INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 11 through July 12, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on August 9, 2007.
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Plan of Correction
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705.1 (3) LICENSURE Gen requirements for residential facilities.
705.1. General requirements for residential facilities.
The residential facility shall:
(3) Comply with applicable Federal, State and local laws and ordinances.
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Observations
The facility failed to maintain covers on electrical panel boxes in the basement and/or other restricted access areas of buildings # 2, 4 & 9 as noted on July 12, 2007.
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Plan of Correction
Covers were placed on electrical boxes in the basements of buildings 2, 4 and 9 on July 13, 2007. The Coordinator of Risk Management and Safety will complete monthly evaluations of the facility including the basements of all buildings to ensure that the facility is in compliance with this standard. Compliance on this area will be noted on the "Monthly Surveillance Report" and forwarded to the Director of Operations. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential 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
The facility failed to ensure privacy in two of the counseling offices located in the Detox building due to the lack of window treatments on the interior vision panels and the exterior windows. This was noted on both days of the visit.
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Plan of Correction
Blinds were installed on both the interior vision panels and exterior windows in the afternoon of July 12, 2007. Monthly surveillance by the Coordinator of Risk Management and Safety will report compliance with blinds being in place and utilized to protect client confidentiality. This information will be forwarded to the Director of Operations. |
705.10 (a) (1) (ii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
The facility failed to provide a second exit from the basement of building #2 which was being used for closed client record storage.
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Plan of Correction
All records will be relocated to a locked storage facility or destroyed as a result of our Plan Of Correction for L 0275. This will eliminate the need for a second exit in the basement of building #2. The only activity in this area will relate to building maintenance. |
705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
The facility failed to provide a handrail for the newly installed exterior steps at the rear exit of building #2.
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Plan of Correction
A handrail was installed on the exterior steps at the rear exit of building #2 on July 17, 2007 (picture of railing emailed separately). |
705.10 (b) (1) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(1) Maintain a minimum of one operable, automatic smoke detector on each floor, including the basement and attic.
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Observations
The facility failed to provide a smoke detector in the attic of building #9 and in the basement of building #4.
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Plan of Correction
An outside contractor has been contracted to provide automatic smoke detectors in the attic of building #9 and the basement of building #4 within 30 days. Initial and ongoing testing for functionality will be completed by our current outside contractor who does inspections on all smoke detectors semi-annually. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
The facility failed to instruct six of thirteen staff reviewed in the use of fire extinguishers within seven days of employment, specifically employees represented by employee records # 4, 6, 8, 9, 14 and 18.
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Plan of Correction
Employees #4, 6, 8, 9, 14 and 18 have received fire safety training, including the use of a fire extinguisher. In order to ensure compliance, our Coordinator of Risk Management and Safety will hold weekly fire safety and emergency preparedness trainings for new employees within 7 days of hire. Compliance will be noted on the fire safety and emergency preparedness section of the "New Hire Checklist", and forwarded to Human Resources. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
The facility failed to instruct six of thirteen staff reviewed as to what their assigned duties would be in the event of an emergency, within seven days of employment, specifically employees represented by employee records # 4, 6, 8, 9, 14 and 18.
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Plan of Correction
Employees #4, 6, 8, 9, 14 and 18 have received emergency preparedness training, including their assigned duties in the event of an emergency. In order to ensure compliance, our Coordinator of Risk Management and Safety will hold weekly fire safety and emergency preparedness trainings for new employees within 7 days of hire. Compliance will be noted on the fire safety and emergency preparedness section of the "New Hire Checklist", and forwarded to Human Resources.
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based upon documentation reviewed on July 12, 2007 and staff interview, the facility failed to have all residents and staff participate in the sleeping hour drills that were held every six months. Only those residents and staff located in the building where the fire alarm was activated were participating.
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Plan of Correction
The Coordinator of Risk Management and Safety will ensure that at least 2 times per year, fire drills conducted on third shift will include evacuation of all buildings. This will be reported on the "Fire Drill Report Form". This information will be reviewed by our Operations Director and then forwarded to the White Deer Run/Cove Forge Behavioral Health Risk Management/Safety Department. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
The facility failed to properly secure client records of discharged clients based on the following:
The facility was storing closed records on shelves in the basement of building #2, and in the enclosed porch of building #4. Although the doors to these areas were locked, maintenance personnel have keys to these areas and they as well as outside contractors have a need to access these areas on occasion.
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Plan of Correction
Within 30 days, all client records currently stored in building #2 and building #4 will be destroyed or moved to a locked storage facility, eliminating unauthorized access to those inactive files. The inactive charts from adult patient which have been discharged more than 7 years ago and the inactive charts from the adolescent patients that have reached the age of 25 will be destroyed. Inactive patient charts that do not meet the above mentioned criteria will be relocated to a locked facility. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
The facility failed to obtain informed and voluntary consents from clients based on the following:
1. The "Insurance Assignment" forms provided for a release of information, however they failed to include a "right to revoke".
