INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 9 - 11, 2008 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 and a plan of correction is due on February 12, 2008.
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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 upon a review of personnel records on January 10, 2008, the facility failed to ensure that all staff completed the mandatory 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. Two of eight staff, #3 & 6, had not completed required tuberculosis/sexually transmitted disease training, and employee #6 had not completed the HIV/AIDS training within the required timeframe.
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Plan of Correction
The staff in need of 6 hours of HIV/AIDS training will be scheduled to attend the May 14, 2008 training provided by the PCB. We are in the process of locating a training on tuberculosis, sexually transmitted diseases and other health related topics. Once we are able to locate this training all staff in need will be scheduled to participate. The Clinical Director/Vice President is responsible for this action. Quarterly training reviews, the first of which is scheduled for March 31, 2008, will internall monitor for compliance. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based upon review of personnel records on January 10, 2008, the facility failed to ensure that staff were instructed in the use of the fire extinguisher upon employment. Two of eight employees records reviewed, #7 & 8, lacked documentation to show that the employees had received the training within seven days of employment.
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Plan of Correction
All personnel receive the Employee Manual which includes a section on fire safety and proper use of fire extinguishers. In the prior two reviews this approach, included as part of employee orientation, was accepted. We will, however modify the orientation check list to include items specifically covered in the Employee Manual. The employee's signature of receipt of that manual will serve as their attest that the referenced orientation materials have been received and reviewed. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based upon review of personnel records on January 10, 2008, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies. Two of eight employees records reviewed, #7 & 8, lacked documentation to show that the employees had received the training within seven days of employment.
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Plan of Correction
The corrective plan is the same as stated in the prior citation on fire safety. Repeated here for clarity,
all personnel receive the Employee Manual which includes a section on fire safety and proper use of fire extinguishers. In the prior two reviews this approach, included as part of employee orientation, was accepted. We will, however modify the orientation check list to include items specifically covered in the Employee Manual. The employee's signature of receipt of that manual will serve as their attest that the referenced orientation materials have been received and reviewed.
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based upon client records reviewed on January 11, 2008, the facility failed to provide a complete client employment history in two of six records reviewed. Client record #4 only listed 2 jobs and only went back to May of 2006 (the client was over 33 years of age). Client record #8 had a check mark indicating that the client was employed part-time, however; no other information indicating where the client was employed, how long they were employed, or any historical data regarding any past employment was documented.
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Plan of Correction
The charts were corrected and counselors provided the missing information. Charts are reviewed on a weekly basis to ensure proper and complete documentation. Evaluations completed the previous week are reviewed the following Tuesday. |
709.92(a) 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:
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Observations
Based upon client records reviewed on January 11, 2008, the facility failed to provide an individualized treatment plan in three of six records reviewed. Client record #3 had a treatment plan that was completed late and was completed on a template form devised for the Partial Hospitalization program. Client record #6 indicated that the client was to be in the Intensive Outpatient program, however the form used to develop the treatment plan was one that was devised for the regular outpatient program. Additionally, the client was receiving 10 hours of treatment which is the Partial Hospitalization program. Client record #7 had an individualized treatment plan that was developed without there being a completed psychosocial evaluation.
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Plan of Correction
All records have been corrected. The template form has been revised and now indicates the proper level of treatment: Intensive Outpatient Treatment or Particial Hospitalization. Charts and treatment plans are monitored on a weekly basis to ensure compliance with the standards. All treatment plans are reviwed by the Clinical Director to ensure that the plan is designed with the cliient's specific needs and recommendations. The IOP has been redesigned to provide three group contacts per week for a total of 8.5 hours. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based upon client records reviewed on January 11, 2008, the facility failed to review and update client treatment plans at least every 60 days in three of six records reviewed. Client records #3 & 6, as per the clinician's documentation in treatment plan updates, indicated that the client was not making progress with the stated goals, however; there were no revisions to existing goals or new goals introduced, nor were any additional tasks added for the client and/or the clinician in order to improve the clients progress in treatment. Client record #8 contained reports on progress that were not specific to the client. The client was female yet the notes contained in the report of progress referred to a male client.
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Plan of Correction
All charts have been corrected. All charts of clients who were seen during the week are reviewed for compliance the following Monday and Tuesday. All treatment plans are carefully reviewed by the Clinical Direstor prior to her signature to ensure that the plans are updated in a timely fashion and that they indicate progress or lack of with the proper revisions, if necessary. Weekly reviews of all clinical ctivity done during the prior week assure compliance. Monitoring from that date to this have indicated no new problems. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based upon client records reviewed on January 11, 2008, it was not possible to determine if the facility was providing counseling services according to the individual treatment and rehabilitation plan. A review of six client records revealed that in one of six client records, specifically #6,the client was appropriate for the partial hospitalization program based on the "narrative" in the psychosocial evaluation. However, in the "conclusion" of the psychosocial evaluation it was indicated that the client was recommended for intensive outpatient treatment. The treatment plan devised for the client was developed on a template based on outpatient treatment, yet the client originally attended 10 hours of treatment per week. This level of care is indicative of partial hospitalization treatment.
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Plan of Correction
This record has been reviewed and the counselor responsible was addressed in supervision. Weekly monitoring of all client files have indicated compliance. The original templates for IOP and PHP have been revised. The IOP has been revised regarding contact hours. Effective February 4, 2008, the IOP has three group contacts per week for a total of 8.5 hours. All charts for client's seen during the week are reviewed the following Monday and Tuesday to ensure compliance to standards. The Clinical Director is charged with monitoring this plan of correction. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based upon a review of client records on January 11, 2008, two of six records reviewed, were missing progress notes. Client record #4 was missing one group progress note and one individual progress note. Client record #5 was missing four individual progress notes.
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Plan of Correction
All charts have been corrected. All progress notes for clients seen during the week must be completed by the end of that same week. Charts are reviewed on Friday for clients seen Monday-Thursday. Charts for clients seen on Friday are reviewed on Monday of the following week. All charts for evaluations completed the prior week are reviewed for compliance on Tuesday of the following week. The Clinical Director is responsible for monitoring compliance with plan of correction |