INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 16, 2013 to April 17, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Guidance for Growing, LLC 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) (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 fire drill records, the facility failed to provide documentation that the facility's fire alarm is in working order.
The findings include:
Fire drill records were reviewed on April 16, 2013. The records were reviewed for the period covering May 2012 to April 2013. The facility was granted an approval on September 7, 2010 to the Physical Plant Standards for Nonresidential Facilities, Chapter 705.28 (d) (7), relative to activating a fire alarm or smoke detector during a fire drill. As a result of the approval, the facility was required to provide documentation that their fire alarm is in working order. Documentation that the facility's fire alarm is in working order was not presented for review.
The Project Director confirmed the findings.
This is a repeat citation. The facility was previously cited on October 25, 2011, April 12, 2011, and April 29, 2012 for noncompliance with this standard.
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Plan of Correction
The project director will put in a written request to the building owner requesting written confirmation the fire alarm is in working order. The project director will set a bi-yearly schedule of contacting the building owner to obtain proof that the fire alarm is functioning. This contact will be made in December and June of each year to ensure that proof of a working fire alarm is readily available at the time of inspection. A calendar reminder will be set in the project director's calendar to prompt him to put a written request to the building owner
On 6/17/2013, the project director called and discuss with the owner of the building having the fire company or L&I come in to verify the fire alarm is working properly on a yearly basis. The expected date of compliance is by 8/20/2013. |
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 treatment plan updates in three of three records required.
The findings include:
The facility policy states: "Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days. The treatment plan update should include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan. Treatment plan updates should be signed and dated by the primary counselor and it is recommended that it be countersigned and dated by the supervisory counselor."
Three client records requiring documentation of a treatment plan update were reviewed on April 16, 2013. The facility failed to document treatment plan updates in three of three records reviewed; in particular client record # 1, 2, and 3.
Client # 1 was admitted to the program on 8/14/12. The individual treatment plan was documented on 8/23/12. The treatment plan update was due at least every 60 days or by 10/23/12. The facility failed to document a treatment plan update for client # 1.
Client # 2 was admitted to the program on 8/14/12. The individual treatment plan was documented on 8/21/12. The treatment plan update was due at least every 60 days or by 10/21/12. The facility failed to document a treatment plan update for client # 2.
Client # 3 was admitted to the program on 9/20/12. The individual treatment plan was documented on 9/25/12. The treatment plan update was due at least every 60 days or by 11/25/12. The facility failed to document a treatment plan update for client # 3.
The Project Director confirmed the findings.
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Plan of Correction
Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days. The treatment plan update should include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan. Treatment plan updates should be signed and dated by the primary counselor and it is recommended that it be countersigned and dated by the supervisory counselor. One client was still active and the treatment plan update was completed. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records and a review of the facility's policy and procedure manual, the facility failed to document a complete client record which included a discharge summary in two of seven records reviewed.
The findings include:
The facility's policy states: "Within one week after discharge, there should be entered into the client's case record a discharge summary describing the reasons for treatment, services offered, response to treatment and client's status or condition upon discharge."
Seven client records requiring documentation of a discharge summary were reviewed on April 16, 2013. The facility failed to document a discharge summary in two of seven records reviewed; specifically client record # 6 and 7.
Client # 6 was admitted to the program on 1/5/13 and discharged on 4/1/13 after leaving the facility against staff advice. The facility was required to document a complete client record which included a discharge summary. The facility failed to document a discharge summary for client record # 6.
Client # 7 was admitted to the program on 1/6/13 and discharged on 3/25/13 after leaving the facility against staff advice. The facility was required to document a complete client record which included a discharge summary. The facility failed to document a discharge summary for client record # 7.
The Project Director confirmed the findings.
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Plan of Correction
The project director will review the client log book on a weekly basis to determine which clients have been discharged. The project director will check client files of discharged clients to ensure that a discharge summary is present for discharged clients. It will be the therapist's responsibility to create the discharge summary and place it in the client's file. The discharge summaries have been completed for the 2 clients cited. |