INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 21, 2011 and March 23, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Perspectives at White Deer Run 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 April, 20, 2011..
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Plan of Correction
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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 on a review of the fire drill log and an interview with the clinical supervisor it was determined that the facility failed to conduct a fire drill during sleeping hours within the past six months.
The findings were:
A review of the fire drill log was conducted on March 21, 2011. The last documented fire drill during sleeping hours occurred on July 25, 2010 at 6:31 am. A discussion with the clinical supervisor on March 21, 2011 confirmed that no fire drill has been conducted during sleeping hours within the last six months.
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Plan of Correction
Facility Support Coordinator will ensure that the patients engage in a fire drill during sleeping hours on a quarterly basis. This process will begin on April 15th, 2011. Facility Support Coordinator will inform the Campus Director when a sleeping hour fire drill has occured for proper tracking and monitoring. Facility Support Coordinator will document these drills in fire drill log accordingly. This will occur on an on-going basis. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill record and a discussion with the clinical supervisor, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
The fire drill record was reviewed on March 21, 2011. The facility only documented a front door exit for each month during fire drills for the months of April 2010, May 2010, June 2010, July 2010, August 2010, September 2010, October 2010, November 2010, December 2010, January 2011 and February 2011. A discussion with the clinical supervisor took place on March 21, 2011 and he confirmed that the front door was the only exit documented from April 2010 through February 2011 fire drills.
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Plan of Correction
Facility Support Coordinator will prepare alternate exit routes for patients on a rotating basis. Facility Support Coordinator will document these alternate exit routes in the fire drill log accordingly. This process will begin on 4/15/2011. This will be an on-going process moving forward. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and a discussion with the Clinical Supervisor, the facility failed to document psychosocial evaluations in seven of seven outpatient client records.
The finding includes:
Twenty client records were reviewed on March 21, 2011 and March 23, 2011. Of the twenty client records, seven were outpatient client records, #14, 15, 16, 17, 18, 19 and 20. Psychosocial evaluations were to be documented in seven outpatient client records, #14, 15, 16, 17, 18, 19 and 20. A discussion with the clinical supervisor on March 23, 2011 confirmed that the psychosocial evaluations did not meet all the components as specified in the facility's policy and procedure for psychosocial evaluations.
Policy title: PSYCHOSOCIAL ASSESSMENT
Policy: It is the policy of the facility to complete a Psychosocial Assessment on all patients admitted to the facility.
Procedure:
1.) The psychosocial assessment is to be completed within 7 days of admission to partial hospitalization, 14 days of admission of intensive hospitalization and 21 days of admission to outpatient programming.
2. The psychosocial assessment will include:
* A composite picture of the patient in relationship to the information obtained which may help to identify possible relationships, conditions and causes leading to the patient's current situation.
*A clear description of the patient's presenting and underlying problems.
* Pain assessment and reassessment when indicated.
*The patient's needs or problems that can or cannot be resolved through treatment or that might inhibit treatment.
* The patient's assets, strengths or other factors that can contribute to the resolution of identified problems.
* The potential or available patient support systems.
* Negative factors that might affect treatment.
* The patient's preferred coping mechanisms.
* Conclusions regarding the patient's appearance, behavior and reaction during the intake process.
* Conclusion regarding the patient's attitude toward and ability to, participate in the treatment process.
Client records #15, 16, 17 and 18 did not include documentation of the date of completion of the psychosocial evaluations. The omission of the date of completion made it impossible to determine if the psychosocial evaluations were completed within the required time frame.
Also, per the facility's policy and procedure manual, which was reviewed on March 23, 2011, it stated that psychosocial evaluations will be completed within 7 days of admission if partial hospitalization, 14 days of admission to intensive outpatient and 21 days of admission to outpatient. A discussion with the clinical supervisor on March 23, 2011 confirmed that the psychosocial evaluations were not documented in records reviewed.
Client #14 was admitted on August 6, 2010 and discharged on September 15, 2010, as of September 15, 2010 documentation of the clients psychosocial evaluation was not documented.
Also, client records #19 and 20 psychosocial evaluations were reviewed and were illegible, making the information and assessment unable to be reviewed.
