INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 2-3, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, St. John Vianney 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 and a plan of correction is due on July 7, 2009.
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to document an individual training plan in four of four personnel records.
Findings:
Four personnel records were reviewed on June 2, 2009. An individual training plan was required in four personnel records. The facility did not document an individual training plan to include potential resources for the identified training subjects in personnel records # 1, 2, 3 and 4.
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Plan of Correction
The Forms Committee has redesigned the Individual Training Plan to include potential resources. The Department manager will audit at the time the plan is completed by each employee for compliance |
709.123(a)(2)(ii) LICENSURE Drug and Alcohol History
709.123. Treatment and rehabilitation.
(a) Intake and admission.
(2) Intake procedures shall include documentation of:
(ii) Drug and alcohol history.
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Observations
Based on a review of client records, the facility failed to document a drug and alcohol history in two of four client records.
Findings:
Five client records were reviewed on June 3, 2009. Drug and alcohol histories were reviewed in four client records. The facility did not document a drug and alcohol history within 72-hours after admission, as stated in the facility ' s policy and procedures manual, in client records # 1 and 4.
Client record # 1 admission date 2/16/09, but the drug and alcohol history was not signed or dated.
Client record # 4 admission date 9/17/08, but the drug and alcohol history was not documented at time of inspection.
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Plan of Correction
The COD Director will re-orient all staff to the policy requirements for completion in 72 hours.
The COD Director will re-orient all staff to the policy of signing and dating all documents at the time of completion.
The COD Director will reorient all staff to the policy of collecting a drug and alcohol history on all clients admitted to the unit.
Medical Records Director will conduct a quarterly audit to monitor compliance |
709.123(b)(1) LICENSURE Individualized Tx Plan
709.123. Treatment and rehabilitation.
(b) Treatment and rehabilitation services.
(1) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document a treatment and rehabilitation plan that was developed with the client in three of four client records.
Findings:
Five client records were reviewed on June 3, 2009. Treatment plans were reviewed in four client records. The facility did not document an individual treatment plan developed with the client in records # 1, 3 and 4.
Treatment plans were signed by the client and the counselor on different days, which does not indicate the client ' s participation in the development of the treatment plan.
Client record #1, treatment plan dated 2/26/09, but client signature 2/27/09.
Client record #3, treatment plan dated 4/23/09, but client signature 4/28/09.
Client record #4, treatment plan dated 9/26/08, but client signature 9/28/08.
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Plan of Correction
The COD Director will reorient all staff to the policy that supports having the cient and the primary therapist develop the Comprehensive Treatment Plan together. Both the client and the primary therapist will sign and date the Comperhensive Treatment Plan at the time of completion
The Mecical REcords Director will conduct a quarterly audit to monitor compliance |
709.123(c)(5) LICENSURE Follow-up information
709.123. Treatment and rehabilitation.
(c) Client records. 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) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in two of two client records.
Findings:
Five client records were reviewed on June 3, 2009. Follow-up information was required in two client records. The facility did not document follow-up information within seven days after discharge, as stated in the facility ' s policy and procedures manual, in client records # 4 and 5.
Client record # 4 discharge date 2/2/09, but follow-up information documented 3/20/08.
Client record # 5 discharge date 12/8/08, but follow-up information documented 2/9/09.
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Plan of Correction
The COD Director will reorient staff to the policy that dictates a 7 day follow up post discharge.
A system will be put into place where medical records will provide the primary therapist with a reminder at day 5 post discharge to make follow up contact on day 7
The Medical Records Director will conduct a quarterly audit to monitor compliance. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the facility ' s fire drill log, the facility failed to document a fire drill during sleeping hours at least every six months.
Findings:
The facility ' s fire drill log was reviewed, and an interview with the facility ' s director of facility maintenance was conducted on June 3, 2009. The facility did not document an unannounced fire drill during sleeping hours at least every six months.
The facility ' s last documented unannounced fire drill during sleeping hours was 10/20/08.
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Plan of Correction
The Safety Officer revised the fire drill schedule to include unannounced fire drills during sleeping hours at least every six months and each drill will be documented by same as indicated in policy |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of the facility ' s letters of agreement, the facility failed to document a written letter of agreement with a licensed hospital or physician for 24-hour emergency psychiatric coverage and 24-hour emergency medical coverage.
Findings:
The facility ' s written letters of agreement were reviewed, and an interview with the facility ' s compliance coordinator was conducted on June 3, 2009. The facility did not document written agreements for 24-hour emergency psychiatric and emergency medical coverage.
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Plan of Correction
The Hospital Administrator will facilitate the renewal of hospital transfer agreements and additional hospitals will be added to the available sites. The transfer agreement has been revised to include the phase "medical and psychiatric emergency transfers will be accepted 24 hours/day. |
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, the facility failed to secure client records within locked storage containers.
A physical plant inspection was conducted on June 3, 2009 at approximately 10:00. The facility did not secure client records within a locked storage container.
Client records were stored on a cart in the nursing station.
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Plan of Correction
The Medical Records Director purchased locking client record storage cabinets. Access to the records is restricted to clinical staff and the medical records department staff. |