INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 3 through January 4, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, York Hospital Behavioral Health, 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 and a plan of correction is due on January 31, 2011.
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Plan of Correction
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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant tour on January 4, 2011 at 2:10 p.m., it was observed that counselor office # 1019 included a heater that was not permanently mounted or installed.
The findings include:
A physical plant inspection took place on January 04, 2011. At approximately 2:10 pm it was observed that the contents counselor office # 1019 included a heater that was not permanently mounted or installed. The director confirmed that the space heater was in the office.
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Plan of Correction
On January 4, 2011, the facility director and the practice manager advised the counselor that her space heater was not permitted. The counselor promptly removed the space heater. On January 4, 2011, the facility director sent an e-mail to all employees of the project reminding them that space heaters are not permitted unless they are permanently mounted or installed. The facility director and practice manager will be jointly responsible for enforcing 705.26 (2). The facility director, practice manager, and/or his/her designee will conduct random monthly inspections of all rooms in the facility to assure that there are no space heaters. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 the fire drill logs and an interview with the facility director, the facility failed to document the amount of time it took for evacuation in ten out of twelve months, as required.
The findings include:
Fire drill logs were reviewed on January 4, 2011. Per regulation, the nonresidential facility shall 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. The facility failed to document the amount of time it took for evacuation in ten out of twelve fire drills conducted.
On January 4, 2011, the facility director was interviewed and confirmed that the form was changed in March and the new forms failed to include the amount of time it took for evacuation.
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Plan of Correction
In March 2010 the governing entity for this project, York Hospital, changed its required format for documenting fire drills. The new format does not include Time Alarm Activated and Time All Clear Sounded. The practice manager will consult with York Hospital Safety and Security to determine if these lines can be added to the fire alarm report. In the interim, Time Alarm Activated and Time All Clear Sounded will be hand-written on the form to comply with 705.28(d)(4). The practice manager (in conjunction with the facility director) will be responsible for compliance with this regulation. |
711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on the review of client records, the facility failed to document an individualized treatment and rehabilitation plans in five out of ten records.
The findings include:
Client records were reviewed on January 4, 2011. The facility did not document individualized treatment plans in client record # 2, 3, 4, 9 and 10.
The plans reviewed in client records # 4 and 9, contained standardized goals and objectives. There was no evidence that the goals and objectives had been written to meet the needs identified in the psychosocial evaluations and were written verbatim for each client.
Client # 2 was admitted on September 13, 2010. The client's last date serviced at the facility was on December 23, 2010. The individual treatment plan was due by the third session on December 16, 2010. There was no individual treatment and rehabilitation plan documented in the client record as of the date of the inspection.
Client # 3 was admitted on October 12, 2010. The client's last date serviced at the facility was on December 28, 2010. The individual treatment plan was due by the third session on October 26, 2010. There was no individual treatment and rehabilitation plan documented in the client record as of the date of the inspection.
Client # 10 was admitted on June 10, 2010. The client was discharged on November 12, 2010. The facility failed to document a timely treatment and rehabilitation plan for this client. The individual treatment plan was due by the third session on July 8, 2010. The facility did not document a treatment plan until September 17, 2010. The treatment plan did not include individualized goals and objectives.
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Plan of Correction
In clinical team meeting on January 26, 2011, the facility director will review with the counselors the need to (1) document an individualized treatment and rehabilitation plan for each client, and (2) complete the individualized treatment and rehabilitation plan by the third session. The facility director will be responsible for monitoring compliance with regulation 711.92(c) via periodic record reviews. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of ten client records and a review of the policy and procedure manual, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in three of six records, as required.
Findings:
Ten client records were reviewed on January 4, 2011. The facility policy and procedure manual was reviewed on January 3, 2011. According to the policy and procedure manual the facility will update the treatment plan every sixty days following the completion of the initial treatment plan. Six client records required treatment plan updates. The facility failed to document treatment and rehabilitation plan updates in client records # 4, 6, and 9.
The initial treatment and rehabilitation plan in record # 4 was completed on October 27, 2010. The treatment and rehabilitation plan update was due on December 27, 2010. As of the date of the licensing inspection the plan was not documented in the client record.
The initial treatment and rehabilitation plan in record # 6 was completed on April 22, 2010. The first treatment and rehabilitation plan update was completed on June 24, 2010. The client was discharged on September 28, 2010. The facility failed to document a treatment and rehabilitation plan update that was due on August 24, 2010.
The initial treatment and rehabilitation plan in record # 9 was completed on September 20, 2010. This client was discharged on December 6, 2010. The facility failed to document a treatment and rehabilitation plan update in this client record that was due on November 20, 2010.
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Plan of Correction
In clinical team meeting on January 26, 2011, the facility director will review with the counselors the need to complete a treatment plan review and update every 60 days. The facility director will be responsible for monitoring compliance with regulation 711.92(d) via periodic record reviews. |
711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to document aftercare plans that included goals with timeframes in four of five discharged records.
The findings include:
Ten client records were reviewed on January 4, 2011. Four client records required aftercare plans. The facility failed to include goals with timeframes in client records # 6, 8, 9, and 10. The facility director confirmed that the aftercare plans did not include goals with timeframes.
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Plan of Correction
In clinical team meeting on January 26, 2011, the facility director will review with the counselors the need to include goals with time frames in the aftercare plan. The facility director will be responsible for monitoring compliance with regulation 711.93(a)(6) via periodic record reviews. |
711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document that follow-ups were completed within 30 days of discharge, as per facility policy, in two of four client records.
The findings included:
Ten client records were reviewed on January 4, 2011. Four client records required the completion of follow-up information. Per facility policy, follow-up will be completed with clients within 30 days of discharge. The facility failed to document that follow-ups were completed within 30 days of discharge in client records # 6 and 7.
Client # 6 was admitted into treatment on March 17, 2010 and discharged on September 28, 2010. Follow-up was due to be completed no later than October 28, 2010. Follow-up was not completed for this client as of the date of the inspection.
Client # 7 was admitted into treatment on June 28, 2010 and discharged on October 7, 2010. Follow-up was due to be completed no later than November 7, 2010. Follow-up was not completed for the client as of the date of the inspection.
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Plan of Correction
In clinical team meeting on January 26, 2011, the facility director will review with the counselors the need to complete and document follow-up with each client within 30 days of discharge. The facility director will be responsible for monitoring compliance with regulation 711.93(a)(7) via periodic record reviews. |