INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 2, 2013 to January 3, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Serento Gardens 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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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill records, the facility failed to prepare alternate exit routes to be used during fire drills.The findings include:Fire drill records were reviewed on January 2, 2013 and January 3, 2013. The records were reviewed from the period covering February 2012 to December 2012. In all the months reviewed, the facility documented the same exit route, south emergency stairs. The findings were confirmed during an interview with the facility director on January 3, 2013 at approximately 2:00 P.M.
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Plan of Correction
A letter of exception will be sent by the Program Director to the Acting Director of the Division of Program Licensure in the Department of Drug and Alcohol Programs as we are not able to utilize the second exit of the building. This exit is reserved for the residents of a minimum security prison located on the upper floors of the building. In the event the exception is not granted, the facility director will talk to the building owner to ensure that we have access to the second exit of the building, the north emergency stairs, as well. The facility director will be responsible for documentation of the alternative exit routes on the fire drill records. |
709.82(a)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short- and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document the long-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan. The findings include:From January 2, 2013 to January 3, 2013, five client records requiring documentation of long-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan were reviewed. The facility did not document the long-term goals for treatment in two of five records reviewed, specifically, client records # 1 and 3.Client # 1 was admitted October 16, 2012. The individual treatment and rehabilitation plan was completed on November 7, 2012, but it did not include documentation of the long-term goals for treatment as of January 3, 2013.Client # 3 was admitted October 18, 2012. The individual treatment and rehabilitation plan was completed on November 8, 2012, but it did not include documentation of the long-term goals for treatment as of January 3, 2013.The findings were confirmed during an interview with the facility director on January 3, 2013 at approximately 2:00 P.M.
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Plan of Correction
The staff was reminded on Monday, January 7, 2013, during their weekly Treatment Team Meeting, that they need to include a minimum of two (2) long term goals on all of the Treatment Plans. The Clinical Director will follow up with the counselors during their weekly Treatment Team Meetings and through sporadice chart reviews to insure compliance. |
709.82(e)(3) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(3) Legal.
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Observations
Based on a review of letters of agreement and an interview with the facility director, the project failed to assists clients in obtaining legal supportive services when necessary. The findings include:On January 2, 2013 and January 3, 2012, the Licensing Specialist asked to see documentation that the facility assists clients in obtaining legal supportive services when necessary. Documentation that the facility assists clients in obtaining legal supportive services when necessary was not presented for review. The findings were confirmed during an interview with the facility director on January 3, 2013 at approximately 2:00 P.M.
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Plan of Correction
An Affiliate Agreement was mailed to a legal service agency on Friday, January 11, 2013. The Office Manager will follow up with the legal service agency to insure that they received the Agreement. Once returned to the agency, the Affiliate Agreement will be placed on file. The Office Manager will be responsible for making sure that the letter of agreement remains in place at the facility and is current. The Clinical Director, during the Treatment Team Meeting on January 14, 2013, will discuss the potential benefits of a legal service to our clients. The Clinical Director will follow up with the counselors on a monthly basis to determine if they are utilizing this legal service agency. |
709.82(e)(4) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(4) Economic.
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Observations
Based on a review of letters of agreement and an interview with the facility director, the project failed to assists clients in obtaining economic supportive services when necessary. The findings include:On January 2, 2013 and January 3, 2012, the Licensing Specialist asked to see documentation that the facility assists clients in obtaining economic supportive services when necessary. Documentation that the facility assists clients in obtaining economic supportive services when necessary was not presented for review. The findings were confirmed during an interview with the facility director on January 3, 2013 at approximately 2:00 P.M.
