INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 28, 2019, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Wyoming Valley Alcohol and Drug Services, Inc. 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:
|
Plan of Correction
|
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
|
Observations
The counseling office that exits into the building lobby has one door that leads into the facility and another door that exits into the building lobby area. The door that leads into the counseling office from the facility can be locked from the inside of the office and prevents exiting into the building lobby area from the counseling office.
These findings were reviewed with facility staff a part of the licensing process.
|
Plan of Correction
There is no longer a counselor in that office. The counselor has been moved. That door will no longer be accessible for exit. Instead the office next door has a second exit and entrance. That office is open at all times. It is marked as an exit going forward. This now gives the office two exits and entrances as needed. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
|
Observations
The facility failed to conduct fire drills at different times of the day.
The facility's hours of operation are Monday through Friday from 8:30AM to 5:00PM.
In the 2018 calendar year, there was one fire drills conducted at 12:00PM, and no fire drills conducted after 12:00PM.
These findings were reviewed with facility staff as part of the licensing process.
|
Plan of Correction
Fire drills will now be conducted throughout all times of the day. The staff have been informed of the necessity via staff meetings. This will be monitored by the clinical supervisor through monthly fire drills and documentation checks. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
|
Observations
The last documented annual performance evaluation for Staff Person #2, a counselor, was June 30, 2017.
These findings were reviewed with facility staff as part of the licensing process.
|
Plan of Correction
This will be rectified by the Clinical Supervisor by auditing employee files on a monthly basis to ensure proper information and reviews are present. Evaluations will be done at minimum once per year. The employee files will also be checked by the CEO monthly as well. These are signed by the employee and supervisor. The clinician in question has had an updated review performed as of March 15, 2019. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
|
Observations
The client rights document that the facility has clients sign does not include notification that clients have the right to inspect their records.
These findings were reviewed with facility staff as part of the licensing process.
|
Plan of Correction
This issue has been rectified as client rights and responsibilities have been changed to include the right to inspect their records . Clients are now aware of right to inspect their records upon intake/evaluation. Client signs the form as well. This form is also in counseling offices. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
|
Observations
The client rights document that the facility has clients sign does not include notification that clients have the right to appeal the facility's decision to limit clients' access to their records.
These findings were reviewed with facility staff as part of the licensing process.
|
Plan of Correction
This has been rectified by clinical supervisor. The document now includes notification that clients have the right to appeal the facility's decision to limit access to their records. This is also discussed and signed by client during intake process. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
The facility failed to clearly document the frequency of counseling on the individualized treatment plans in 5 of 7 applicable client records reviewed.
A total of 7 outpatient records were reviewed during the on-site inspection.
Client #1 was admitted for treatment on August 2, 2018. The client's individualized treatment plan was dated September 28, 2018. The treatment plan reads, "The client will attend ongoing individual, outpatient counseling biweekly-monthly..."
Client #3 was admitted for treatment on January 3, 2019. The client's individualized treatment plan was dated January 15, 2019. The treatment plan did not document the frequency of counseling.
Client #4 was admitted for treatment on October 10, 2018. The client's individualized treatment plan was dated October 24, 2018. The treatment plan did not document the frequency of counseling.
Client #5 was admitted for treatment on October 23, 2018. The client's individualized treatment plan was dated November 13, 2018. The treatment plan reads, "The client will attend ongoing individual, outpatient counseling biweekly-monthly..."
Client #6 was admitted for treatment on August 14, 2018. The client's individualized treatment plan was dated August 22, 2018. The treatment plan reads, "The client will attend ongoing individual, outpatient counseling biweekly-monthly..."
These findings were reviewed with facility staff as part of the licensing process.
|
Plan of Correction
Treatment plans have already been changed to reflect the frequency of counseling. This has been done by the Clinical Supervisor. In addition, the frequency will be written and discussed with client more specifically based on client needs. This will be monitored through weekly chart audits and also discussed in staff meetings by clinical supervisor. |
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.
|
Observations
The facility failed to ensure that it updated treatment plans at least once every 60 days in 2 of 5 applicable client records reviewed during the on-site inspection.
A total of 7 outpatient records were reviewed during the on-site inspection.
Client #6 was admitted for outpatient treatment on August 14, 2018, and was discharged on November 28, 2018. The client's individualized treatment plan was dated August 22, 2018, and the treatment plan update was due, October 22, 2018, but the treatment plan was never updated.
Client #7 was admitted for outpatient treatment on July 16, 2018, and was discharged on December 28, 2018. The client's individualized treatment plan was dated October 19, 2018, and the treatment plan update was due, December 19, 2018, but the treatment plan was never updated.
These findings were reviewed with facility staff as part of the licensing process.
|
Plan of Correction
This has been addressed by the Clinical Supervisor moving forward. It is discussed at staff meetings and through email. In addition, this will be checked regularly by clinical supervisor during weekly chart audits. Training will occur at staff meetings as well in regards to treatment plans being updated at least once every 60 days. Paperwork requirements are discussed at each staff meeting. |