INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 22 - 23, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, WES Corporation 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 January 5, 2011.
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Plan of Correction
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705.22 (1) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a physical plant inspection, the facility failed to maintain all structures, fences and playground equipment on the grounds of the facility so as to be free from any danger to health and safety.
The findings include:
A physical plant inspection was conducted on November 23, 2010 at approximately 3 PM.
The facility failed to ensure that the grounds were free from any danger to health and safety.
Metal and wooden rods were carelessly leaning on the emergency exit door on the first floor.
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Plan of Correction
705.22(1)
Metal and wooden rods have been removed from the emergency exit door on the first floor. This was done immediately. Maintenance and housekeeping staff have been counseled. The facility director will monitor for compliance to insure that this does not re-occur. |
705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on physical plant inspections conducted on November 22, 2010 and November 23, 2010, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The findings include:
Inspections of the facility physical plant were conducted on November 22, 2010 at 4:30 PM and November 23, 2010 at 9 AM and 10:30 AM.
The facility has one ladies room and one mens room located on the second floor. The bathrooms are used by staff, clients and visitors. The ladies room located on the second floor has three stalls. Two out of three stalls in the ladies room were not functional. One of the stalls was out of order and another could not be used as it was soiled.
The soiled toilet in the ladies room had been cleaned by the time of the final physical plant inspection at approximately 3 PM on November 23, 2010.
The mens room located on the second floor had an out of order sink.
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Plan of Correction
All plumbing repairs have been made to both the male and female bathrooms. The inoperable toilet in the ladies room has been replaced with a new toilet. Both bathrooms are cleaned three times a day and more if needed. The housekeeping staff has been counseled. The facilities director will monitor for compliance. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on observation during the physical plant inspection conducted on November 23, 2010 and a conversation with the clinical supervisor, the facility failed to ensure that there were no heaters located within the facility that were not permanently mounted or installed.
The findings include:
Four heaters that were not permanently mounted or installed were observed in the facility's office space.
The clinical supervisor confirmed that the facility had portable space heaters in the office space.
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Plan of Correction
All heaters that are not permanently mounted or installed have been removed from the offices effective immediately. All staff have been counseled and the program director and facilities director will monitor for compliance. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on observation during the physical plant inspection conducted on November 23, 2010, the facility failed to ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
The findings include:
The physical plant inspection was conducted at approximately 3 PM on November 23, 2010.
1. A chair was blocking the second floor emergency exit.
2. Metal and wooden rods were leaning on the emergency exit door on the first floor.
3. The first floor emergency fire exit door had chairs blocking the exit; in addition, the emergency exit door could not be opened by this surveyor. The security guard was able to open the emergency exit.
He stated that there is a certain way that the door must be opened; however, in an emergency one may not have time to "figure out" how to open the door.
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Plan of Correction
1. The chair blocking the second floor emergency exit has been removed.
2. The metal and wooden rods have been removed from the emergency exit door on the first floor.
3. The chairs that were blocking the emergency fire exit door have been removed and the emergency door has been repaired so that it opens easily. All maintenance and housingkeeping staff have been counseled and the facilities director will monitor for compliance. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a physical plant inspection and a conversation with the Facility Director, the facility failed to maintain confidentiality of client identity and records.
The findings include:
A physical plant inspection was conducted on November 23, 2010 at approximately 3 PM.
A client sign in sheet was observed at the entrance to the facility. The sign in sheet included a list of client first and last names, the date, number of tokens received, and the name of the client's counselor.
The Facility Director confirmed during a conversation that the sign in sheet is maintained as a transportation distribution list.
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Plan of Correction
The client sign in sheet used to monitor the distribution of tokens has been revised and the clients will now sign first name and last initial to insure confidentiality. All clients have been informed of the change in procedure. The program director or designee will monitor for compliance. |
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 review of the facility's policy and procedures, the facility failed to document a psychosocial evaluation which included support systems as per facility policy in five of five client records.
