INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the October 19, 2010 licensure renewal inspection. The follow-up inspection was conducted on January 31, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Gaudenzia DRC Inc. 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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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on an inspection of the facility's physical plant and an interview with the Director of Operations, the facility failed to store all trash, garbage and rubbish in covered containers.
The findings include:
A Physical plant inspection was conducted on January 31, 2011 between approximately 6:45 A.M. and 7:45 A.M. The facility was required to store all trash, garbage and rubbish in covered containers. At the time of inspection, approximately fourteen large bags of trash, empty boxes and a mattress were in a pile beside the trash dumpster.
An interview with the Director of Operations on January 31, 2011 confirmed that the facility did not store all trash, garbage and rubbish in covered containers.
This is a repeat citation form the October 19, 2010 inspection. On October 19, 2010, the facility was cited for failure to store all trash, garbage and rubbish in covered containers. The facility's plan of correction submitted on 11/23/10 and approved on 1/05/11 stated the following:
"A training to review the storage of trash, garbage, and rubbish in covered containers will be facilitated on December 15, 2010. The training will ensure that all maintenance staff dispose of trash in the covered trash containers as required by the Division of Drug and Alcohol Licensure DOH Policy 705.22(4).
All storage of trash, garbage, and rubbish will be reviewed weekly and monitored during monthly Continuous Quality Improvement (CQI) meetings to ensure compliance, completion, and timelines by the Operations Director.
Persons Responsible: Division Director, Operations Director, Inpatient Program Director.
Timeframe for Completion: January 20, 2011"
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Plan of Correction
To ensure that all garbage/rubbish is stored in covered containers, the facility has added one more dumpster and has scheduled one extra rubbish removal per week. A Shift Dumpster Log has been developed outlining the date and shift the dumpster was monitored and will be completed by the Shift Supervisors.
Training on the Shift Dumpster Log will be facilitated by the Operations Director with the Shift Supervisors on June 1, 2011.
All Shift Dumpster Log's will be reviewed and monitored before monthly Continuous Quality Improvement (CQI) meetings to ensure compliance, completion, and timelines by the Division and Operation Directors.
Persons Responsible:
Division Director
Operations Director
Timeframes for Completion: June 1, 2011
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705.5 (a) (3) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(3) A storage area for clothing.
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Observations
Based on a physical plant inspection and an interview with the Director of Security, the facility failed to provide a storage area for clothing for each resident.
The findings include:
An inspection of the facility's physical plant was conducted on January 31, 2011 between approximately 6:45 A.M. and 7:45 A.M. The facility was required to provide each resident with a storage area for clothing. At the time of inspection, the male residents on the 5th floor did not have sufficient storage for their clothing.
In rooms # 501, 502, 503, 504, 505, 506, 507, 508, 509, 511, 517, 519, 521, 522, 523 and 524, clients were provided with two drawers to store their belongings. Because the drawers were small, clients stored their additional belongings in trash bags, in boxes, and on the vacant beds.
An interview with the Director of Security on January 31, 2011 confirmed that sufficient storage for clothing was not provided for each resident.
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Plan of Correction
Dressers and lockers were purchased on May 10, 2011 and put on the 5th Floor Men's Unit to give each resident a storage area for their clothing.
Staff will monitor all Inpatient Units during hourly rounds to ensure that each resident has amble space for storage of their clothing per DOH Policy 705.5(a)(3). Monthly Continuous Quality Improvement (CQI) meetings will be held to ensure compliance, completion, and timelines.
Persons Responsible:
Division Director
Inpatient Director
Operations Director
Timeframes for Completion: August 5, 2011
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection and an interview with the Director of Security, the facility failed to ventilate all toilets and wash rooms by exhaust fan or window.
The findings include:
An inspection of the facility's physical plant was conducted on January 31, 2011 between approximately 6:45 A.M. and 7:45 A.M. The facility was required to ventilate all toilets and wash rooms by exhaust fan or window. The bathrooms in bedrooms # 544, 548, and 550 did not have an operable exhaust fan or operable window for ventilation.