2. Information contained on the facility's PCP's exceeded that which is permissible under 4 Pa. Code 255.5.
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Plan of Correction
The Forms Committee Chairperson and the Acting Executive Director approved the revisions to the "Insurance Assignment Release" form on August 6, 2007. The revised form was emailed to the Regional Directors and Regional Administrators on August 6, and they and/or their supervisory designee will instruct staff on its use, with the form to be implemented no later than Thursday, August 9, 2007. Beginning on September 10, 2007 compliance will be monitored monthly by random chart audits conducted by the supervisors and/or their clinical staff designee, for a minimum of three months. |
709.62(c)(3)(iii) LICENSURE Personal history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
The facility failed to include military history and sexual history in the nursing assessment histories for all client records reviewed.
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Plan of Correction
The addition of the military and sexual history to the Nursing Assessment will be discussed at the Forms Committee meeting on August 8, 2007 and will be developed by the Nursing Leadership Committee on August 29, 2007. The Forms Committee Chairperson will present the revised form to Senior Quality Leadership Committee on September 11, 2007 for review and approval. Approved form will be distributed by September 17, 2007. Trainings by Director of Nursing or designee will be provided to clinical staff with full implementation by October 1, 2007. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
The facility failed to provide an evaluative assessment in their nursing assessment summaries due to the following:
The nursing assessment summaries in four of five records reviewed, #1, 2, 3, 4 and 5, provided a repeat of the historical data rather than an evaluation.
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Plan of Correction
Additional trainings will be conducted before August 31, 2007 by Nursing Management with all nursing staff regarding writing an evaluative summary instead of repeating historical data. Thereafter, monthly audits will be completed by Nursing Management for a minimum of 3 months with submission of findings to The Quality Improvement Department. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The facility failed to provide psychosocial evaluations that were evaluative and individualized, and failed to identify the client's attitude toward treatment based on the following:
1. Most areas of client records #2, 5, 6 and 8 were identical rather than individualized.
2. Information was more historical than evaluative or it was from the client's point of view rather than from the counselor's evaluation.
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Plan of Correction
The Unit Supervisors will train the professional clinical staff to provide psychosocial evaluations that are evaluative and individualized and identify the client's attitude toward treatment. This will be evidenced by weekly evaluation of 2 charts per staff by the Unit Supervisor The Clinical Director will meet monthly with the Unit Supervisors individually to review compliance and progress. This process was implemented on July 23, 2007. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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
The facility failed to provide individualized treatment plans in four of nine records reviewed, #2, 5, 6, and 8 contained identical short and long term goals and action steps.
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Plan of Correction
The unit supervisors will train the professional clinical staff to provide treatment and rehabilitation plans that are individualized. This will be evidenced by weekly evaluation of 2 charts per staff by the Unit Supervisor. The Clinical Director will meet monthly with the Unit Supervisors individually to review compliance and progress. This process was implemented on July 23, 2007 |
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
The facility failed to document treatment plan updates in three of six records reviewed, client records # 4, 5 and 6.
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Plan of Correction
The Unit Supervisors will train the professional clinical staff to provide treatment plan updates at least every 15 days. This will be evidenced by weekly evaluation of 2 charts per staff by the Unit Supervisor. The Clinical Director will meet monthly with the Unit Supervisors individually to review compliance and progress. This process was implemented on July 23, 2007. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
The facility failed to provide individual assessments of client's in the group progress notes in the majority of clinical records reviewed.
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Plan of Correction
Beginning immediately, notes, which refer to structured activities, as opposed to group counseling will be referred to as such. The Unit Supervisors will provide training on group counseling progress notes that are evaluative. This will be evidenced by weekly evaluations of 2 charts per staff by the Unit Supervisor. The Clinical Director will meet monthly with the Unit Supervisors individually to review compliance and progress. This process was implemented on July 23, 2007. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
The facility failed to complete discharge summaries within seven days of discharge in three of seven client records reviewed, #2, 5 and 6.
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Plan of Correction
The Unit Supervisors will train the professional clinical staff to ensure that discharge summaries are completed within 7 days as per our policy and procedure #709.53. Adherence to this policy will be monitored by the Director of Medical Records and reported to the Clinical Director and Unit Supervisors on an ongoing monthly basis. |
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
The facility failed to complete a follow up in two of six client records reviewed, #4 and 5, and was late in conducting a follow up in client record #6.
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Plan of Correction
The Clinical Director will train the designated staff to ensure that follow up information is completed within 1-4 weeks per our policy and procedure #709.53. Adherence to this policy will be monitored by the Continuing Care Coordinator and Director of Medical Records and reported to the Clinical Director on a monthly basis. |