The findings include:
The facilities policy titled "Comprehensive Bio-Psychosocial History " states:
"WES will ensure that a comprehensive biopsychosocial evaluation is developed on each consumer. The evaluation must provide a composite picture of the individual in relation to the data collected and must identify possible causes leading to the consumer's current situation. The consumer's assigned program therapist must complete the biopsychosocial evaluation within 30 days following the consumer's admission and registration process." The policy further stated that the biopsychosocial will include the following elements: the consumer's support system; the consumer's strengths and barriers to treatment; and a comprehensive list of social elements of a consumer's life...
Five client records were reviewed on November 23, 2010. All records reviewed required documentation of a psychosocial evaluation. The facility did not document a psychosocial evaluation per policy in client records # 1, 2, 3, 4 and 5.
Client # 1 was admitted to the program on 7/15/10. A psychosocial evaluation was documented on 7/29/10; however, the psychosocial evaluation failed to include support systems.
Client # 2 was admitted to the program on 10/13/10, a psychosocial evaluation was documented on 11/13/10; however, the psychosocial evaluation failed to include support systems.
Client # 3 was admitted to the program on 7/14/10, a psychosocial evaluation was documented on 7/16/10; however, the psychosocial evaluation failed to include support systems.
Client # 4 was admitted to the program on 7/8/10, a psychosocial evaluation was documented late on 9/18/10; in addition, the psychosocial evaluation failed to include support systems.
Client # 5 was admitted to the program on 7/6/10, a psychosocial evaluation was documented late on 8/25/10; in addition, the psychosocial evaluation failed to include support systems.
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Plan of Correction
WES will ensure that a comprehensive biopsychosocial evaluation will be completed on each client within the first 30 days of treatment as per policy. All elements of the evaluation will be completed with specific attention given to the social supports of the client. In the event that the therapist is unable to complete the evaluation within the 30 day timeframe due to the client's non-compliance it shall be documented in the client record. All staff will be counseled on the documentation protocol. The program director or designee will monitor for compliance. |
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.
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Observations
Based on a review of client records and a review of the facility's policy and procedures, the facility failed to document a proposed type of support service in the individual treatment and rehabilitation plan in five of five client records.
The findings include:
The facilities policy titled "Initial and Updated Treatment Plans" states: A comprehensive individualized treatment plan shall:
I. Be formulate with the consultation of the consumer when appropriate to the client's age, and/or with the consumer's consent, his family, personal guardian, or appropriate other persons.
II. Be based upon a diagnostic evaluation which includes examination of the medical, psychological, social, cultural, behavioral, familial, education, vocational, and developmental aspects of the client's situation.
III. Set forth treatment objectives and prescribe an integrated program of therapies, activities, experiences, and appropriate education designed to meet the objectives.
IV. Result from the collaborative recommendation of the consumer's interdisciplinary treatment team.
V. Be maintained and updated with progress notes and be retained in the client's medical record on a form developed by WES and approved by licensing and funding bodies.
...All initial and updated treatment plans must reflect CBH and State requirements for development and review. The treatment plan will be reviewed to determine if the goals and objectives of the plan have been met. The review should include the modality, expected duration, the person or persons responsible for carrying out the plan, the specific outcomes and how these outcomes connect with the modality and activities specified in the plan.
...Treatment plans will be modified as appropriate. ...Any client who wishes to voice objections concerning his/her treatment has the right to be heard and have the objections determined through the WES grievance process. All clients are advised of this process and are encouraged to use it when they believe their treatment plan is not necessary or appropriate to their needs.
The facility's written policy also states that the treatment plan shall include: Type and frequency of treatment and rehabilitation services and the proposed type of support services which could include medical, psychiatric/psychological, economic, legal, AA and NA services.
