INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted February 1, 2023, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Catholic Charities Diocese of Harrisburg was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on the review of the facility's fire drill log for the months of January 2022 through December 2022, the facility failed to conduct an unannounced fire drill at least once a month.
Documentation showed that a fire drill was not conducted in the month of November 2022.
This finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
The program director will create a yearly list, assigning staff who are responsible each month to complete the fire drill. The schedule will take into account different days and times, including overnight hours. Staff will be provided the list, so they know in advance when they are assigned to complete the fire drill. At the first staff meeting of the month, staff will be reminded that they need to complete and document the fire drill for that month. The program director will check to see if the fire drill was completed before the second staff meeting of the month. If it was not completed, then another reminder will be done at the second staff meeting. The program director will follow up within 7 days to ensure the fire drill was completed before the end of the month. A re-training of the fire drill procedures will be conducted no later than March 15, 2023. As of this writing, we are in compliance with monthly fire drills. |
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 four client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated every 30 days in three out of four applicable records reviewed.
Client #1 was admitted on November 10, 2022 and was active at the time of the complaint investigation. The treatment and rehabilitation plan was completed on December 1, 2022, and a treatment plan update was due to be completed by January 1, 2023 and February 1, 2023; however, the treatment plan updates were not completed.
Client #2 was admitted on October 5, 2022 and was active at the time of the complaint investigation. The treatment plan and rehabilitation plan was completed on October 26, 2022 and treatment plan updates were completed on November 23, 2022 and December 23, 2022; however, the next treatment plan update was due by January 23, 2022 and was not completed.
Client #4 was admitted on October 19, 2022 and was active at the time of the complaint investigation. The treatment and rehabilitation plan was completed on November 9, 2022, and a treatment plan update was due to be completed by December 9, 2022 and January 9, 2023; however, the treatment plan updates were not completed.
These findings were discussed with facility staff during the complaint investigation.
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Plan of Correction
Beginning immediately, counselors will review all charts to determine level of non-compliance regarding updated treatment plans. For charts lacking past updated treatment plans, those plan will be filed in the chart. This will be completed by March 31, 2023. Moving forward, treatment plans will be updated within 24 hours of the 30 day mark by counselors. The program director will check charts randomly each month to ensure charts are compliant. There will be two Resident Attendants (RA) who will review charts each shift they work and notify the counselor when a treatment plan updated is needed. Counselors will be re-trained on the policy related to treatment plan updates. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Client #1 was admitted on November 10, 2022 and was active at the time of the complaint investigation. The treatment and rehabilitation plan completed on December 1, 2022 indicated the client was to receive weekly individual and group counseling. The progress notes indicated that the client did not receive individual counseling during the weeks of 12/28/22, 1/24/23, and 1/31/23. Also, the client did not receive group counseling during the weeks of 11/24/22, 12/1/22, 12/8/22, 12/29/22, 1/5/23, and 1/12/23.
Client #2 was admitted on October 5, 2022 and was active at the time of the complaint investigation. The treatment plan and rehabilitation plan completed on October 26, 2022 and the treatment plan updates completed on November 23, 2022 and December 23, 2022 indicated the client was to receive weekly individual and group counseling. The progress notes indicated that the client did not receive individual counseling during the weeks of 10/18/22, 10/25/22, 11/1/22, 11/16/22, 11/23/22, 12/6/22, 12/13/22, 12/20/22, 12/27/22, and 1/3/23. Also, the client did not receive group counseling during the weeks of 11/24/22, 12/1/22, 12/8/22, 12/29/22, 1/5/23, 1/12/23, and 1/26/23.
Client #3 was admitted on November 14, 2022 and was active at the time of the complaint investigation. The treatment and rehabilitation plan completed on December 5, 2022 and the treatment plan update completed on January 5, 2023 indicated that the client the client was to receive weekly individual and group counseling. The progress notes indicated that the client did not receive individual counseling during the weeks of 11/30/22, 12/12/22, 1/4/22.
Client #4 was admitted on October 19, 2022 and was active at the time of the complaint investigation. The treatment and rehabilitation plan completed on November 9, 2022, indicated that the client was to receive weekly individual and group counseling. The progress notes indicated that the client did not receive group counseling during the weeks of 11/16/22, 11/23/22, 11/30/22, 12/7/22, 12/20/22, and 12/27/22. Also, the progress notes indicated that the client did not receive an individual session between November 15, 2022 and the date of the complaint investigation.
