INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 4, 2013 to February 5, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northwestern Human Services of Delaware County 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:
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Plan of Correction
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705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on observations on February 5, 2013, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents.
The findings include:
A physical plant inspection was conducted on February 5, 2013. It was observed during the inspection at approximately 11:00 A.M., that the facility had two dumpsters located in the rear of their parking lot. One of the dumpsters had trash filled to top of the dumpster and the top lids were open. Also, the top lids of the other dumpster were open.
The findings were confirmed during an interview with the facility director on February 5, 2013 at approximately 11:02 A.M.
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Plan of Correction
On 2/5/13 at apporximately 5pm, the cleaning department closed the lid on the dumpster that had the top lid open. On 2/6/13, at approximatley 8am, the dumpster that had trash filled to the top was emptied by the waste management company and the lid was also closed at that time on that particular dumpster. Going forward, the facility's maintainence and cleaning department will conduct hourly checks of the outside trash recipticles in order to ensure that the containers are remaining covered. This task will be added to the daily rounds and checklist that the cleaning department submits to the facility director each week. The facility's director of maintenence will be responisble for making sure that all dumpsters on site are emptied weekly, does not have trash filled to the top, and that the lids are closed properly. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the administrative material, the facility failed to make available to the public an annual report that included a financial statement of income and expenses.
The findings include:
The administrative material was reviewed on February 4, 2013 and February 5, 2013. The document presented at the time of review as the annual report for the facility's July 1, 2011 to June 30, 2012 fiscal year did not include a financial statement of income and expenses.
The findings were confirmed during an interview with the facility director on February 5, 2013 at approximately 3:00 P.M.
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Plan of Correction
The corporate director of finance will submit the statement of income and expenses to the corporate communications department to ensure they have the documentation to publish in the annual report. The facility director will monitor that this has been submitted annualy. |
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 in two of two records reviewed.
The findings include:
The facility's policy titled: "Aftercare Planning," states:
"A.The Intake Worker is responsible for developing the Aftercare Plan jointly with the client during the intake process.
B.The Counselor is responsible for completing the Aftercare Plan with the client during discharge with clients who have completed treatment.
C.The Counselor is responsible for informing the client of all policies/procedures regarding Aftercare Planning."
On February 5, 2013, two client records requiring documentation of an aftercare plan were reviewed. The facility did not document an aftercare plan in two of two records reviewed, specifically, client records # 9 and 10.
Client # 9 was admitted June 4, 2012 and was successfully discharged August 1, 2012. The aftercare plan was due during discharge on August 1, 2012; however, client record # 9 did not include documentation of an aftercare plan as of February 5, 2012.
Client # 10 was admitted February 28, 2012 and was successfully discharged August 7, 2012. The aftercare plan was due during discharge on August 7, 2012; however, client record # 10 did not include documentation of an aftercare plan as of February 5, 2012.
The findings were confirmed during an interview with the facility director on February 5, 2013 at approximately 3:00 P.M.
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Plan of Correction
The clinical supervisor will provide training to all clinical staff on the completion of the aftercare plan for clients who have completed treatment. After the training has been completed, the clinical supervisor will track the aftercare plans, which are located in the discharge packet, to enusre they are completed in their entirety for each client who has completed treatment. The program's clinical supervisor will be responsible for ensuring that all aftercare plans for clients are completed on time in accordance with the facility's policy and procedures. |
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 did not document a date of completion for follow-up information in two of five records reviewed.
The findings include:
The facility's policy titled: "Follow-Up," states:
"Client Refuses Treatment and Walks Off of the Treatment Program:
1.Medical records staff mails a 30-day follow-up letter to the client within 30 days.
2.The envelope is not marked with any return address to ensure client confidentiality."
On February 5, 2013, five client records requiring documentation of follow-up information were reviewed. The facility did not document follow-up information in two of five records reviewed, specifically, client records # 8 and 11.
Client # 8 was admitted January 24, 2012 and was discharged September 27, 2012. The follow-up information was due October 27, 2012. The follow-up information was completed but did not include a date of completion as of February 5, 2013.
Client # 11 was admitted January 24, 2012 and was discharged August 1, 2012. The follow-up information was due August 31, 2012. The follow-up information was completed but did not include a date of completion as of February 5, 2013.
The findings were confirmed during an interview with the facility director on February 5, 2013 at approximately 3:00 P.M.
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Plan of Correction
The medical records supervisor will re-train all medical records staff on the proper procedure for preparing follow-up letters and properly date-stamping them within the allowed timeframe based on the state regulation. The facility director will track and monitor this process. |