An interview with the Director of Security on January 31, 2011 confirmed that ventilation was not provided in the identified bathrooms.
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Plan of Correction
The facility has contacted several HVAC contractors for estimates to install ventilation in the wash rooms. The bathrooms in bedrooms 544, 548, and 550 will be in compliance with standard 705.6 (5) by June 20, 2011.
Staff will monitor all Inpatient bathrooms to ensure that the facility complies with the standard 705.6 (5) which states that the residential facility shall ventilate toilet and wash rooms by exhaust fans or window.
Work orders will be generated as needed and monthly Continuous Quality Improvement (CQI) meetings will be held to ensure compliance, completion, and timelines.
Persons Responsible:
Division Director
Inpatient Director
Operations Director
Timeframes for Completion: August 5, 2011
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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 an inspection of the facility's physical plant and an interview with the Director of Security, the facility failed to prohibit the use of heaters that are not permanently mounted or installed.
The findings include:
A physical plant inspection was conducted on January 31, 2011 approximately between 6:45 A.M. and 7:45 A.M. At the time of inspection a portable space heater was observed in office #461.
An interview with the Director of Security on January 31, 2011 confirmed the presence of a portable space heater in office #461.
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Plan of Correction
The heater in Room #461 was removed on the day of the inspection on January 31, 2011. All areas of the Inpatient Program were inspected on that date and there were no other portable heaters in the program.
A review of DOH Policy 705.8(2) will occur on May 25, 2011 during the Inpatient Program staff meeting.
Monthly Continuous Quality Improvement (CQI) and weekly staff meetings during the next 90 days will review compliance, completion, and timelines of the POC.
Persons Responsible:
Division Director
Inpatient Director
Operations Director
Timeframes for Completion: August 5, 2011
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705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on observation during a physical plant inspection, the facility failed to follow their policy and procedures titled Client Intake - Hygiene and Clothing Screening which pertains to their bed bug protocol.
The findings include:
An inspection of the facility's physical plant was conducted on January 31, 2011 approximately between 6:45 A.M. and 7:45 A.M. Although there were no bed bugs found during the inspection, it was determined that the facility failed to follow their own policy and procedures developed to ensure that the facility remain free of bed bug infestations.
The facility failed to follow section (C)(5) of their policy and procedure titled "CLIENT INTAKE - HYGIENE AND CLOTHING SCREENING" Dated November, 2008. Section (C)(5) states: " The client ' s luggage and/or baggage are to be bagged and sealed and taken to storage. If the belongings have been brought in in [sic] plastic bags, those bags must be discarded immediately in an outdoor container after the belongings have been re-bagged for removal to the laundry room and the luggage have been bagged for storage.
In rooms # 501, 502, 503, 504, 505, 506, 507, 508, 509, 511, 517, 519, 521, 522, 523 and 524 clients clothing was stored in unsealed trash bags and boxes.
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Plan of Correction
Facility will use the Gaudenzia Inc Bed Bug policy which was formulated on November 3, 2008. Clients will complete Hygiene and Clothing Screening Form which outlines the process of screening for bed bugs.
Training on the Prevention and Treatment of Bed Bugs occurred on February 24, 2011.
A monthly review and report of the Hygiene and Clothing Screening Forms will be completed and presented during the monthly CQI meetings.
Persons Responsible:
Division Director
Operations Director
Security Director
Timeframes for Completion: August 5, 2011
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based upon a review of client records and a discussion with the Facility Director, the facility failed to comply with 4 Pa. Code 255.5 relating to projects and coordinating bodies: disclosure of client-oriented information, in four of five records reviewed.
The findings include:
On January 31, 2011, five client records were reviewed for consents to release information and client related correspondences. Four out of the five records reviewed contained consent to release information forms that indicated that the client must revoke the consent in writing. A facility may not act in reliance on a consent that is known to have been revoked.
In client records # 1, 3, 4 and 5, the release forms disclosing information to a criminal justice entity erroneously informed the clients that the revocations of consents to release information must be in writing. The facility must accept and act on verbal revocations.
