INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 6-8, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Coatesville Treatment Center 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of administrative documentation, the facility failed to ensure that staff received the mandatory communicable disease training as required for one of sixteen staff reviewed.
The findings include:
The Staffing Requirements Facility Summary Report was reviewed May 6, 7 and 8, 2013. .
Sixteen employees were required to have documentation of HIV/AIDS and TB/STD training.
The facility failed to provide documentation of the required HIV/AIDS and TB/STD training for employee # 14 within the first two years of employee.
Employee # 14 was hired February 22, 2011. Employee # 14 is a part time front office support staff. HIV/AIDS and TB/STD training was to be completed within the first two years of employment, by February 22, 2013. At the time of inspection the employee # 14 had not received the HIV/AIDS and STD/TB training.
Discussion with the facility director May 8, 2013 confirmed the training had not been completed.
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Plan of Correction
Clinic Director will ensure that Part-time Office Assistant completes HIV and TB/STD training by July 31st. Clinic Director with ensure all new support staff receive HIV and TB/STD training within the first two years of employment. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on the physical plant inspection, the facility failed ensure that the hot water temperature did not exceed 120 findings include:
The physical plant inspection took place on May 8, 2013. The sink in the main building outside of the patient bathroom was hotter than 120 degrees faranheit. The water was too hot to hold hand under it for more than one second.
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Plan of Correction
Health and Saftey Offcier adjusted the temperature on the water 5/9/2013. A temperature gage will be purchased by 6/21/2013. Health and Saftey officer will check the water temperature at least once per month with the gage. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ventilate the staff bathroom by an exhaust fan or window.
The findings include:
Based on a physical plant inspection on May 8, 2013, the exhaust fan located in the staff bathroom in the counseling building did not function.
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Plan of Correction
The ventilation fan was fixed by contractor on 5/14/2013. Health & Safety Officer will report any plant issues directly to Clinic Director. Clinic Director will continue to address all plant issue with the landlord/contractor. |
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 observation and a physical plant inspection, the facility permitted the use of a heater that was not permanently mounted or installed in a counseling office.
The findings include:
On May 7, 2013 and May 8, 2013 this writer was placed in a specific counselor's office to complete the inspection documentation. A portable heater was observed to be under the counselor's desk.
During the physical plant inspection on May 8, 2013, the portable heater was observed to be under the counselor's desk.
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Plan of Correction
Portable Heater was removed form the facility on 5/8/2013. On May 15, 2013, Clinic Director informed all staff during meeting that no protable heaters can be kept inside of the offices. Health & Safety Officer will conducted quarterly office inspections to ensure portable heaters and other hazardous materials are not maintained in the the offices. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records, the facility failed to document fire extinguisher training upon staff employment in three of three newly hired personnel.
The findings include:
Fourteen personnel records were reviewed May 6 and 7, 2013. Three personnel records were reviewed to verify that newly hired personnel had been instructed in the use of a fire extinguisher upon employment.. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel records # 5, 9 and 11.
Employee # 5 was hired on October 8, 2012. Fire extinguisher training was due upon hire but the fire extinguisher training was not completed until November 8, 2012.
Employee # 9 was hired on November 6, 2012. Fire extinguisher training was due upon hire, but the fire extinguisher training was not completed until January 22, 2013.
Employee # 11 was hired as a student intern August 29, 2012. Fire extinguisher training was due upon hire but the fire extinguisher training was not completed until September 20, 2012.
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Plan of Correction
All new staff will complete Health & Saftey Trainings within the first week of hire. The trainings will be facilitated by the Health and Saftety Officer. Clinic Director reviewed the requirements for Health & Safety trainings on 5/9/2013. Clinic Director will ensure the trainings are completed within the first week of hire and filed in the personnel records. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of administrative documentation, the facility failed to prepare alternate exit routes during fire drills.
