INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 8-9, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Marworth 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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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on observation during the physical plant inspection, the facility's hot water exceeded 120
The findings include:
The physical plant inspection took place on July 8, 2013. At 2:00 p.m. the hot water temperature registered 130 This was confirmed by the Maintenance Supervisor and was not disputed.
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Plan of Correction
Water temperature was lowered to 120 degrees by Facilites supervisor during the survey and was retested during survey and found to be in compliance. Compliance will be monitored during the monthly facility walk thru conducted by the Dir of QI, Mgr Guest Services, and Facilities Supervisor. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on observation during the physical plant inspection, the facility failed to have a heater that was permanently mounted or installed.
The findings include:
The physical plant inspection took place on July 8, 2013 between the hours of 1:00 p.m. and 2:00 p.m. At 1:45 p.m. a space heater was observed in the Utilization Review office on the second floor of the main building. The heater was not permanently mounted or installed.
The finding was confirmed by the Maintenance Supervisor and was not disputed.
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Plan of Correction
The space heater was removed from the facility by the Facility Supervisor during the the licensure inspection. Compliance will be monitored thru the monthly facility walk thru conducted by the Dir of QI, Mgr Guest Services and Facilities Supervisor. |
709.82(a)(3) LICENSURE Treatment and rehabilitation services
709.82. 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan which includes the proposed type of support service in three of seven client records.
The findings include:
Thirty client records were reviewed on July 8-10, 2013. Seven client records were from the partial hospitalization activity. Individual treatment and rehabilitation plans shall be developed with the client to include written documentation of the proposed type of support service. The facility failed to document an individual rehabilitation and treatment plan which included the proposed type of support service in client records # 6, 7 and 10.
Client # 6 was admitted June 26, 2013. The individual treatment and rehabilitation plan was completed on June 27, 2013 and did not include the proposed type of support service.
Client # 7 was admitted June 17, 2013. The individual treatment and rehabilitation plan was completed on June 14, 2013 and did not include the proposed type of support service.
Client # 10 was admitted April 3, 2013. The individual treatment and rehabilitation plan was completed on April 9, 2013 and did not include the proposed type of support service.
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Plan of Correction
The Outpatient staff will be educated to include support services on the treatment plans by the Program Coordinator. Program Coordinator will monitor compliance thru monthly treatment plan reviews. For the clients noted in the citation they are no longer active at this level of care so the records are now closed at this level however support services will be documented on the treatment plan at the next level of care which they are active in for 2 of the three Program coordinator will monitor this and for the third support services were included on the continuing care plan as confirmed by the Program Coordinator. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to provide counseling to a client on a regular and scheduled basis including individual counseling, at least twice weekly in three of seven records reviewed in the partial hospitalization activity.
The findings include:
Thirty client records were reviewed on July 8-10, 2013. Seven of the thirty client records were from the partial hospitalization activity. All seven clients were required to receive individual counseling at least twice weekly. Client records # 6, 7, and 12 did not document individual counseling at least twice weekly.
Client # 6 was admitted on June 26, 2013. Documentation of two individual sessions per week was not completed for the week of June 30- July 6, 2013.
Client # 7 was admitted on June 17, 2013. Documentation of two individual sessions per week was not completed for the week of June 17-21, 2013.
Client # 12 was admitted on June 26, 2013. Documentation of two individual sessions per week was not completed for the week of July 1-5, 2013.
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Plan of Correction
The Partial Hospitalization Counselor will develop a schedule at the beginning of each week indentifying the date& time of the 2 individula sessions for each patient & enter into the appointment book.To monitor and ensure the 2 individual sessions have occured the Progrm Coordinator will review the Record of Services for each patient at the end of the week. Also a random sample of charts will be checked for documentation of the sessions. If individual sessions cannot be provided due to conflicts in a patient's schedule a Counseling Note will be entered inot the case record. An addendum will be added to the client records identified in this citation to clarify why the clients did not receivethe individual sessions for the weeks identified. |
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 the review of client records, the facility failed to document a follow-up attempt in two of three client records.
The findings include:
Three client records requiring documentation of follow-up were reviewed July 8-9, 2013. The facility policy states that all non-referred clients will be followed-up with within seven days of discharge. The facility did not document follow-up in two of three records reviewed, specifically records # 18 and 19.
Client #18 was admitted on 2/6/13 and was discharged on 3/6/13. Documentation of follow-up was due by 3/13/13. The facility failed to document follow-up in this client record as of the date of the inspection.
Client #19 was admitted on 5/3/13 and was discharged on 5/13/13. Documentation of follow-up was due by 5/20/13. The facility failed to document follow-up in this client record as of the date of the inspection.
The Director of Counseling Programs confirmed the findings.
