INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 16, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Conewago - Pottsville 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 and a plan of correction is due on August 9, 2009.
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Plan of Correction
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709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
Based on a review of administrative materials and staff interview, the facility failed to maintain documented records of quarterly inspections of the drug storage areas, as per their written policy. The findings include:The facility's policy and procedure manual was reviewed on July 16, 2009. The facility's policy stated that quarterly inspections would be completed and documented in a log book. The log documenting quarterly inspections of the drug storage areas was requested to be reviewed on July 16, 2009. The log documenting quarterly inspections of the drug storage areas included an inspection completed in September 2008 and in December 2008; however, there was no documentation to show that an inspection had been completed in March 2009 or June 2009, as required.
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Plan of Correction
The facility director will review the existing contract with the local pharmacy to ensure that quarterly inspections are conducted and documented as required by the Facility's Policy and Procedure's Manual on January 12, 2009. The facility will ensure that documentation of the quarterly inspections are kept at the facility. Facility director will monitor on a monthly basis in conjunction with the corporate compliance officer by 8/31/09 to ensure compliance.
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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records and staff interview, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of one client record. The findings include:Five client records were reviewed on July 16, 2009. One client record was required to have a documented letter of termination. A letter of termination was not documented in client record #3. Upon discussion with the facility director, the facility did not notify client #3, in writing, of a decision to involuntarily terminate the client's treatment at the project.
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Plan of Correction
The facility director will retrain all clinical staff on the appropriate completion of the facility's termination procedures on August 12, 2009 during the weekly clinical staff meeting. Facility director will monitor on a monthly basis in conjunction with the corporate compliance officer by 8/31/09 to ensure compliance. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
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Observations
Based on a review of client records and staff interview, the facility failed to document follow-up information in three of three client records. The findings include:Five client records were reviewed on July 16, 2009. Three client records were required to have documentation of follow-up. Follow-up was not documented in client records #3, 4 and 5. Based on a discussion with the facility director, follow-up was not completed on clients #3, 4 and 5.
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Plan of Correction
The facility director will retrain all applicable staff on August 12, 2009 on the appropriate completion of facility follow up protocols during the weekly clinical staff meeting. Facility director will monitor on a monthly basis in conjunction with the corporate compliance officer by 8/31/09 to ensure compliance. |