In client records # 1, 3, 4 and 5, the release forms disclosing information to a government agency erroneously informed the clients that the revocations of consents to release information must be in writing. The facility must accept and act on verbal revocations.
In client records # 1, 3 and 4, the release forms disclosing information to a funding source erroneously informed the clients that the revocations of consents to release information must be in writing. The facility must accept and act on verbal revocations.
The facility was previously cited on January 25, 2008 under tag L-0277 for erroneously informing the clients that the revocations of consents to release information, must be in writing. The facility must accept and act on verbal revocations. The consent form indicated that the client must provide written revocation. The facility's plan of correction submitted on 3/18/08 and approved on 4/30/08 stated the following:
"A confidentiality training and re-training will be conducted for clinical staff on the purpose of informed and voluntary release of information. The release of information form will be revised to include and reflect verbal consent by the client.
The Medical Department will ensure that all clients identifying information will be removed from medication containers before collection and disposal. All medication control systems will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and monitored for four (4) months to ensure compliance, completion, and timelines. This process will be monitored by the Nurse Manager and reviewed by the Division Director.
Persons Responsible:
Division Director, Nurse Manager
Timeframe for Completion: March 27th 2008"
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Plan of Correction
The Confidential Request to Release Information form has been revised to state, "I understand that my records are protected under the Federal Confidentiality Regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulation. I also understand that I may revoke this consent at any time verbally, or in writing to the Program Director..."
A record-keeping training to include a review of the revised Confidentiality Request to Release Information Form and Policy and Procedure standards will be facilitated on June 1, 2011 to ensure that all staff release client information per DOH Policy 709.28(a)(1) and 4 Pa. Code 255.5.
All consent to release information documentation and compliance timeframes will continue to be reviewed and monitored before monthly Continuous Quality Improvement (CQI) meetings to ensure compliance, completion, and timelines by the Program Director and Clinical Supervisor.
Persons Responsible:
Inpatient Program Director
Inpatient Clinical Supervisor
Timeframes for Completion: August 5, 2011
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709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on an inspection of the facility's physical plant, and an interview with the Director of Security, the facility failed to secure all client records within locked storage containers.
The findings include:
An inspection of the facility's physical plant was conducted on January 31, 2011 between approximately 6:45 A.M. and 7:45 A.M. The facility was required to secure all client records within locked storage containers. At the time of inspection, discharged client records were stored in boxes on the floor of office #461.
An interview with the Director of Security on January 31, 2011 confirmed that the closed records were maintained in the "Coordinator's office" , and the office was not dedicated solely for the purpose of record storage.
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Plan of Correction
On February 7, 2011 the chart's in Room #461 where moved to a designated Record Room #550 which will be for the sole purpose of record storage within locked storage containers.
The Clinical Supervisor, Residential Coordinator and Record Room Clerk will be trained on DOH Policy 709.28(b): Confidentiality on May 25, 2011.
The Record Room will be monitored daily to ensure compliance, completion, and timelines concerning security of client records within locked file cabinets by the Program Director and Clinical Supervisor.
Persons Responsible:
Inpatient Program Director
Inpatient Clinical Supervisor
Timeframes for Completion: August 5, 2011
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709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
Based on observation and an interview with the Director of Operations, the facility failed to demonstrate a data collection and record keeping system that allowed for the efficient retrieval of data, specifically, a client census and a list of active and discharged clients with the dates of admission and discharge..
The findings include:
On January 31, 2011, shortly after arriving at the facility at approximately 6:30 AM, the Licensing Specialist requested a list of active and discharged clients including the dates of admission and discharge and a client census report. The facility was unable to provide a list with the requested information until 11:00 AM. In addition, the facility was unable to provide the five active client records requested until 50 minutes following the request. A detailed timeline is provided below:
On January 31, 2011 at approximately 8:15 AM, the Director of Operations informed the Licensing Specialist that he did not have access to a client census report, but this information would be available when the Program Director arrived at 9:00 AM.
