INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the November 2, 2011 to November 3, 2011 licensure renewal inspection. The follow-up inspection was conducted on June 12, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, New Directions 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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709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on the review of the facility plan of correction, the facility failed to document annual goals and objectives which included time frames and available resources.The findings included:The Strategic plan (project goals and objectives) was requested for review for the July 1, 2012 through to June 30, 2013 fiscal year. This plan was in draft form at the time of the review and had not been reviewed by the governing body in May 2012 as per the plan of correction.This is a repeat citation from the November 2, 2011 to November 3, 2011 licensing inspection.The findings were reviewed with the Project Director and were not disputed.
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Plan of Correction
The strategic plan was reviewed at the June meeting of the governing body. Revisions are currently pending and final approval is expected at the July meeting. In the future, the Project Director will submit the strategic plan for the upcoming fiscal year to the governing body at a point early enough in the prior fiscal year to allow for adequate review prior to the fiscal year to which it applies. |
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 a review of the patient records, the facility failed to provide a psychosocial evaluation in one of three patient records.The findings include: Three patient records were reviewed for a psychosocial evaluation. A psychosocial evaluation was not completed in one of four patient records, # 3.Patient record # 3- The patient was admitted on 4/23/2012. A psychosocial evaluation was due within 30 days. The evaluation was not documented in the record as of the date of the review. Also, the drug and alcohol history and personal history documentation was not in the record as of the date of the review.The findings were reviewed with the Facility Director at the time of review and confirmed
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Plan of Correction
Effective immediately the Clinical Supervisor will track and sign off on the satisfactory completion of all psychosocial histories and evaluations for incoming patients prior to the 30 day deadline. In cases where the dedline is not met, the Program Director will be alerted. The Clinical Supervisor will work with the clinician involved to identify factors contributing to the failure to satisfactorily conply with this requirement and strategize appropriate remedial action depending on circumstance. |