INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on October 11, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center For Addictive Disease - Main Line Affiliates 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) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facilities fire drill log, the facility failed to conduct unannounced fire drills at least once a month.
The findings include:
On October 11, 2011, fire drill logs were reviewed covering the period from October 19, 2010 through September 29, 2011. The facility failed to conduct fire drills during four out of twelve months.
The facility failed to conduct unannounced fire drills during the months of January 2011, April 2011, June 2011, and July 2011.
The office manager confirmed the findings.
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Plan of Correction
The Office Manger will assure fire drills are complete monthly and are at least two weeks apart. This will be accomplished by the Office Manger establishing a deadline of when paperwork from drills needs to be received and reviewed. She will add a review date to the fire drill log to indicate that she has reviewed the findings and also assure that it is completed monthly. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility's fire drill log, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
On October 11, 2011, fire drill logs were reviewed covering the period from October 19, 2010 through September 29, 2011.
The facility failed to document alternate exits during ten of ten conducted fire drills.
Alternate exit routes were not documented on the fire drill logs for the months of October 19, 2010, November 3, 2010, November 30, 2010, December 21, 2010, February 1, 2011, February 17, 2011, March 29, 2011, May 4, 2011, August 17, 2011, and September 29, 2011.
The office manager did not dispute the findings.
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Plan of Correction
The Office Manger will ensure that alternative routes are used during fire drills by her review of the documentation submitted monthly to her by office staff completing fire drill. A staff meeting will be held 11/10/11 to review this expectation. A box will be added to the fire drill form for her review that includes alternative exits were used. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facilities fire drill log, the facility failed to set off a fire alarm or smoke detector during each drill and failed to comply with an exception which required the facility to provide documentation that the smoke detectors and fire alarms were in working order.
The findings include:
On October 11, 2011 the facilities fire drill log and administrative documentation was reviewed.
The facility did not set off a fire alarm or smoke detector during ten of ten conducted fire drills.
The facility has an exception to the Department of Health's Physical Plant Standards for Nonresidential Facilities, Chapter 705.28 (d)(7), relative to activating a fire alarm or smoke detector during a fire drill. However, the exception states: "Since smoke alarms/fire detectors will not consistently be activated during fire drills, documentation that the alarms/detectors are in working order needs to be available for review during licensing inspections."
The facility failed to provide documentation that the fire alarms/smoke detectors are in working order.
The office manager confirmed the findings.
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Plan of Correction
The Office Manager will schedule with the outside vendor to hold fire drills with activation of the alarms and checks of smoke detectors twice in the upcoming year. These will be placed on both the Office Manger and Director's calendars in order to ensure they occur.
A drill was held by the outside vendor where alarms were sounded and smoke detectors checked on 10/19. Another is scheduled for May 2012. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. 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, the facility failed to document a psychosocial evaluation that included the client's problems/needs, assets/strengths, support systems, coping mechanisms and/or negative factors as they would relate to treatment. In addition, the psychosocial evaluations failed to include the counselor's evaluation of the client.
The findings include:
On October 11, 2011, five client records were reviewed for documentation of a psychosocial evaluation. The facility failed to document an evaluative psychosocial in five of five client records reviewed.
Client # 1 was admitted to the program on 11/10/10 and discharged on 5/26/11.
The psychosocial was documented on 11/10/10. However, the facility failed to document an evaluation of support systems and negative factors. In addition, the psychosocial was not evaluative as the document contained a list and stated "the patient reports."
Client # 2 was admitted to the program on 12/29/10 and discharged on 7/21/11.
The psychosocial was documented on 12/29/10. However, the facility failed to document an evaluation that included the client's problems/needs, assets/strengths, support systems, and coping mechanisms. In addition, the psychosocial evaluation failed to document the counselor's conclusions and impressions. Furthermore, the psychosocial was not evaluative as the document contained a list and stated "the patient reports."
Client # 3 was admitted to the program on 5/3/11. The psychosocial was documented on 5/3/11. However, the facility failed to document an evaluation of support systems and coping mechanisms. In addition, the psychosocial was not evaluative as the document contained a list and stated "the patient reports."
Client # 4 was admitted to the program on 5/18/11. The psychosocial was documented on 5/18/11. However, the facility failed to document an evaluation that included the client's problems/needs, assets/strengths, support systems, coping mechanisms, and negative factors.
In addition, the psychosocial evaluation failed to document conclusions regarding the client's attitude toward and ability to participate in the treatment process. Furthermore, the psychosocial was not evaluative as the document contained a list and stated "the patient reports."
Client # 5 was admitted to the program on 1/14/11. The psychosocial was documented on 1/14/11. However, the facility failed to document an evaluation that included the client's problems/needs, assets/strengths, support systems, coping mechanisms, and negative factors.
In addition, the psychosocial was not evaluative as the document contained a list and stated "the patient reports."
The clinical director did not dispute the findings.
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Plan of Correction
Two Staff meetings will be conducted, one by Clinical Director on 11/10/11 and another by the Director on 11/17/11. The Staff meeting will inform all clinicians who complete Psychosocial evaluations that utilization of "patient reports" is not acceptable. "Patient reports" does not cover the counselor's evaluation. The staff will be given contrasting examples between "Patient reports" and a counselor evaluation in order to identify the difference. The Clinical Director will review all psychosocial evaluations completed in December 2011 for complete evaluation by the counselor. Results will be shared with the counselors in the January staff meeting. Results that are seen to be Counselor specific will become part of a Performance Management issue for the specific counselor. |
711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document a complete client record which includes follow-up information.
The findings include:
The facility's policy titled "Follow-up Policy" states:
"For those patients completing their CAD treatment successfully, this will be done using the Patient Satisfaction Surveys on their last day of treatment. For those patients who do not complete, but are administratively discharged, the Patient Satisfaction Survey will be mailed out within 30 days of their last treatment day. All surveys, either mailed to the patient or given to them to complete on their last day, will be documented in a binder showing the patient name, the date of discharge, and the date the survey was completed/mailed."
On October 11, 2011, two client records were reviewed for documentation of follow-up information. The facility failed to document follow-up information in one of two client records reviewed.
Client # 2 was admitted to the program on 12/29/10 and discharged on 7/21/11. The facility failed to provide documentation of follow-up information by 8/21/11.
The facility director confirmed the findings.
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Plan of Correction
The Director will approach the Governing Body to revise the policy for the second sentence to read "For those patients who do not complete, but are administratively discharged, the Patient Satisfaction Survey will be mailed out within 30 days of their discharge date." This allows for the client who is attending once per week to not show up two weeks, be contacted by staff and given opportunity to continue with care the following week. This allows for a total of three to four weeks to re-engage in treatment before discharge date is established.
All staff will be reminded weekly by the Clinical Director during team meeting to discharge clients who have been out of care three to four weeks. The Director will check the Discharge Survey manual monthly to assure that discharges are occurring and surveys are being given on the last day or being mailed within 30days of the date of discharge. |