At approximately 9:40 AM, the Licensing Specialist received a client census report for active and discharged clients, but the report did not include client admission and discharge dates.
At approximately at 10:30 AM, the Licensing Specialist received the admission dates for the active clients, and at approximately 11:00 AM, the Licensing Specialist received the admission and discharge dates for the discharges clients.
At approximately 11:00 AM, the Licensing Specialist provided the facility a list of five active client records to be reviewed.
At approximately 11:50 AM, the licensing Specialist received the five selected client records.
An interview with the Director of Operations on January 31, 2011 confirmed that the facility did not demonstrate an efficient data collection and record keeping system.
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Plan of Correction
A Daily Roster which outlines the current active and discharge charts has been developed by the Program Director to allow for the efficient retrieval of data.
The Clinical Supervisor, Residential Coordinator and Record Room Clerk will be trained on the use of the Daily Roster on May 25, 2011.
All Daily Rosters will be reviewed daily and during the Continuous Quality Improvement (CQI) meetings for three (3) months to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Inpatient Program Director
Inpatient Clinical Supervisor
Timeframes for Completion: August 5, 2011
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709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based upon a review of client records and an interview with the Facility Director, the facility failed to document a record of service to include all services provided in three of five records reviewed.
The findings include:
Five client records were reviewed for the record of services on January 31, 2011. Three out five records reviewed lacked documentation to show all services provided, specifically, # 1, 2 and 4.
Client # 1 was admitted on 11/19/10. There was no record of services in the client record as of 1/31/11.
Client # 2 was admitted on 12/29/10. There was no record of services in the client record as of 1/31/11.
Client # 4 was admitted on 11/22/10. There was no record of services in the client record as of 1/31/11.
An interview with the Facility Director on January 31, 2011 confirmed that a record of services was missing in client records # 1, 2 and 4.
This is a repeat citation form the October 19, 2010 inspection. In addition, the facility was previously cited for noncompliance of this standard on October 28, 2008.
On October 19, 2010, the facility was cited for failure to document a record of service to include all services provided. The facility's plan of correction submitted on 11/23/10 and approved on 1/05/11 stated the following:
"To ensure that a record of service and all services provided are completed in every client record, Inpatient Director and Clinical Supervisor will conduct a training with the clinical staff on DOH Policy 709.53(a)(3) on November 19, 2010. The training will review the different components of the record of service which include: the dates of the service, who provided the service and the duration of the service.
All documentation of record of services will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings to ensure compliance, completion, and timeframes by the Program Director.
Persons Responsible:
Inpatient Director
Clinical Supervisor
Timeframe for Completion: January 20, 2011."
On October 28, 2008, the facility was cited for failure to document a record of service to include all services provided. The facility's plan of correction submitted on 12/2/08 and approved on 12/2/08 stated the following:
"All record of service documentation and compliance timeframes will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and monitored for three (3) months to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Executive Director, Division Director
Timeframe for Completion: January 30, 2008"
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Plan of Correction
A record-keeping training to include a review of the Record of Service will be facilitated on June 1, 2011 to ensure that all staff document progress notes on the Record of Service as required by the Division of Drug and Alcohol Licensure.
All Record of Services documentation and compliance will be reviewed weekly and monitored during monthly Continuous Quality Improvement (CQI) meetings for three (3) months to ensure compliance, completion, and timelines.
Persons Responsible:
IP Program Director
IP Clinical Supervisor
Timeframes for Completion: August 5, 2011
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709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based upon a review of client records and an interview with the facility director, the facility failed to develop a plan appropriate for the group and/or individual following the static group sessions in three of five records reviewed.
The findings include:
Five client records were reviewed on January 31, 2011 for progress notes. The facility failed to develop a plan appropriate for the group and/or individual following the static group sessions in three of five records reviewed, specifically # 1, 3 and 4.
In client records # 1, 3 and 4, the plan listed in the progress notes for the static group sessions held on January 20, 21 and 24 was identical for each day and for each client.
An interview with the facility director on January 31, 2010 confirmed that the facility failed to develop a plan appropriate for the group and/or individual in the identified static group progress notes.