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Plan of Correction
Training with the outpatient clinical staff will be conducted by the Clinical Supervisor on April 15, 2011 to ensure understanding of the intake/admission standard regarding documentation of the Psychosocial evaluations and legibility, with a focus on time frames in accordance with the White Deer Run policy. In addition to their signature, outpatient clinical staff is required to note the date that documentation was completed. The Clinical Supervisor will conduct random monthly chart audits as well as quarterly supervision to ensure ongoing compliance of this standard. Documentation of chart audits will be sent to the White Deer Run Quality Improvement Department and included in the quarterly supervision of each clinician. An EIP (Employee Improvement Plan) will be initiated for clinicians not compliant with the Policy and legibility of the Psychosocial evaluation, with progressive disciplinary action to be taken as needed. This process will be an on-going effort.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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
Based on a review of client records and a discussion with the Clinical Supervisor, the facility failed to document individual treatment and rehabilitation plans in three of seven outpatient client records.
The finding includes:
Twenty client records were reviewed on March 21, 2011 and March 23, 2011. Individual treatment and rehabilitation plans were to be documented in seven outpatient client records, #14, 15, 16, 17, 18, 19 and 20. The individual treatment and rehabilitation plans were not documented in three outpatient client records required, #14,15 and 16. A discussion with the clinical supervisor on March 23, 2011 confirmed that the individual treatment and rehabilitation plans were not documented in records records reviewed.
Policy title: Treatment Planning Process
Policy: All clients will participate in the process of developing an individualized treatment plan designed to meet their unique treatment needs. That plan will be updated on a regular basis and will be revised as needed.
Procedure:
1.) The primary counselor interviews the client to completed the psychosocial assessment or review with the client, the psychosocial assessment that was sent out to this program. This process is to be completed within 7 days of admission to partial hospitalization, 14 days of admission to intensive outpatient and 21 days of admission to outpatient services.
2.) The Preliminary Treatment Plan is completed within upon admission date.
3.) Next, the counselor completed the "Diagnostic Summary" and "Master Problem List" in preparation for development of a "Treatment Care Plan". The Treatment Care Plan is to be completed within 7 days of admission to partial hospitalization, 14 days if intensive outpatient and 21 days if outpatient and must actively involve the client's input from the previous sessions.
Client record #14 was admitted on August 6, 2010 and discharged on September 15, 2010. The client's individualized treatment plan was to be completed by August 26, 2010. Documentation of the client's last session was September 15, 2010. There was no documentation of an individualized treatment plan in the client's record.
Client record #15 was admitted on June 29, 2010 and discharged on September 3, 2010. The client's individualized treatment plan was to be completed by July 18, 2010. Documentation of the client's last session was August 16, 2010. There was no documentation of an individualized treatment plan in the client's record.
Client record #16 was admitted on July 30, 2010 and discharged on September 10, 2010. The client's individualized treatment plan was to be completed by August 20, 2010. Documentation of the client's last session was August 31, 2010. There was no documentation of an individualized treatment plan in the client's record.
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Plan of Correction
Training with the outpatient clinical staff will be conducted by the Clinical Supervisor on April 15, 2011 to ensure comprehension of the standard regarding documentation of an individual treatment and rehabilitation plan, with a focus on time frames in accordance with the White Deer Run policy. The Clinical Supervisor will conduct random monthly chart audits as well as quarterly supervision to ensure ongoing compliance; findings will be documented in the quarterly supervision of each clinician. An EIP (Employee Improvement Plan) will be initiated for clinicians not compliant with the Policy, with progressive disciplinary action to be taken as needed. This will be an on-going process.
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records and a discussion with the Clinical Supervisor, the facility failed to document a discharge summary within one week after the client's discharge in two of three outpatient discharge client records.
The findings include:
Twenty client records were reviewed on March 21, 2011 and March 23, 2011. Of the twenty, seven were outpatient clients. Three of the seven outpatient clients were required to have a discharge summary, #14, 15 and 16. The facility did not document a discharge summary within one week after discharge in client records # 14 and 15.
Client # 14 was admitted on August 6, 2010 and was discharged on September 15, 2010. The discharge summary was due by September 22, 2010. The discharge summary was not documented during the review of the client's record on March 23, 2011.
Client # 15 was admitted on June 29, 2010 and was discharged on September 3, 2010. The discharge summary was due by September 10, 2010. The discharge summary was completed on July 29, 2010, 37 days before the client was discharged.
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Plan of Correction
Training with the outpatient clinical staff will be conducted by the Clinical Supervisor on April 15, 2011 to ensure comprehension of the standard regarding documentation of a Discharge Summary, with a focus on time frames in accordance with the White Deer Run policy. The Clinical Supervisor will conduct random monthly chart audits as well as quarterly supervision to ensure ongoing compliance; findings will be documented in the quarterly supervision of each clinician. An EIP (Employee Improvement Plan) will be initiated for clinicians not compliant with the Policy, with progressive disciplinary action to be taken as needed. This will be an on-going process.
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