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Plan of Correction
An Affiliate Agreement was mailed to a local county assistance office on Friday, January 11, 2013. The Office Manager will follow up with the local county assistance office to insure that they received the Agreement. Once returned to the agency, the Affiliate Agreement will be placed on file. The Office Manager will be responsible for making sure that the letter of agreement remains in place at the facility and is current. The Clinical Director, during the Treatment Team Meeting on January 14, 2013, will discuss the potential benefits of a local county assistance office to our clients. The Clinical Director will follow up with the counselors on a monthly basis to determine if they are utilizing this local county assistance office |
709.84(e) LICENSURE Project management services
709.84. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to develop a written client follow-up policy that includes the time frame for completing follow-up when clients have been discharged and not referred to an outside resource.The findings include:On January 2, 2013 and January 3, 2013, the facility's policy and procedures manual was reviewed. The facility's policy titled: "Standards for Partial Hospitalization Activities," states:"When the client has been discharged and referred to an outside resource, the agency will, with written consent of the client and within 7 days from the day the referral is made, determine from the resource the disposition of the referral. When clients have not been referred, a follow up contact shall be initiated on all clients who have been discharged to determine how they are doing, and to offer and appropriate agency services."The facility's follow-up policy did not include the time frame for completing follow-up when clients have been discharged and not referred to an outside resource. The findings were confirmed during an interview with the facility director on January 3, 2013 at approximately 2:00 P.M.
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Plan of Correction
The policy manual has be revised by the Program Director to state that a follow up contact shall be initiated within 30 days of discharge on all clients who have been discharged to determine how they are doing, and to offer any appropriate agency services. The Policy revision will be presented to the Board of Directors for approval during the upcoming Board meeting held the last Monday of each month. The Program Director will make certain the policy remains in place. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on a review of personnel records, the facility failed to provide documentation for the results of reference investigations. The findings include:On January 2, 2013 to January 3, 2013, three personnel records requiring documentation of a FBI fingerprint background check in accordance with the Child Protective Services Law Act 73 were reviewed. The facility did not provide documentation of a FBI fingerprint background check in one of three records reviewed, specifically, personnel record # 5.Employee # 5 is a counselor and was hired for his current position on November 14, 2012. Employee # 5 was due to have a FBI fingerprint background check upon employment at the facility. However, personnel record # 5 did not include documentation of a FBI fingerprint background check as of January 3, 2013. The findings were confirmed during an interview with the facility director on January 3, 2013 at approximately 2:00 P.M.
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Plan of Correction
Employee #5 counselor was told to complete his FBI fingerprint background check by January 31, 2013. The Clinical Director will monitor his progress and insure that he was compliant with this request by January 31, 2013. All future employees will be required to submit FBI fingerprint backgrounds; the Vice President will be ensure that the FBI fingerprint background is submitted on all future employees prior to the first date of hire. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document the long-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan. The findings include:From January 2, 2013 to January 3, 2013, ten client records requiring documentation of long-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan were reviewed. The facility did not document the long-term goals for treatment in three of ten records reviewed, specifically, client records # 4, 9, and 10.Client # 4 was admitted October 1, 2012. The individual treatment and rehabilitation plan was completed on October 23, 2012, but it did not include documentation of the long-term goals for treatment as of January 3, 2013.Client # 9 was admitted September 17, 2012. The individual treatment and rehabilitation plan was completed on October 1, 2012, but it did not include documentation of the long-term goals for treatment as of January 3, 2013.Client # 10 was admitted September 6, 2012. The individual treatment and rehabilitation plan was completed on October 18, 2012, but it did not include documentation of the long-term goals for treatment as of January 3, 2013.The findings were confirmed during an interview with the facility director on January 3, 2013 at approximately 2:00 P.M.
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Plan of Correction
The staff was reminded on Monday, January 7, 2013, during their weekly Treatment Team Meeting, that they need to include a minimum of two (2) long term goals on all of the Treatment Plans. The Clinical Director will follow up with the counselors during their weekly Treatment Team Meetings and through sporadic chart reviews to insure compliance. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan that included a contact person and criteria for re-entry into the project.The findings include:The facility's policy titled: "THE TREATMENT PHILOSPHY OF SERENTO GARDENS IS PRIMARILY BEHAVIROAL, IN THAT TREATMENT IS DIRECTED TOWARDS SPECIFIC PROBLEM AREAS AND SEEKS PROGRESS IN TERMS OF BEHAVIORAL CHANGE. THE GOAL OF THERAPY IS FOR THE CLIENT TO UNLEARN MALDAPTIVE BEHAVIRAL CHANGE. THE GOAL OF THERAPY IS FOR THE CLIENT TO UNLEARN MALADAPTIVE BEHAVIORS, AND TO LEARN ALTERNATE ADAPTIVE BEHAVIORS OR SKILLS LEARNED IN THERAPY MUST GENERALIZE NON TREATMENT SITUATIONS."From January 2, 2013 to January 3, 2013, two client records requiring documentation of an aftercare plan were reviewed. The facility did not document an aftercare plan that included a contact person and criteria for re-entry into the project in two of two records reviewed, specifically, client records # 11 and 13.Client # 11 was admitted May 29, 2012 and discharged July 24, 2012. The aftercare plan was completed July 24, 2012. However, the aftercare plan did not include a contact person and criteria for re-entry into the project.Client # 13 was admitted May 23, 2012 and discharged October 23, 2012. The aftercare plan was completed October 23, 2012. However, the aftercare plan did not include a contact person and criteria for re-entry into the project.The findings were confirmed during an interview with the facility director on January 3, 2013 at approximately 2:00 P.M.
