INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 13-15, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, St. Joseph Institute, LLC, 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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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.
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Observations
Based on a review of the facility policies and procedures during the licensing inspection of November 13-15, 2017, the facility failed to provide proof that the project policies and procedures were updated with a written sign off of the manual by the Project Director.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A signature page was implemented and placed in the Policy and Procedure Manual. It was signed on December 11, 2017 and will be dated annually by the Project Director. Compliance will be monitored by the Quality Improvement Coordinator. |
709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
The facility's Unusual Incident Report Binder was reviewed during the licensing inspection on November 13-15, 2017. The facility failed to provide proof that written incidents were filed with the Department within 3 business days documenting events at the facility that required the presence of police or ambulance personnel. Ambulance personnel were contacted and arrived on the following dates:
1/11/2017, 1/25/2017, 2/9/2017, 2/14/2017, 2/26/2017, 4/4/2017, 4/24/2017, 4/26/2017, 4/27/2017, 5/27/2017. 6/12/2017, 6/12/2017, 6/13/2017, 6/14/2017, 7/5/2017, 7/6/2017, 7/13/2017, 8/9/2017, 9/27/2017.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the December 13-15, 2016 licensing inspection.
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Plan of Correction
The fax machine in the Nursing office was programmed on November 14, 2017 to print a fax confirmation sheet for every fax sent. On the same date, the Nursing Supervisor trained all nursing staff on the procedure of obtaining a fax confirmation sheet and stapling it to the DDAP Unusual Incident Report. Nursing staff was re-trained on the use of the fax confirmation sheet on 12/8/2017. These reports will continue to be filed in the Unusual Incident Binder. The Nursing Supervisor will monitor that it is done in each situation through supervisory follow-ups. |
709.64(c)(1) LICENSURE Medical/dental support services
709.64. Project management services.
(c) The project shall assist the client in obtaining the following supportive services when necessary:
(1) Medical/dental.
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Observations
Based on a review of five patient records on November 13-15, 2017, the facility failed to provide documentation of a Detox Support Plan in two of five patient records.
Patient #3 was admitted to treatment on March 1, 2017 and was discharged from detox on March 13, 2017. A Detox Support Plan was not found in the patient record at the time of the inspection.
Patient #4 was admitted on May 5, 2017 and was discharged from detox on 5/9/2017. A Detox Support Plan was not found in the patient record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Detox Support Plan (labeled Transition Plan) was implemented on September 25, 2017 to help the client in obtaining supportive services. The Clinical Director trained all Clinical staff on this form at their Clinical Supervision meeting on 9/25/2017. The 2 charts that were out of compliance at inspection were clients prior to the implementation of the Transition Plan. Clinical Staff was re-trained at the Clinical Team Meeting on 12/12/2017. The Clinical Director will monitor charts for compliance during monthly chart audits. Supervisory follow-ups will be done with Clinical staff as needed. Overall compliance will be reported, documented and monitored at bi-monthly Committee of the Whole meetings. |
715.23(b)(14) LICENSURE Patient records
(b) Each patient file shall include the following information:
(14) Case consultation notes regarding the patient.
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Observations
Based on a review of patient records on November 13-15, 2015, the facility failed to document a Case Consultation note in one of four patient records.
Client #3 was admitted on March 1, 2017 and was discharged from detox on March 13, 2017. There was no documentation of a Case Consultation in the patient record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Case Consultation form was created in March and Clinical staff was trained and implemented the form on March 22, 2017 by the Clinical Director. The one chart that was out of compliance at inspection was a client prior to the implementation of the Case Consultation form. Clinical Staff was re-trained at the Clinical Team Meeting on 12/12/2017. The Clinical Director will monitor charts for compliance during monthly chart audits. Supervisory follow-ups will be done as needed by the Clinical Director. Overall compliance will be reported, documented and monitored at bi-monthly Committee of the Whole meetings. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on a review of patient records on November 13-15, 2017, the facility failed to provide a Psychosocial Evaluation in one of four patient records reviewed.
Patient #3 was admitted on March 1, 2017 and was discharged on March 13, 2017. There was no documented Psychosocial Evaluation in the patient record at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff was trained on the importance of completing the Psychosocial Evaluation and timeliness of documentation at the Clinical Team Meeting on 12/12/2017. The Clinical Director will monitor charts for compliance during monthly chart audits. Supervisory follow-ups will be done as needed. Overall compliance will be reported, documented and monitored at bi-monthly Committee of the Whole meetings. |
715.23(d) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
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Observations
Based on a review of patient records on November 13-15, 2017, the facility failed to document a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the program in one of five patient records.
Patient #3 was admitted to treatment on March 1, 2017 and was discharged on March 13, 2017. There was no evidence of a treatment plan in the patient record at the time of the inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff was trained on the importance of completing the Treatment Plan and timeliness of documentation at the Clinical Team Meeting on 12/12/2017. The Clinical Director will monitor charts for compliance during monthly chart audits. Supervisory follow-ups will be done as needed. Overall compliance will be reported, documented and monitored at bi-monthly Committee of the Whole meetings |