INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 23 through March 25, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, NET Treatment Services, Inc.- NET Steps 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 April 23, 2010.
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of staff development procedures and an interview with the facility and compliance director the facility failed to document individual training plans annually.
Findings:
An interview with the compliance and facility director on March 24, 2010 verified individual staff development plans were to be documented annually in the month of January. A review of staff development records on March 23, 2010 documented eight of eight individual staff development plans with the individual training plans developed in March 2010. Eight of eight individual training plans were two months late based on established organizational procedures.
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Plan of Correction
Methodology for Achieving and Maintaining Compliance:
A tracking system will be developed and implemented to ensure all staff training plans will be done annually per NET STEPS policies and procedures on staff development.
The Facility Director will train applicable staff, and monitor for compliance.
Proposed Timeframe for Achieving Compliance:
Effective June 1st, 2010, and will be ongoing.
Staff Responsible: Human Resources Representative & Facility Director
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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on staff interviews and client record review the Facility failed to document physical examinations in three of seven records.
Findings:
Based on a review of seven client records and an interview with the clinical supervisor and facility on March 25, 2010, physical examinations are required to be documented in the client record within eight days of admission. Three of seven records reviewed documented physical examinations more than eight days from the date of admission..
Client record # 4. Admitted on March 1, 2010. Physical examination documented in the record on March 17, 2010. The examination in record #4 was documented seven days late.
Client record # 6. Admitted on June 8, 2009. Physical examination documented in the record on June 29 2009. The examination in record #6 was documented twelve days late.
Client record #7. Admitted on November 3, 2009. Physical examination documented in the record on November 21, 2009. The examination in record #6 was documented ten days late.
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Plan of Correction
This is a Residential program citation
The drug free residential program will conduct a training including all staff to remind and reinforce the importance of having clients referred to the Doctor or Physician Assistant for a physical within eight days from their date of admission.
Clinical Supervisor and Program Director will review this policy in regular staff meetings and will use quality assurance processes to ensure physicals are occurring within eight days.
Projected date: April 26, 2010
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709.92(a) 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:
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Observations
Based on staff interviews and client record review the facility failed to develop an individual treatment and rehabilitation plan within thirty day of admission.
Findings:
Three of eight client records reviewed on March 24, 2010 failed to document a treatment and rehabilitation plan within thirty days of admission. An interview with the the facility and compliance director on March 23, 2010, verified that treatment planning procedures required the treatment plans to be completed within thirty days of admission.
Client record # 1. The client was admitted on May 13, 2009. The treatment plan was to be documented in the record on June 14, 2010. The treatment plan in the record reviewed on March 24, 2010 was dated June 30, 2009. The treatment plan was 16 days late.
Client record # 6. The client was admitted on January 12, 2010. The treatment plan was to be documented in the record on February 12, 2010. The treatment plan in the record reviewed on March 24, 2010 was dated February 22, 2009. The treatment plan was 6 days late.
Client record # 7. The client was admitted on January 5, 2010. The treatment plan was to be documented in the record on February 6, 2010. The treatment plan in the record reviewed on March 24, 2010 was dated March 8, 2010. The treatment plan was 28 days late.
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Plan of Correction
Methodology for Achieving and Maintaining Compliance:
All Master Treatment and Rehabilitation plans will be developed with the client within 15 days of admission, while in the Orientation Phase, before transitioning into the Outpatient, IOP or Partial Hospital treatment tracks. The Facility Director, PI/QA Director, and the Intake Supervisor will train applicable staff on this procedure and monitor for compliance.
Proposed Timeframe for Achieving Compliance:
Effective 5-1-10 and will be ongoing.
This will be monitored by PI/QA Director or designate
Staff Responsible:
Facility Director, PI/QA Director, Intake Supervisor
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