INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 19, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Central Behavioral Health 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:
|
Plan of Correction
|
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of three personnel files, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in one record reviewed.Employee #4 was hired as a counselor on November 11, 2021 and was current in that position at the time of the inspection. Employee #4 was not instructed in the use of the fire extinguishers until December 1, 2021, according to documentation in the file. The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the August 19, 2021 annual licensing inspection.
|
Plan of Correction
Facility director will go over fire and emergency procedures with new hires into the program within one week of their hire and will be added to the "onboarding" checklist that is used with all new staff members. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
|
Observations
Based on a review of client records, the facility failed to develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights to include that the project may not discriminate in the provision of services on the basis of marital status in three out of three records reviewed. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the August 19, 2021 annual licensing inspection.
|
Plan of Correction
On 11/16/2022 the facility director amended the client rights form to include the following:
"the right to be provided services at this facility and to be refereed for services at other facilities without regard to my race, ethnicity, color, religion, creed, handicap, ancestry, national origin, age, sex, marital status or sexual orientation."
This form replaces the previous version in the electronic medical record and will be generated for all future clients into the program. There are no current clients in the program and the clients who's charts were inspected were all discharged prior to the inspection.
The facility director will review all new clients entered into the program in the future to ensure that the revised form has been completed. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of client records, the facility failed to document the frequency of treatment and rehabilitation services in treatment plans in two of three applicable client records reviewed. Client # 1 was admitted on January 24, 2022 and discharged on February 18, 2022. The individual treatment and rehabilitation plan signed by the client on January 24, 2022, did not include the frequency of treatment and rehabilitation services.Client # 2 was admitted on September 20, 2021 and discharged on December 22, 2021. The individual treatment and rehabilitation plan signed by the client on September 20, 2021 did not include the frequency of treatment and rehabilitation services.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the August 19, 2021 annual licensing inspection.
|
Plan of Correction
Facility Director met with counseling staff on 11/2/2022 to remind staff that all treatment plans are to include the frequency of treatment. Going forward, all treatment plans will require a final review from Facility Director before being finalized to ensure this is occurring. |
709.92(a)(3) 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:
(3) Proposed type of support service.
|
Observations
Based on a review of client records, the facility failed to ensure that individual treatment and rehabilitation plans included documentation of the proposed type of support services in two of three applicable records reviewed.Client # 1 was admitted on January 24, 2022 and discharged on February 18, 2022. The individual treatment and rehabilitation plan signed by the client on January 24, 2022, did not include the proposed type of support services.Client # 2 was admitted on September 20, 2021 and discharged on December 22, 2021. The individual treatment and rehabilitation plan signed by the client on September 20, 2021, did not include the proposed type of support services.The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility Director met with counseling staff on 11/2/2022 to remind staff that all treatment plans are to include the proposed type of support services. Going forward, all treatment plans will require a final review from Facility Director before being finalized to ensure this is occurring. This will be done through the electronic medical record so that after the counselor completes the treatment plan with the client, it will be forwarded to the facility director for review to ensure that all necessary treatment plan elements are included.
As there are no current clients in the program, this will be done for all future clients. All clients who's charts were inspected were discharged prior to the inspection. |
709.93(a)(8) 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:
(8) Case consultation notes.
|
Observations
Based on a review of client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project including case consultation notes in one of one applicable record reviewed. Client # 2 was admitted on September 20, 2021 and discharged on December 22, 2021. The client record did not contain documentation of case consultation notes.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility Director met with counseling staff on 11/2/2022 to remind staff that case consultations are to be completed every 90 days, regardless of the level of client involvement at the time.
Facility director has created a recurring reminder every 90 to ensure that all program participants cases are being consulted on regardless of their current level of involvement. The facility director will review documentation needs for clients in the program during each weekly individual supervision meeting with counselor staff, and during that time both counselor and facility director will complete the case consultation form together and upload it into the electronic medical record, along with a reminder in the system as to when the next consultation is due (within 90 days). Both counselor and facility director will check reminders in the system for when the next case consultation is due. When a client is being discharged from the program before being in the program for 90 days, a case consultation will be completed with counselor and facility director staff at the time of the client's discharge.
This will apply to all future clients entered into the program, as there are no current clients in the program and clients whose charts were inspected had all been discharged prior to inspection. |