These findings were discussed with facility staff during the complaint investigation.
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Plan of Correction
Treatment services are being provided based on the treatment plans. Counselors are behind on documenting the process notes for the sessions with residents. All charts will be reviewed to determine which are lacking appropriate documentation and will be updated. This will occur by March 31, 2023. Moving forward, progress notes will be in the chart within 24 hours of providing the services to the residents. Retraining will be done with the counselors on the policy for progress notes and documentation of services by the program director. This will be completed by 3/31/23. The program director will randomly check charts each month to ensure they are in compliance. |
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
Based on a review of four client records, the facility failed to ensure a complete client record to include progress notes. Treatment session progress notes were missing in four of the four records reviewed.
Client #1 was admitted on November 10, 2022 and was active at the time of the complaint investigation. The treatment and rehabilitation plan completed on December 1, 2022 indicated the client was to receive weekly individual and group counseling. Individual session progress notes were missing for the weeks of 12/28/22, 1/24/23, and 1/31/23. Group counseling session notes were missing for the weeks of 11/24/22, 12/1/22, 12/8/22, 12/29/22, 1/5/23, and 1/12/23.
Client #2 was admitted on October 5, 2022 and was active at the time of the complaint investigation. The treatment plan and rehabilitation plan completed on October 26, 2022 and the treatment plan updates completed on November 23, 2022 and December 23, 2022 indicated the client was to receive weekly individual and group counseling. Individual session notes were missing for the weeks of 10/18/22, 10/25/22, 11/1/22, 11/16/22, 11/23/22, 12/6/22, 12/13/22, 12/20/22, 12/27/22, and 1/3/23. Group session notes were missing for the weeks of 11/24/22, 12/1/22, 12/8/22, 12/29/22, 1/5/23, 1/12/23, and 1/26/23.
Client #3 was admitted on November 14, 2022 and was active at the time of the complaint investigation. The treatment and rehabilitation plan completed on December 5, 2022 and the treatment plan update completed on January 5, 2023 indicated that the client the client was to receive weekly individual and group counseling. Individual session notes were missing for the weeks of 11/30/22, 12/12/22, and 1/4/22.
Client #4 was admitted on October 19, 2022 and was active at the time of the complaint investigation. The treatment and rehabilitation plan completed on November 9, 2022, indicated that the client was to receive weekly individual and group counseling. Group session notes were missing for the weeks of 11/16/22, 11/23/22, 11/30/22, 12/7/22, 12/20/22, and 12/27/22. Individual session notes were missing for the weeks of 11/22/22, 11/29/22, and the months of December 2022 and January 2023.
These findings were discussed with facility staff during the complaint investigation.
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Plan of Correction
All charts will be reviewed to determine which are out of compliance. By March 31, 2023, all charts will be updated with missing progress notes and treatment notes. Moving forward, the program director will re-train counselors on the policy for submitting documenting in the chart. Counselors will have 24 hours to document progress notes and treatment notes in the chart. Each month the program director will randomly check charts for compliance. If a chart is out of compliance the counselor will have 5 working days to bring it into compliance. A check at 5 days will be done by the program director. |
709.53(a)(8) LICENSURE Case Consultation 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:
(8) Case consultation notes.
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Observations
Based on a review of four client records, the facility failed to ensure a complete client record to include the client's involvement with the project. Case consultation notes were missing in four out of the four applicable records reviewed.
Client #1 was admitted on November 10, 2022 and was active at the time of the complaint investigation. There were no case consultation notes in the client chart.
Client #2 was admitted on October 5, 2022 and was active at the time of the complaint investigation. There were no case consultation notes in the client chart.
Client #3 was admitted on November 14, 2022 and was active at the time of the complaint investigation. There were no case consultation notes in the client chart.
Client #4 was admitted on October 19, 2022 and was active at the time of the complaint investigation. There were no case consultation notes in the client chart.
These findings were discussed with facility staff during the complaint investigation.
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Plan of Correction
Corrective action was started on 2/1/23 to complete case consultations during all staff meetings. On 2/1/23, 2 case consultations were completed for residents who were close to discharge. On 2/15/23, 4 case consults were completed during all staff meeting. On 3/1/23 the final 4 case consults will be completed. At that time we will be in compliance with case consults. Moving forward the program director will track on a chart for all staff to see who is due for a case consultation. |