INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 30-31, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, My Sister's Place Thomas Jefferson University 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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711.51(b)(3)(iii) LICENSURE Personal History
711.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document a personal history of the client according to the facility's policy and procedures. The findings include:The facility's policy states, all assessments will be legible and completed within 30 days of admission, this includes the completion of the client's personal history. On January 31, 2012 five client records requiring documentation of the client's personal history were reviewed. Two out of five client records lacked documentation of a personal history, specifically client records # 2 and 3. Client # 2 was admitted on October 20, 2011. As of the date of inspection there was no documentation of a personal history for client #2.Client # 3 was admitted on May 18, 2011 and discharged on September 26, 2011. As of the date of inspection, there was no documentation of a personal history for client # 3. On January 31, 2011 an interview was conducted with the clinical supervisor, which confirmed the personal histories were not documented.
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Plan of Correction
All admissions (transfers or self-referrals) will require the Psycho-Social History (PSH) to be completed which includes the personal history. The Clinic Supervisor will monitor each admission to ensure completion within the 30 days of admission and sing-off on all PSH's. All previous collateral information will be included in the chart, but not in lieu of the MSP PSH. The Clinical Supervisor will provide the training and the Residential Director will reinforce the DOH regulations and MSP P & P.
Person(s) responsible: Primary Counselor, Clinical Supervisor, Residential Director
Timeframe for completion: Immediate |
711.51(b)(5) LICENSURE Physical Examination
711.51. 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 and the facility's policy and procedure manual, the facility failed to document physical examinations in accordance with the facility's policies and procedures. The findings include: In reference to physical exams, the facility's policy states: Physical exams are to be completed prior to admission. If a client is admitted without a physical exam, an appointment will be scheduled with a physician within 48 hours. On January 31, 2012 five client records were reviewed for documentation of physical examinations. The facility neglected to record the vital signs and general appearance in the physical examination in one client record specifically, # 1 and documented the physical examination late in client record #3. Client # 1 was admitted on March 10, 2011. The physical examination was completed on January 25, 2011; however the physical examination did not include documentation of the client's vital signs and general appearance. Client # 3 was admitted on May 18, 2011. The physical examination should have been scheduled by May 20, 2011 but had not been completed until September 9, 2011. On January 31, 2012 a conversation was held with the Program Director, which confirmed the findings.
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Plan of Correction
The nurse will develop a check list that will be attached to the front of each physical that will reflect the DOH compliance issues for medical examination. This review of the medical records received will be completed within 2 working days allowing for any missing items to be addressed with the Medical Director, Clinical Supervisor, and the Residential Director.
The Residential Director will notify the nurse of all impending admissions in order to ensure that all physicals are completed within the DOH allowed timeframe prior to admission or will require scheduling within 48 hours and completion within 7 days of admission, per DOH. The nurse will communicate barriers or problems to the Residential Director as well as compliance of physicals.
All impending admissions will be discussed in the daily de-briefing meeting and a POA for missing documentation or missing physicals upon admission will be discussed, recorded, and follow-up will be immediate.
Person(s) responsible: Nurse, Clinic Supervisor, Residential Director
Timeframe for completion: Immediate |
711.51(b)(6) LICENSURE Psychosocial Evaluation
711.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial assessment and/or failed to document a psychosocial assessment that included the client's composite picture, assets and strengths, client problems and needs, support systems, negative factors that could interfere with treatment, and the client's attitude towards treatment. The findings include:The facility's policy states, the psychosocial evaluation is to be completed within 30 days of the patient's admittance into the program. On January 31, 2012, five client records requiring documentation of psychosocial evaluations were reviewed. Two out of five client records lacked documentation of a an evaluative clinical assessment, records #1 & 2, and one out of five was missing a psychosocial evaluation, specifically client record # 3. Client # 1 was admitted on March 10, 2011. The psychosocial evaluation was completed on Apri 7, 2011 and did not include a clinical assessment of the client's negative factors that could interfere with treatment and attitude towards treatment.Client # 2 was admitted on October 20, 2011. The psychosocial evaluation was undated and did not include a clinical assessment of the client's composite picture, assets and strengths, problems and needs, and support systems.Client # 3 was admitted on May 18, 2011 and discharged on September 26, 2011, as of the date of inspection, there was no documentation of a psychosocial evaluation for client # 3. On January 31, 2011 an interview was conducted with the clinical supervisor, which confirmed the psychosocial assessments were non-evaluative or missing.
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Plan of Correction
All admissions (transfers or self-referrals) will require the Psycho-Social History (PSH) to be completed. The Clinic Supervisor will monitor each admission to ensure completion within the 30 days of admission and sing-off on all PSH's. All previous collateral information will be included in the chart, but not in lieu of the MSP PSH. The Clinical Supervisor will provide the training and the Residential Director will reinforce the DOH regulations and MSP P & P.
Person(s) responsible: Primary Counselor, Clinical Supervisor, Residential Director
Timeframe for completion: Immediate |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on on observation during a physical plant inspection, the facility failed to ensure the facility was in good repair at all timesThe findings include:An physical plant inspection was conducted on January 31, 2012 at 9:40 AM. At 9:57 AM water was observed to be leaking around the cold water knob of the sink in bedroom #38 when the cold water is turned on. At 10:04 AM it was found that the sink in bedroom # 36 was detached from the wall from which it was previously affixed. At 10:09 AM the plate covering the electrical socket in bedroom # 29 was cracked, leaving the wiring exposed. Furthermore, the wall space surrounding this outlet was covered in brown markings from an unidentified substance. The facility director was present during the inspection and confirmed the findings.
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Plan of Correction
All repairs will be immediately corrected. The use of the "Work Acquisition form" is reinforced with all women and staff.
House Managers are to submit their completed room checks to the Lead House Manager who will, in turn, bring all critical issues to the Residential Director so that a contractor can be contacted to make the necessary repairs.
Lead House Manager must remind all House Managers, all shifts, that room inspections could be possibly safety issues and, as such, anything appearing broken, must be communicated on the "Request" form and in the communication log. This training should occur monthly and needs to be documented in the minutes.
Person(s) responsible: Lead House Manager, House Managers, Residential Director
Timeframe for competion: Immediate |