INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the supervisory review of the November 8 and 9, 2012 licensure renewal inspection. The follow-up inspection was conducted on June 24-25, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Pennsylvania Care LLC d/b/a Miners Medical 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 personnel and training records, the facility failed to provide documentation of TB/STD and HIV/AIDS training in one of one record reviewed.
The findings include:
Two personnel records were reviewed on June 25, 2013. One record was required to document four hours of TB/STD training and six hours of HIV/AIDS training within the first year of employment.
Employee #2 was hired on May 28, 2010. This employee was required to obtain four hours of TB/STD training and six hours of HIV/AIDS training with Department approved curriculum by May 28, 2011. The Employee failed to obtain the 4 hours of TB/STD training as of the date of the inspection.
The findings were reviewed with the project director and quality improvement staff member. The findings were confirmed.
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Plan of Correction
The facility failed to comply with regulation 704.11 ( C )(1) requiring clinical staff person #2 to receive 4 hours of TB/STD training within their first year of employment. It will be the responsibility of the Facility Director and/or Senior Counselor to ensure that all staff receives the required training in TB/STD. Staff person #2 will receive TB/STD training by 9.10.2013. A copy of the training certificate will be placed in staff person #2 personnel record. Miner's Medical will implement a facility Training Tracking form to be reviewed monthly by Facility Director and/or Senior Counselor. |
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 a comprehensive psychosocial evaluations in four of six patient records.
The findings include:
Fifteen patient records were reviewed on June 24-25, 2013. Six patient records were reviewed for documentation of a comprehensive psychosocial evaluation. The facility failed to document a comprehensive psychosocial evaluation in records # 1, 8, 9 and 13.
Patient # 1 was admitted 5/2/2013. The documented psychosocial evaluation failed to include a clinical assessment of the patient's coping mechanisms.
Patient # 8 was admitted 3/18/2013. The documented psychosocial evaluation failed to include a clinical assessment of the patient's coping mechanisms.
Patient # 9 was admitted 5/8/2013. The documented psychosocial evaluation failed to include a clinical assessment of the patient's coping mechanisms.
Patient # 13 was admitted 3/6/2013. The documented psychosocial evaluation failed to include a clinical assessment of the patient's coping mechanisms.
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Plan of Correction
The facility failed to comply with Observation #1871 regarding documentation in resident #1, 8, 9, and 13's psychosocial evaluation to include a clinical assessment of the patients' coping mechanisms. On 8.1.2013, the Facility Director and Senior Counselor will provide a staff training session in the area of clinical assessment to include assessing each client's coping mechanisms, and how to document a client's coping mechanism or lack of coping mechanisms on a comprehensive psychosocial evaluation. Ongoing monitoring and supervision will be provided by the Facility Director and Senior Counselor. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of patient records, the facility failed to document a complete discharge summary that included the patient's reason for treatment, services offered and client's status upon discharge in five of six patient records.
The findings include:
Fifteen patient records were reviewed on June 24-25, 2013. Six records were reviewed for discharge summaries. Four of the six records failed to document the client's reason for entering treatment, specifically records # 3, 4, 5 and 6. Four of the six records also failed to document the client's status upon discharge, specifically records # 3, 4, 6 and 7.
Patient # 3 was admitted on 8/11/2011 and discharged on 1/29/2013. The discharge summary failed to document the patient's reasons for treatment and the patient's status upon discharge.
Patient # 4 was admitted on 3/1/2012 and discharged on 3/25/2013. The discharge summary failed to document the patient's reasons for treatment and the patient's status upon discharge.
Patient # 5 was admitted on 5/17/2012 and discharged on 2/5/2013. The discharge summary failed to document the patient's status upon discharge.
Patient # 6 was admitted on 12/27/2011 and discharged on 1/29/2013. The discharge summary failed to document the patient's reasons for treatment and the patient's status upon discharge.
Patient # 7 was admitted on 5/31/2012 and discharged on 1/1/2013. The discharge summary failed to document the patient's reasons for treatment.
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Plan of Correction
The facility failed to comply with Observation #1909 regarding the discharge summary providing the following information: the patient's reasons for treatment and the patient's status upon discharge.
On 8.1.2013, the Facility Director and Senior Counselor will provide a staff training session in the area of writing a comprehensive discharge summary that includes, but is not limited to, all Department and Facility required information. Training will also include proper documentation of Discharge Summaries to include: Patient's Reason for Treatment, Services Offered, and Patient's Status upon discharge. Ongoing monitoring and supervision will be provided by the Facility Director and Senior Counselor.
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