Five client records were reviewed on November 23, 2010. All records reviewed were required to document an individual treatment and rehabilitation plan which includes a proposed type of support service. The facility did not document a proposed type of support service in client records # 3 and 5.
Client # 3 was admitted to the program on 7/14/10. The individual treatment and rehabilitation plan was documented on 8/13/10; however, the treatment plan failed to include a proposed type of support service.
Client # 5 was admitted to the program on 7/6/10. The individual treatment and rehabilitation plan was documented on 8/6/10; however, the treatment plan failed to include a proposed type of support service.
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Plan of Correction
All individual treatment and rehabilitation plans will include appropriate proposed type of support service. All staff will be counseled and receive supervision to ensure that all client records are in compliance. Program Director or designee will monitor for compliance. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records and a review of the facility's policy and procedures manual the facility failed to document a treatment plan update per policy in two of three client records..
The findings include:
The facility 's policy titled "Treatment and Rehabilitation Plan" states: "The Comprehensive Treatment plan will be completed within thirty (30) days of admission; Treatment plan updates occur every (60) days thereafter."
Five client records were reviewed on November 23, 2010. Three client records were due for documentation of a treatment plan update. The facility did not document a treatment plan update per policy in client records # 4 and 5.
Client # 4 was admitted to the program on 7/8/10. An individual treatment plan was documented on 8/6/10 and a treatment and rehabilitation plan update was documented late on 10/12/10. The treatment and rehabilitation plan update was due 10/6/10.
Client # 5 was admitted to the program on 7/6/10 and discharged on 10/29/10. An individual treatment plan was documented on 8/6/10; however, the facility failed to document a treatment and rehabilitation plan update by 10/6/10.
This is a repeat deficiency.
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Plan of Correction
All client records will have a treatment plan update per WES policy. In the event that the therapist is unable to complete a treatment plan update due to client's non-compliance documentation shall be provided in the client record. All staff will be counseled on the policy and protocol. The program director of designee will monitor for compliance. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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
Based on a review of client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in two of five client records.
The findings include:
Five client records were reviewed on November 23, 2010. All records reviewed were required to assure that counseling services are provided according to the individual treatment and rehabilitation plan. The facility failed to provide counseling services according to the treatment plan in client records # 1, and 4.
Client # 1 was admitted to the program on 7/15/10 and discharged on 9/29/10. The preliminary treatment plan was documented on 7/15/10 and the individual treatment plan was documented on 8/13/10. The treatment plan states that client # 1 will receive individual counseling weekly and group counseling 3 times a week; however, based on a review of the record of service and progress notes, the facility failed to provide counseling services according to the treatment plan. The record of service for September indicates that the client did not attend a session for that month, and as a result, client # 1 was discharged 9/29/10.
The record of service for August indicates that the client attend one session on 8/30/10.
The record of service for July indicates that the client attended two sessions, an intake on 7/15/10 and a session on 7/29/10. The client did not receive individual counseling weekly.
Client # 4 was admitted to the program on 7/8/10 and discharged on 10/28/10. The preliminary treatment plan was documented on 7/8/10 and the individual treatment plan was documented on 8/6/10. The treatment plan states that client # 4 will receive receive individual counseling weekly and group counseling 3 times a week; however, based on a review of the record of service and progress notes, the facility failed to provide counseling services according to the treatment plan. The record of service for October indicates that the client attended sessions on 10/11/10 and 10/12/10. The record of service for September indicates that the client attend one session on 9/20/10. The record of service for August indicates that the client attended sessions on 8/17/10, 8/18/10 and 8/19/10. The record of service for July indicates that the client attended three sessions, an intake on 7/8/10, and sessions on 7/13/10, and 7/28/10. The client did not receive individual counseling weekly.
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Plan of Correction
All clients will receive counseling services as stated in their individual treatment plans. In the event that the client is non-compliant documentation will be provided to indicate on the record of service if the client is a "no show". All staff will be counseled and program director or designee will monitor for compliance. |