 and discharged on March 6, 2023. A treatment plan was completed on December 27, 2022 and an update was due by January 26, 2023 but not completed February 28, 2023.
Client #5 was admitted on April 28, 2023 and a current client at the time of the inspection. A treatment plan was completed on April 30, 2023 and an update was due by May 30, 2023 but not completed until June 14, 2023.
Client #6 was admitted on February 10, 2023 and a current client at the time of the inspection. A treatment plan was completed on March 1, 2023 and an update was due by April 1, 2023 but not completed until April 28, 2023.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 19, 2022 annual licensing inspection.
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Plan of Correction
Clinical Manager will run a weekly report in the electronic medical record to identify clients with a treatment plan expiring within the next 7 days and coordinate with clinical staff to ensure the treatment plan is updated prior to expiring. Clinical manager will discuss barriers to completing the treatment plan in a timely manner and the clinical team will collaborate to overcome any barriers to completion. Documentation for late treatment plans will be included in the treatment plan to outline any extenuating circumstances that may occur. Clinical Manager will complete weekly chart reviews to ensure treatment plans are completed within a timely manner. A weekly clinical review will be sent to the Director and Regional Director will conduct monthly chart audits |
709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records, the facility failed to provide counseling to clients on a regular and scheduled basis in six of seven records.
Client #1 was admitted on February 7, 2023 and discharged on June 2, 2023. No individual therapy sessions provided during the weeks of February 19, February 26, March 5, March 12, April 2, April 9, April 16, May 7, May 14, and May 28.
Client #2 was admitted on February 15, 2023 and discharged on June 22, 2023. No individual therapy sessions provided during the weeks of February 19, March 5, March 12, April 2, April 9, April 23, May 7, May 28, June 11, and June 18.
Client #3 was admitted on November 23, 2022 and discharged on March 6, 2023. No individual therapy sessions provided during the timeframe of January 25, 2023 and February 28, 2023.
Client #4 was admitted on May 17, 2023 and a current client at the time of inspection. No individual therapy sessions provided during the weeks of May 21, May 28, and June 11.
Client #5 was admitted on April 28, 2023 and a current client at the time of inspection. No individual therapy sessions provided during the weeks of April 30, May 7, May 14, May 28, June 11, and June 18.
Client #6 was admitted on February 10, 2023 and a current client at the time of the inspection. No individual therapy sessions provided during the weeks of February 19, March 5, March 12, March 26, April 2, April 9, April 23, April 30, May 14, and June 11.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will provide training to all clinical staff on the requirements for regularity of counseling provided, documentation procedures for no-show or cancelled sessions, and rescheduling missed sessions. Clinical Manager will complete weekly chart reviews to ensure the regularity of counseling provided is completed appropriately. A weekly clinical review will be sent to the Director and Regional Director will conduct monthly chart audits. |
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.
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Observations
Based on a review of client records, the facility failed to provide follow up information in two of two applicable records reviewed.
Client #3 was admitted on November 23, 2022 and discharged on March 6, 2023. No follow up information was documented for this client.
Client #7 was admitted on August 23, 2022 and discharged on December 3, 2022. No follow up information was documented for this client.
Agency policy and procedures states follow up attempts will be made at 30 days, 60 days, and 90 days post discharge.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the July 19, 2022 annual licensing inspection.
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Plan of Correction
Program Director and Clinical Manager will add the follow-up process to the Aftercare Plans form that will be implemented effective immediately.
Before chart is closed, the Director or Clinical Manager will review the chart to ensure it includes the 7-day follow-up.
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709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records and staff interviews, the facility failed to document that work done by the clients at the facility is an integral part of the treatment and rehabilitation plan in seven of seven client records.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the July 19, 2022 annual licensing inspection.
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Plan of Correction
Clinical Manager will provide training to clinical staff on September 5, 2023 regarding work as treatment being added to the treatment plan for all clients. . Clinical Manager will review all treatment plans prior to approval to verify that work as treatment is documented. Clinical Manager will complete weekly chart reviews to ensure work as treatment is included in each treatment plan update. A weekly clinical review will be sent to the Director and Regional Director will conduct monthly chart audits. |