INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 22, 2018 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, Center For Families 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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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
An administrative review of the September 2017 through April 2018 fire drill logs was conducted during the onsite inspection. The facility failed to document on their written drill log which exit route was used for each fire drill conducted.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The safety drill record form was amended during the onsite visit to include indication of exit route used. Inservice training reviewing the report form was conducted. Monthly auditing by Director will ensure this portion is filled out. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on the review of 5 client records, the facility failed to document verification that the client was offered a copy of every consent to release form that was signed by the client in all 5 client records.Client #1 was admitted into the partial hospitalization program on 5/15/18 and was still active at the time of the inspection.Client #2 was admitted into the partial hospitalization program on 4/02/18 and was still active at the time of the inspection.Client #3 was admitted into the partial hospitalization program on 11/29/17 and was still active at the time of the inspection.Client #4 was admitted into the partial hospitalization program on 1/08/18 and was discharged on 4/10/18.Client #5 was admitted into the partial hospitalization program on 10/24/17 and was discharged on 12/13/17.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The form was amended to indicate that clients were offered a copy of every consent to release form. It states: "I have been offered a copy of any forms I signed including releases of information."
Director of Compliance was responsible for ensuring that the form gets amended.
Admission forms will be randomly audited monthly to ensure that this form is getting signed. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of 5 client records, 2 records were missing the type and frequency of treatment and rehabilitation services on the client's documented comprehensive treatment plan.Client #2 was admitted into the partial hospitalization program on 4/02/18 and was still active at the time of the inspection. The client's comprehensive treatment plan was completed on 4/4/18.Client #4 was admitted into the partial hospitalization program on 1/08/18 and was discharged on 4/10/18. The client's comprehensive treatment plan was completed on 1/10/18.The findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
An initial treatment plan will be completed upon admission and within the first 24 hours. All client charts will be audited weekly by ED using a monitoring tool to ensure compliance. The initial treatment plan will include type and frequency of specific treatment and rehabilitation services.Both the Executive Director and the Clinical Supervisor will audit charts every 15 days to ensure that each initial treatment plan is completed upon admission. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of 5 client records, there were treatment plan updates completed after the regulatory timeframe or missing at the time of the inspection in 4 client records.Client #2 was admitted into the partial hospitalization program on 4/02/18 and was still active at the time of the inspection. The comprehensive treatment plan was completed on 4/04/18 and the next update was due no later than 5/04/18. However, the update was not completed until 5/21/18.Client #3 was admitted into the partial hospitalization program on 11/29/17 and was still active at the time of the inspection. There was a treatment plan update completed on 2/17/18 and the next update was due no later than 3/17/18. However, the update was not completed until 4/26/18.Client #4 was admitted into the partial hospitalization program on 1/08/18 and was discharged on 4/10/18. The comprehensive treatment plan was completed on 1/10/18 and the next update was due no later than 2/10/18. However, the update was not completed until 3/22/18.Client #5 was admitted into the partial hospitalization program on 10/24/17 and was discharged on 12/13/17. The comprehensive treatment plan was completed on 10/26/17 and the next update was due no later than 11/26/17. However, the update was not completed at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Both the Executive Director and the Clinical Supervisor will work conjunctively to audit charts every 15 days to ensure that each treatment plan update is completed within the 30 day timeframe. Further a training will be provided to all staff to stress the important of treatment plan updates and ensure they are aware treatment plan updates are due every 30 days. |