On October 19, 2010, the facility was cited for failure to develop a plan appropriate for the group and/or individual following the static group sessions. Static group session notes were preprinted and were not developed specifically for the session. The facility's plan of correction submitted on 11/23/10 and approved on 1/05/10 stated the following:
"To ensure that an individualized plan is developed for group and/or individual sessions, a training with the clinical staff on DOH Policy 709.53(a)(5) will be conducted on November 19, 2010 by the Inpatient Director and the Clinical Supervisor.
Progress note documentation will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings to ensure compliance, completion, and timeframes by the Program Director.
Persons Responsible:
Inpatient Director
Clinical Supervisor
Timeframes for Completion: January 20, 2011."
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Plan of Correction
To ensure that an individualized plan is developed for group and/or individual sessions, the Clinical Supervisor will conduct weekly audits on random inpatient charts.
Training with the clinical staff will be conducted on June 1, 2011 by the Inpatient Director and the Clinical Supervisor. This training will review the Data Assessment Plan (DAP) format and will allow the counselors to practice writing individual plans for their clients.
Persons Responsible:
Inpatient Director
Clinical Supervisor
Timeframes for Completion: August 5, 2011
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709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a physical plant inspection and an interview with the of Operations, the facility failed to notify the Department within 90 days of the occurrence of a change in the authorized maximum client capacity.
The findings include:
A Physical plant inspection was conducted on January 31, 2011 between approximately 6:45 A.M. and 7:45 A.M. The facility ' s authorized maximum capacity for Inpatient Non-Hospital clients is 48. At the time of inspection, the total number of beds observed was 63.
There were 8 beds on the 4th floor women's unit.
Room # 454 = 3 beds
Room # 462 = 2 beds
Room # 464 = 3 beds
There were 10 beds on the 5th floor women's unit.
Room # 544 = 2 beds
Room # 547 = 2 beds
Room # 548 = 2 beds
Room # 550 = 2 beds
Room # 551 = 2 beds
There were 45 beds on the 5th floor men's unit.
Room # 501 = 3 beds
Room # 502 = 3 beds
Room # 503 = 3 beds
Room # 504 = 3 beds
Room # 505 = 3 beds
Room # 506 = 3 beds
Room # 507 = 3 beds
Room # 508 = 3 beds
Room # 509 = 3 beds
Room # 511 = 2 beds
Room # 517 = 2 beds
Room # 519 = 2 beds
Room # 521 = 2 beds
Room # 522 = 4 beds
Room # 523 = 2 beds
Room # 524 = 4 beds
The facility did not notify the Department of this change in the authorized maximum client capacity.
An interview with the Director of Operations on January 31, 2011 confirmed that the total number of beds exceeded the authorized maximum client capacity. The Director of Operations also confirmed that facility did not notify the Department of this change in capacity.
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Plan of Correction
On January 31, 2011, a total of 2 beds were moved from the 4th floor women's unit and a total 13 beds were moved from the 5th floor men's unit.
If the facility decides to change the maximum authorized capacity of 48 beds in the Inpatient Program, the Director will notify DOH within 90 days.
The daily roster and bed sheet will be used to monitored daily to ensure compliance of policy 709.14 (b)(5).
Persons Responsible:
Division Director
Inpatient Director
Operations Director
Inpatient Clinical Supervisor
Timeframes for Completion: August 5, 2011
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of areas of noncompliance identified during this onsite follow-up inspection that had previously been cited, the facility failed to comply with prior plans of correction approved by the Department.
The findings include:
On January 31, 2011 the facility was again found to be out of compliance with the following standards:
1.709.28(a)(1) Confidentiality of client identity and records. The facility was previously cited on January 25, 2008 under tag L-0277 for erroneously informing the clients that the revocations of consents to release information, must be in writing. The facility must accept and act on verbal revocations. The consent form indicated that the client must provide written revocation. The facility's plan of correction submitted on 3/18/08 and approved on 4/30/08 stated the following:
"A confidentiality training and re-training will be conducted for clinical staff on the purpose of informed and voluntary release of information. The release of information form will be revised to include and reflect verbal consent by the client.