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Plan of Correction
A new Aftercare Plan form was revised to include an area where the counselor can include the name of a contact person and telephone number. In addition, the revised Aftercare Plan form describes the criteria for re-entry into the project. The revised Aftercare Plan form was presented to the counselors during the January 7, 2013 Treatment Team Meeting. The Clinical Director will follow up with the counselors during the weekly Treatment Team Meetings and through sporadic chart reviews to insure compliance. |
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.
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Observations
Based on a review of client records, the facility failed to document follow-up information or document follow-up information according to their standard practice for completing follow-up information.The findings include:The facility's policy titled: "Standards for Outpatient Activities," states:"It is the policy of Serento Gardens to attempt to follow up contact on all clients. Follow up is done by the primary counselor through the clerical department. All clients will be mailed a follow up survey to return mail to the agency.Additionally, random, client satisfaction surveys are mailed in order to obtain additional feedback on agency services.Follow up contacts to outside referral sources will occur within seven days of the referral to determine whether or not the patient has arrived."The facility's follow-up policy does not include the time frame for completing follow-up when clients have been discharged and not referred to an outside resource. However, during an interview with the facility director on January 3, 2013, the facility director stated the facility's standard practice is to complete follow-up within thirty days from the date of discharged.From January 2, 2013 to January 3, 2013, three client records requiring documentation of follow-up information were reviewed. The facility did not document follow-up information according to their standard practice in one of three records reviewed, specifically, client record # 11. The facility also did not document follow-up information in one of three records reviewed, specifically, client record # 12.Client # 11 was admitted May 29, 2012 and was discharged July 24, 2012. The follow-up information was due August 23, 2012. However, the follow-up information was not completed until September 12, 2012.Client # 12 was admitted December 22, 2011 and was discharged October 3, 2012. The follow-up information was due November 2, 2012. However, client record # 12 did not include documentation of follow-up information as of January 3, 2013. The findings were confirmed during an interview with the facility director on January 3, 2013 at approximately 2:00 P.M.This is a repeat citation. The facility was cited on January 12, 2012 for noncompliance with this standard.
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Plan of Correction
The counselors were addressed during the Treatment Team Meeting on January 7, 2013 regarding timely documentation of follow-up information. The Clinical Director will insure that the counselors maintain this documentation in a timely fashion through sporadic chart reviews. The follow-up information was completed on client #12 on January 11, 2013. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to develop a written client follow-up policy that includes the time frame for completing follow-up when clients have been discharged and not referred to an outside resource.The findings include:On January 2, 2013 and January 3, 2012, the facility's policy and procedures manual was reviewed. The facility's policy titled: "Standards for Outpatient Activities," states:"It is the policy of Serento Gardens to attempt to follow up contact on all clients. Follow up is done by the primary counselor through the clerical department. All clients will be mailed a follow up survey to return mail to the agency.Additionally, random, client satisfaction surveys are mailed in order to obtain additional feedback on agency services.Follow up contacts to outside referral sources will occur within seven days of the referral to determine whether or not the patient has arrived."The facility's follow-up policy does not include the time frame for completing follow-up when clients have been discharged and not referred to an outside resource. Te findings were confirmed during an interview with the facility director on January 3, 2013 at approximately 2:00 P.M.
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Plan of Correction
The policy manual has be revised by the Program Director to state that a follow up contact shall be initiated with 30 days of discharge on all clients who have been discharged and not referred to an outside resource. The Policy revision will be presented to the Board of Directors for approval during the upcoming Board meeting held the last Monday of each month. The Program Director will make certain the policy remains in place. |