INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 5, 2009 through October 6, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Directions Treatment Services 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 November 7, 2009.
|
Plan of Correction
|
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.
|
Observations
Based on the review of the physical plant tour, the facility failed to ensure that no portable heaters were in the facility.Findings:During the tour of the facility on October 6, 2009 a portable heater was found in the clinical supervisor's office.
|
Plan of Correction
A memo will be emailed to all staff today by the Program Director with read receipt requested advising them that space heaters may not be used in offices unless they are mounted. An offer will be made to mount heaters in offices where there is a persistent heating problem. |
709.93(a)(8) 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:
(8) Case consultation notes.
|
Observations
Based on a review of client records, the facility failed to document complete case consultations notes in three of four client records.Findings:Twelve client records were reviewed on October 6, 2009. Case consultations were required in four client records. In accordance with the facility's policy and procedure, case consultation notes are to be documented every 90 days after admission. Client record #2 was admitted on 5/21/09 and as of the date of review there was no case consultation documented in the record. Client record #3 was admitted on 4/6/09 and as of the date of review there was no case consultation documented in the record. Client record #10 was admitted on 12/2/08 and as of the date of review there was no case consultation documented in the record.
|
Plan of Correction
Case consultations in all three of the files referenced in this citation were located subsequent to the inspector's departure. To further facilitate the retrieval of these documents in future inspections, the program is currently reindexing all current patient files and establishing an enhanced indexing system for future files. This will include labeled tabs in the chart that more specifically delineate document types within the file. Case consults that previously had been grouped with other document types will be in a separate section. This plan will be executed by the counseling staff for their existing caseloads' charts and additional empty charts are being prepared by an administrative assistant for future use. The satisfactory completion of these assisgnments will be verified by the Program Director. |
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.
|
Observations
Based on a review of client records, the facility failed to document follow-up information in three of six client records.Findings:Twelve client records were reviewed on October 6, 2009. Follow-up information was required in six client records. In accordance with the facility's policy, follow-ups are to be done 90 days following discharge. Client record #8 was admitted on 8/5/03 and discharged on 6/16/09; there was documentation of follow-up information available. Client record #9 was admitted on 3/31/08 and discharged on 6/16/09; there was no documentation of follow-up provided during the review. Client record #12 was admitted on 6/27/05 and discharged on 5/5/09; there was no documentation of follow-up provided during the review.
|
Plan of Correction
The Program Director and Clinical Supervisor are currently reviewing the follow up procedure. An administrative Assistant has been assigned the task of generating a list and sending out the follow up letters. The plan that is being formulated includes a monthly review that letters have been sent and a review of discharged charts to insure that follow up documentation is included by the due date. Additionally, we are identifying all patients discharged in the last 6 months and determining whether or not follow ups were done. In those cases where they were not we will be sending out belated follow up forms. The Program Director will generate a list of patients discharged in the last 6 months. An administrative assistant will send out the letters and Program Director will verify that this was done. |