The Medical Department will ensure that all clients identifying information will be removed from medication containers before collection and disposal. All medication control systems will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and monitored for four (4) months to ensure compliance, completion, and timelines. This process will be monitored by the Nurse Manager and reviewed by the Division Director.
Persons Responsible:
Division Director, Nurse Manager
Timeframe for Completion: March 27th 2008"
2. 709.53(a)(3) Record of services provided. On October 19, 2010, the facility was cited for failure to document a record of service to include all services provided. The facility's plan of correction submitted on 11/23/10 and approved on 1/05/11 stated the following:
"To ensure that a record of service and all services provided are completed in every client record, Inpatient Director and Clinical Supervisor will conduct a training with the clinical staff on DOH Policy 709.53(a)(3) on November 19, 2010. The training will review the different components of the record of service which include: the dates of the service, who provided the service and the duration of the service.
All documentation of record of services will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings to ensure compliance, completion, and timeframes by the Program Director.
Persons Responsible:
Inpatient Director
Clinical Supervisor
Timeframe for Completion: January 20, 2011."
On October 28, 2008, the facility was cited for failure to document a record of service to include all services provided. The facility's plan of correction submitted on 12/2/08 and approved on 12/2/08 stated the following:
"All record of service documentation and compliance timeframes will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and monitored for three (3) months to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Executive Director, Division Director
Timeframe for Completion: January 30, 2008"
3. 709.53(a)(5) Progress notes. On October 19, 2010, the facility was cited for failure to develop a plan appropriate for the group and/or individual following the static group sessions. Static group session notes were preprinted and were not developed specifically for the session. The facility's plan of correction submitted on 11/23/10 and approved on 1/05/10 stated the following:
"To ensure that an individualized plan is developed for group and/or individual sessions, a training with the clinical staff on DOH Policy 709.53(a)(5) will be conducted on November 19, 2010 by the Inpatient Director and the Clinical Supervisor.
Progress note documentation will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings to ensure compliance, completion, and timeframes by the Program Director.
Persons Responsible:
Inpatient Director
Clinical Supervisor
Timeframes for Completion: January 20, 2011."
4. 705.2(4) Building exterior and grounds. On October 19, 2010, the facility was cited for failure to store all trash, garbage and rubbish in covered containers. The facility's plan of correction submitted on 11/23/10 and approved on 1/05/11 stated the following:
"A training to review the storage of trash, garbage, and rubbish in covered containers will be facilitated on December 15, 2010. The training will ensure that all maintenance staff dispose of trash in the covered trash containers as required by the Division of Drug and Alcohol Licensure DOH Policy 705.22(4).
All storage of trash, garbage, and rubbish will be reviewed weekly and monitored during monthly Continuous Quality Improvement (CQI) meetings to ensure compliance, completion, and timelines by the Operations Director.
Persons Responsible: Division Director, Operations Director, Inpatient Program Director.
Timeframe for Completion: January 20, 2011"
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Plan of Correction
The Inpatient Director has reviewed the Plan of Correction for the following deficiencies that the facility has been previously cited for and the Plan of Correction that the facility failed to comply with.
709.28 (a)(1) ? Confidentiality of Client identity and records on January 25, 2008.
709.53 (a)(3) ? Record of Service provided on October 19, 2010.
709.53 (a)(5) ? Progress Notes on October 19, 2010.
705.2 (4) ? Building exterior and grounds on October 19, 2010.
A Record Keeping Training will be conducted on June 1, 2011 on the following standards:
709.28 (a)(1) ? Confidentiality of Client identity and records
709.53 (a)(3) ? Record of Service provided
709.53 (a)(5) ? Progress Notes
All clinical documentation compliance will be reviewed weekly and monitored during monthly Continuous Quality Improvement (CQI) meetings for three (3) months to ensure compliance, completion, and time lines.
Persons Responsible:
Division Director
Inpatient Director
Operations Director
Timeframes for Completion: August 5, 2011
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