Facility cited for letting unauthorized therapist provide therapy and failure to follow patient grievance policies

Poplar Springs Hospital was investigated and cited by the Virginia Department of Behavioral Health and Developmental Services (DBHDS) for violations related to therapy provided by unauthorized personnel, noncompliance with human rights regulations,medication administration, and improper maintenance of medical records.

DBHDS found that in one patient case, therapy was not provided by a professional legally authorized to do so. The DBHDS determined:

“Employee #6 was assigned to provide individual therapy to Individual #1 during the period of March 2012 thru mid-August 2012. Employee #6 did not receive approval of supervision from the Board of Health Professionals until December 7, 2012.” DBHDS notes that “until the supervisee receives Board approval for the supervision contract, no supervised experience will be permitted to count towards licensure. Therefore, an individual is not approved to provide “therapy” until the official letter is received.”

During the same on-site inspection, the DBHDS also found that the facility was  non-compliant with human rights regulations because it failed to follow the complaint resolution process and failed to ensure confidentiality of patient information. The DBHDS found that the facility failed to secure confidential patient treatment information during its own internal investigation into a patient grievance. As part of the grievance investigation, numerous e-mails were transmitted between the provider and the complainant, but they were not included in the patient’s medical record and were left unsecured.

DBHDS also cited the facility for not administering medications as prescribed. A review of individual #1 Medication Administration Record showed that he/she was prescribed Trazadone 400mg. However, the individual was only given 200mg on one night and 100mg on another night instead of the full 400mg. The Chief Nursing Officer confirmed there was no documentation in the record to explain why the full dosage of 400mg was not given. Another MAR was reviewed and showed that Intuniv, a medication used to treat ADHD, was not available for 6 days during the month of September 2012.

DBHDS also found deficiencies related to maintaining complete and accurate medical records for each resident, which includes dated and completed documentation and correct descriptions in individualized service plans. In one instance, DBHDS found inconsistencies in regards to the documentation of allergies for one resident. The psychiatric evaluation of the resident listed no allergies, but the biopsychosocial assessment noted allergies of latex, oats, and biaxin. In addition, the “allergy section” of several patient observation records were left blank or noted “N/A.”

As a result of the cited deficiencies, the facility was required, among other things, to revise the grievance policy to assure compliance with state regulations and train program directors and nursing directors on the policy and procedure. The facility was also required to revise the Supervision towards Licensure policy to ensure that licensed therapists provide therapy to residents.