INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 22, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, ADAPPT Outpatient Treatment Services 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, conducted February 22, 2017 it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
A group session could be overheard in the hallway outside the group room to the left of the main entrance into the counseling suite.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director met with the Outpatient Counselor and the Clinical Supervisor to discuss the need to ensure privacy/confidentiality in counseling, activity, and other office space areas. Doors must be closed. Staff shall be aware of the importance of confidentiality of counseling sessions. At no time shall counseling sessions be seen or heard.
A "white noise machine" has been ordered and expected date of delivery is 3/8/17. The machine shall be in use at all times during counseling sessions to further aid in ensuring privacy. |
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 on a review of client records, records numbers 2, 4, 6 and 7 had treatment plan updates completed after the regulatory timeframe or missing at the time of the inspection.
Client #2 was admitted 7/16/16 and was an active patient at time of inspection. A treatment plan update was completed 11/6/16 and the next update was due no later than 1/6/17. However, there was no update completed at time of inspection.
Client #4 was admitted on 1/18/16 discharged on 9/21/16. A treatment plan update was completed 6/17/16 and the next update was due no later than 8/17/16. However, there was no update completed at time of inspection.
Client #6 was admitted on 1/18/16 and discharged on 7/18/16. A treatment plan was completed 1/18/16 and the next update was due no later than 3/18/16. However, the plan update was not completed until 6/27/16.
Client #7 was admitted on 5/16/16 and discharged on 11/17/16. A treatment plan update was completed on 6/21/16 and the next update was due no later than 8/21/16. However, the update was not completed until 9/16/16.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Albeit late, all necessary documentation
related to treatment plan updates
has been completed and placed in the "active" chart for client #2.
Notes indicating "missing documentation" related to treatment plan updates for discharged clients, #4, 6, & 7 have been placed in the client file. Documentation missing was related to a counseling staff on FMLA and the unexpected notification that she would not be able to return to her position.
The Clinical Supervisor shall do weekly checks to ensure that this mandatory protocol/procedure is followed. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include progress notes, case consultations, and follow up information, in client records #1, 2, 3, 4, 5, 6 and 7.
Client #1 was admitted on 12/01/16 and was an active client at the time of inspection. The client record did not contain documentation of progress notes matching the record of service as of the date of the inspection.
Client #2 was admitted on 7/6/16 and was an active patient at the time of inspection. The client record did not contain documentation of progress notes matching the record of service as of the date of the inspection.
Client #3 was admitted on 10/26/16 and was an active patient at the time of inspection. The client record did not contain documentation of progress notes matching the record of service as of the date of the inspection.
Client #4 was admitted on 1/18/16 and was discharged on 9/21/16. The client record did not contain any documentation of progress notes matching the record of service or a case consultation as of the date of the inspection.
Client #5 was admitted on 4/14/16 and was discharged on 10/15/16. The client record did not contain documentation of progress notes matching the record of service as of the date of the inspection.
Client #6 was admitted on 1/18/16 and was discharged on 7/18/16. The client record did not contain documentation of progress notes matching the record of service and the client record did not contain documentation of follow-up as of the date of the inspection.
Client #7 was admitted on 5/16/16 and was discharged on 11/17/16. The client record did not contain documentation of progress notes matching the record of service, case consultation, and follow-up as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All necessary documentation (progress notes) have been placed in the active charts for Client 1, 2, and 3.
A note has been placed in the "discharged" charts indicating "missing documents" due to an unexpected counselor resignation/separation. The Facility Director has met with the Clinical Supervisor and Outpatient Counselor to re-enforce the protocol and timeframes to follow regarding client charts.
A timely Record of Service shall remain in the client chart at all times. The Facility Director shall make periodic checks of client files, and the Clinical Supervisor shall review charts on a weekly basis and ensure that at no time should the "Record of Service be removed from the client file. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records, the facility failed to demonstrate sufficient coverage of staff certified in CPR during the project's hours of operation from September 2016 through date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director shall ensure that at least one staff person trained in CPR/First Aid is onsite during the project's hours of operation. The Facility Director shall also maintain a spreadsheet related to current certified staff dates of certification and expiration dates to ensure timely re-certifications. Both the Clinical Supervisor and the Counselor are scheduled to attend CPR/First-Aid training on March 15, 2017. Confirmation of their successful completion of the training courses shall be placed in their training files. |