INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 21, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, Three Rivers Youth 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
The facility failed to provide documentation of CPR certification to ensure at least one staff person trained in these skills was onsite during the project's hours of operation based on a review of two personnel/training records on May 21, 2018.
No staff had documentation of CPR certification.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project/Facility Director will schedule the CPR certification training for staff on 6/18/18.
The Project/Facility Director will follow-up with staff training plans on a regular basis and schedule CPR Certification training prior to expiration date to ensure that at least one staff person is trained on CPR onsite during office hours with documentation of the CPR Certification. |
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
The facility failed to document the exit route used during fire drills based on a review of the May 2017 through April 2018 fire drill records on May 21, 2018. In addition, the facility failed to document that alternate exit routes were prepared to be used during fire drills.
The exit route used for each drill was documented as "all" on the fire drill records.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project/Facility Director will document the specific exit route used during a fire drill on a monthly basis. The Project/Facility Director will plan to use alternative exit routes during fire drills on a monthly basis.
The Project/Facility Director will check the fire drill log on a monthly basis to ensure the exit routes used are documented. The Project/Facility Director will check Fire log book on quarterly basis to ensure alternative exits routes are used during fire drills. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to document written acknowledgement by the client that they were notified of all of their rights in seven of seven client records reviewed on May 21, 2018.
There was no documentation that the client was informed that 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 and that the client had the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their record in client records # 1, 2, 3, 4, 5, 6 and 7.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project/Facility Director will update the Client Rights written acknowledgement documentation to include that client was informed that 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 and that the client had the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their record in client records.
The Project/Facility Director will inform staff of the changes on the form. The updated client rights documentation will be used immediately by staff and clients for written acknowledgement. The Project/Facility Director will review client records on a monthly basis to ensure compliance of client rights notification/acknowlegment. |
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
The facility failed to document that counseling services were provided according to the individual treatment and rehabilitation plan in three of seven client records reviewed on May 21, 2018.
The individual treatment plans indicated the client would receive individual counseling weekly. The only individual counseling session was documented at intake in the following client records.
Client # 3 was admitted on December 11, 2017. The treatment plan was documented on December 13, 2017.
Client # 4 was admitted on October 6, 2017 and discharged on February 8, 2018. The treatment plan was documented on October 13, 2017.
Client # 6 was admitted on April 18, 2018. The treatment plan was documented on April 25, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project/Facility Director will offer refresher trainings to the staff on counseling services related to individual treatment and rehabilitation plans. The training will include proper completion of treatment plans and following the implementation accordingly to the plan.
The Project/Facility Director will follow-up with staff regarding client treatment plans during Supervisions and will randomly check client records on a monthly basis to ensure counseling services are provided as per the treatment plan. |
709.93(a) 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:
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Observations
The facility failed to document a complete client record in four of seven client records reviewed on May 21, 2018.
A record of services provided was not documented in the following client records.
Client # 2 was admitted on January 12, 2018.
Client # 5 was admitted on June 16, 2017.
Progress notes were not documented in the following client records.
Client # 3 was admitted December 11, 2017. The record of services indicated group counseling was provided on the following dates but no progress notes were documented: 12/13/17, 12/14/17, 12/15/17, 12/18/17, 12/20/17, 12/21/17, 12/26/17, 12/27/17, 2/1/18, 2/2/18 and 3/1/18.
Client # 4 was admitted on October 6, 2017 and discharged on February 8, 2018. The record of services indicated group counseling was provided on the following dates but no progress notes were documented: 10/26/17, 10/27/17, 11/1/17, 11/2/17, 11/3/17, 11/8/17, 11/9/17, 11/10/17, 11/15/17, 11/16/17, 11/17/17, 11/22/17, 11/29/17, 12/1/17, 1/3/18, 1/8/18, 1/24/18 and 1/29/18.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project/Facility Director will offer a refresher training and technical support to staff on documentation and effective techniques on completion of client records including but not limited to Progress notes and record of service.
The Project/Facility Director will follow-up with staff on proper documentation in client records and time management during Supervisions. The Project/ Facility Director will randomly check client records on a monthly basis. |