INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 3-4, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Renewal Treatment, 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 and a plan of correction is due on March 1, 2010.
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Plan of Correction
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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.
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Observations
Based on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill logs were reviewed on February 4, 2010. The facility did not document any alternate exits used during fire drills. The front door was the exit route used during every fire drill.
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Plan of Correction
The Program Director,Clinical Supervisors and Security Supervisor provided facility staff with instruction and training on the requirement for using both means of egress (primary and alternate)ensuring that the alternative route is utilized during the monthly fire drills. This instruction and training has been completed. The Program Director shall ensure that the alternative means of fire drill evacuation shall be used four times (quarterly)a year. The route of evacuation shall be documented in the fire drill log showing which means of egress was used during the monthly evacuation drill. The Facility Director will review this log quarterly and will ensure that the alternative route of evacuation is scheduled for use and utilized at least four times (quarterly) a year. This plan of correction is currently in place. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records and interviews with the facility director and clinical supervisors, the facility failed to document treatment plan updates every thirty days as per regulation in eight of ten client records.
The findings include:
Thirteen inpatient client records were reviewed on February 3-4, 2010. Ten of the clients reviewed were receiving treatment long enough to require a treatment plan update. The facility did not document treatment plan updates every thirty days in client record # 1, 2, 3, 4, 5, 7, 9, and 11.
Client # 1 was admitted on October 28, 2009 and discharged on December 30, 2009. The comprehensive treatment plan was developed on November 6, 2009 and a treatment plan update was due by December 6, 2009. There was no documentation of a treatment plan update.
Client # 2 was admitted on October 15, 2009 and discharged on November 30, 2009. The comprehensive treatment plan was developed on October 23, 2009 and a treatment plan update was due by November 23, 2009. There was no documentation of a treatment plan update.
Client # 3 was admitted on September 28, 2009 and discharged on November 30, 2009. The comprehensive treatment plan was developed on October 7, 2009 and a treatment plan update was due by November 7, 2009. There was no documentation of a treatment plan update.
Client # 4 was admitted on December 17, 2009. The comprehensive treatment plan was developed on December 21, 2009 and a treatment plan update was due by January 21, 2010. The treatment plan update was completed on February 1, 2010.
Client # 5 was admitted on December 7, 2009. The comprehensive treatment plan was developed on December 10, 2009 and a treatment plan update was due by January 10, 2010. There was no documentation of a treatment plan update.
Client # 7 was admitted on October 26, 2009 and discharged on December 9, 2009. The comprehensive treatment plan was developed on October 30, 2009 and a treatment plan update was due by November 30, 2009. There was no documentation of a treatment plan update.
Client # 9 was admitted on October 5, 2009 and discharged on November 16, 2009. The comprehensive treatment plan was developed on October 13, 2009 and a treatment plan update was due by November 13, 2009. There was no documentation of a treatment plan update.
Client #11 was admitted on December 7, 2009. The comprehensive treatment plan was developed on December 16, 2009 and a treatment plan update was due by January 16, 2010. The treatment plan update was completed on January 26, 2010.
During an interview with the facility director and clinical supervisors which took place on February 3 and 4, 2010, it was confirmed that the treatment plan updates are not completed every thirty days.
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Plan of Correction
The Project Director, Program Director and Clinical Supervisors have provided instruction and training for the counseling staff on the proper completion and time frame requirements for documented treatment plan updates every thirty days as per regulations. Additional training will be provided to the counseling staff during annual refresher training. The Clinical Supervisors shall review all client charts and ensure the completion of the treatment plan updates per regulation during documented monthly chart reviews. This plan of correction is currently effective and in place. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 client record review and staff interview, the facility failed to document a seven day follow up as per agency policy in two of six client records.
The findings include:
Thirteen inpatient client records were reviewed on February 3-4, 2010. Six of the clients reviewed were discharged and therefore documentation of a seven month follow up was required in six client records. The facility did not document a seven day follow up in client records # 1 and 3.
Client #1 was admitted on October 28, 2009 and was discharged on December 30, 2009. A seven day follow up was due by January 6, 2010. There was no follow up documentation.
Client #3 was admitted on September 28, 2009 was discharged on November 10, 2009. A seven day follow up was due by November 17, 2009. There was no follow up documentation.
Interviews with the clinical supervisor and counselor took place on February 3, 2010. Both confirmed that there was no follow up contact documented in client records # 1 and 3.
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Plan of Correction
The Project Director, Program Director and Clinical Supervisors provided the staff with instruction and training in regards to the follow-up policy. Training on the follow-up policy will also take place during annual refresher training. The counseling staff shall contact the recieving Outpatient Counselor within seven (7) days of the intial outpatient appointment. This contact will be for the purpose of the ensuring continuity of care. The follow-up will be documented in each client's chart. The Clinical Supervisors shall ensure compliance with the follow-up regulation by reviewing the client charts on a monthly basis and ensuring that the follow ups are being documented within the required time frames. This plan of correction is currently effective and in place. |