The findings include:
Administrative documentation reviewed included documentation of fire drills conducted monthly between June 21, 2012 and April 26, 2013. There were no exits documented for fire drills dated July 30, 2012, August 24, 2012, September 14, 2012, October 14, 2012, November 30, 2012, January 14, 2013, March 21, 2013 and April 26, 2013.
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Plan of Correction
Alternate exit routes are utilized during every fire drill. Health & Safety officers will cleary document on the report that alternate routes are being utilized. Clinic Director will ensure that the Health & Safety officer is completing all required documentation monthly. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of administrative documentation, the facility failed to conduct fire drills during normal staffing conditions.
The findings include:
Administrative documentation reviewed included documentation of fire drills conducted monthly between June 21, 2012 and April 26, 2013. Ten of the documented drills were conducted during the afternoon shift, when there was limited staff or patients onsite. The majority of service activity occurs before noon. There was only one drill conducted during those hours and most of the staff failed to participate in the drill.
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Plan of Correction
Health & Safety Officer will ensre that fire drills are conducted during various portions of the day when the majority of the service activity occurs. Clinic Director will ensure that the Health & Saftey Officer is conducting dirlls during various times of the day from month to month. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of patient records, the facility failed to document psychosocial evaluations that provided a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation in six of seven client records reviewed.
The findings include:
Fifteen client records were reviewed May 6-8, 2013. Seven client records were reviewed for psychosocial evaluations.
Client records # 1, 2, 3, 5, 6 and 8 failed to include a psychosocial evaluation that included a composite picture of the negative factors that might inhibit treatment, and the client's attitude toward treatment. Client records # 1, 2, 3 and 5 failed to include an evaluation of the client's problems and needs.
The documentation included a repeat of the patient reported information and did not include an evaluation by the clinician for all required components.
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Plan of Correction
Clinical Supervisors will conduct a trainin with all Clinical Staff on June 24th to specifically cover how to complete comprehensice psychosocial evaluations. Clinical Supervisors will review and sign off on all psychosocial evaluations starting June 24, 2013. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document a treatment plan update in three of five client records.
The findings include:
Fifteen client records were reviewed May 6-8, 2013. Five client records were reviewed for treatment plan updates. Per regulation and the facility policy, treatment plan updates are required to be completed within 60 days of the comprehensive treatment plan. The facility failed to document a treatment plan update in client records # 4, 5 and 7.
Client # 4 was admitted March 27, 2012. A treatment plan update was required in November 2012, but was not completed.
Client # 5 was admitted December 26, 2012. The comprehensive treatment plan was completed on January 16, 2013. A treatment plan update was due by March 16, 2013. The facility failed to document the completion of a treatment plan update as of May 8, 2013.
Client # 7 was admitted January 4, 2012. A treatment plan update for September 2012 was not completed. A treatment plan for January 2013 and March 2013 was not documented at the time of the inspection, May 8, 2013.
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Plan of Correction
Clinical Staff will be required to turn in clinical documentation during bi-weekly clinical supervision with their direct supervisor. Clinical Supervisors will sign all treatment plans and address Counselors that are not completing their treatment plans on time and institute corrective plans as needed. Clinical Supervisors will provide a training on treatment planing with all Counselors on 6/24/2013 and cover time periods in which clinical paperwork is due. |
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 a review of client records, the facility failed to document follow up information as per agency policy in one of two client records.
The findings include:
Four discharged client records were reviewed May 8, 2013. Three client records required a documented follow up attempt. Per agency policy, follow up contact will be completed within 30 days of discharge for clients not referred to other programs. Follow up was not documented within 30 days of discharge in client record # 13.
Client # 13 was admitted May 1, 2001 and discharged December 4, 2012. There was no follow up contact documented in the client record at the time of the inspection.
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Plan of Correction
Based on prior plan of correction, all discharge follow-ups are completed by Clinical Supervisors and are maintained in a discharge follow-up binder. Clinical Supervisor will utilize Tower to begin immediate follow-up with patients that have been discharged to ensure the follow-ups are completed within 7 days. Clinical Supervisors will monitor this practice and review discharges by the end of each week to ensure all have been completed. |