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Plan of Correction
All follow up is now centralized thru the Medical Records Department and this department is responsible for sending out follow up to all Routine and Non-routine discharges at all levels of care and the letter that accompanies the questionnaire will be scanned into the case record. The Medical Records Supervisor will randomly check closed files for these follow up letters. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records the facility failed to assure counseling services were being provided according to the individual treatment and rehabilitation plan in five of six client records reviewed.
The findings include:
Six client records requiring documentation that services were being provided in accordance with the treatment plan were reviewed on July 8-9, 2013. The facility failed to provide documentation that services were being provided in accordance with the treatment plan in five of six records reviewed, specifically client records # 20, 21, 23, 24, and 25.
Client # 20 was admitted on 3/19/13 and was still an active client at the time of the inspection. This client was to get one individual counseling session per week and one group counseling session per week. The facility failed to document individual counseling sessions for the weeks of 6/2/13, 6/9/13, and 6/23/13. The facility failed to document group counseling sessions for the week of 6/9/13.
Client # 21 was admitted on 3/11/13 and was still an active client at the time of the inspection. This client was to get one individual counseling session per week and one group counseling session per week. The facility failed to document individual counseling sessions for the weeks of 3/31/13, 4/7/13, 4/21/13, 4/28/13, 5/6/13, and 5/19/13. The facility failed to document group counseling sessions for the weeks of 5/26/13 and 6/2/13.
Client # 23 was admitted on 4/29/13 and was still an active client at the time of the inspection. This client was to get one individual counseling session per week and one group counseling session per week. The facility failed to document individual counseling sessions for the weeks of 5/26/13, 6/2/13, 6/9/13, and 6/30/13. There have not been any group counseling sessions documented since this client ' s admission.
Client # 24 was admitted on 3/27/13 and was still an active client at the time of the inspection. This client was to get one individual counseling session per week. The facility failed to document individual counseling sessions for the weeks of 5/5/13, 5/12/13, 5/19/13, 5/26/13, 6/2/13, 6/9/13, and 6/16/13.
Client # 25 was admitted on 4/3/13 and was still an active client at the time of the inspection. This client was to get one individual counseling session per week and one group counseling session per week. The facility failed to document individual counseling sessions for the weeks of 4/21/13, 4/28/13, 5/12/13, 5/19/13, 6/2/13, 6/9/13, 6/16/13, 6/23/13, and 6/30/13. The facility failed to document group counseling sessions for the weeks of 5/5/13, 5/19/13, 5/26/13, 6/2/13, and 6/16/13.
The Facility Director confirmed the findings.
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Plan of Correction
Modalities have been added to the Electronic Medical Record to more accurately reflect the provision of counseling services in an Outpatient setting (i.e. individual 1x/bi-weekly).The outpatient staff was trained on the availability of the new modalities by the Program Coordinator. The Program Coordinator will monitor compliance with the modalities within a treatment plan thru supervision with a counselor on an on going basis.An addemdum will be added to the client records indentified in this citation to clarify why the clients did not receive counseling in accordance with the treatment plan for the weeks identified. |
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.
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Observations
Based on the review of client records, the facility failed to document a follow-up attempt in four of five client records.
The findings include:
Five client records requiring documentation of follow-up were reviewed July 8-9, 2013. The facility policy states that for referred clients follow-up contact will me made within 7 days of the date of the referral. Follow-up will be made within 7 days of discharge via questionnaire for non-routine discharges and within 90 days via questionnaire for routine discharges. The facility did not document a follow-up four of five records reviewed, specifically records # 26, 27, 29, and 30.
Client #26 was admitted on 4/8/13 and was a non-routine discharge on 5/20/13. Documentation of follow-up was due by 5/27/13. The facility failed to document follow-up in this client record as of the date of the inspection.
Client #27 was admitted on 4/1/13 and was a routine discharge on 4/16/13 with a referral to outpatient services. Documentation of follow-up was due by 4/23/13. The facility failed to document follow-up in this client record as of the date of the inspection.
Client #29 was admitted on 1/8/13 and was a routine discharge on 2/22/13. Documentation of follow-up was due by 5/23/13. The facility failed to document follow-up in this client record as of the date of the inspection.
Client #30 was admitted on 4/29/13 and was a non-routine discharge on 5/29/13. Documentation of follow-up was due by 6/5/13. The facility failed to document follow-up in this client record as of the date of the inspection.
The Facility Director and Director of Quality Improvement confirmed the findings.
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Plan of Correction
All follow up is now centralized thru the Medical Records Department and this department is responsible for sending out follow up to all Routine and Non-routine discharges at all levels of care and the letter that accompanies the questionnaire will be scanned into the case record. The Medical Records Supervisor will randomly check closed files for these letters. |