INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 21, 2009 and January 22, 2009, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Berks Counseling Center, Inc., 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 February 24, 2009.
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Plan of Correction
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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to ensure the hot water temperature did not exceed 120 degrees Farenheit. Findings:A physical plant inspection was conducted on January 22, 2009 between 9:00 and 10:00 am. The hot water in the female bathroom used by clients registered at 140 degrees Farenheit.
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Plan of Correction
The temperature of the water on our floor is controlled by the land lord of the building. A formal request was made to the building administrator,, regarding lowering the temperature of the hot water to 12O degrees or lower.
Building Administrator related she would lower the water temperature at the main hot water heater in the basement of the building to a temperature that is in compliance with the standard.
BCC's Quality Assurance/Safety Committee will test the temperature of the hot water every month to ensure compliance with this standard.
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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 a physical plant inspection, the facility failed to ensure that no portable space heaters would be permitted within the facility. Findings: A physical plant inspection took place on January 22, 2009 between 9:00 and 10:00 am. The Licensing Specialist observed several space heaters within the facility and individual counseling offices.
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Plan of Correction
As of January 26, 2009, all space heaters were removed from within this facility and individual counseling offices.
Quality Assurance /Safety Committee will monitor compliance to this standard weekly until the end of March, 2009. Weekly monitoring for compliance to this standard will begin again in September, 2009, to ensure portable space heaters were not
reintroduced within the facility and individual counseling offices for the fall and winter months.
The environmental temperature of this facility is controlled by the landlord of this building. The landlord has been contacted many times, throughout the fall and winter months of 2008, regarding the low temperature of the environment on our floor.
Building administrator, was notified of BCC's noncompliance to this standard as a result of the portable space heaters and the importance of regulating the environmental temperature to an acceptable temperature which would not require personnel to need additional heating appliances.
As of February 2, 2009, the environmental temperature of this facility has improved.
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709.82(e)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(1) Medical/dental.
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Observations
Based on a review of administrative policies and procedures, the facility failed to document a current letter of agreement for dental services. Findings:Based on a review of administrative policies and procedures on January 21, 2009, the facility failed to document a current letter of agreement for dental services. The most recent letter of agreement for dental services documented at the facility expired in 2007.
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Plan of Correction
The previous vendor for dental services has declined continuing to be a referral source for dental services for clients at BCC.
BCC Office Manager and BCC Clinical Director,are actively contacting other dental services in the downtown Reading area and are exploring the accessibility and appropriateness of these Dental offices to be a referral source for dental services for BCC clients.
A letter of agreement will be implemented with one specific Dental service by March 31st, 2009.
The contract will be renewed and a new referral contract signed on a yearly basis. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document a drug and alcohol history for each client. Findings:Eight client records were reviewed on January 23, 2009. Documentation of a drug and alcohol history was required in each client record. The facility failed to conduct a drug and alcohol history and/or document a review of drug and alcohol histories completed by the previous provider in three out of eight client records, #1, 5, and 7. In client record #1, there was documentation of a drug and alcohol history from a previous provider dated March 18, 2008, however, there was no documentation from the facility that this information was reviewed and updated with the client, who was admitted to the facility on May 16, 2008. In client record #5, there was documentation of a drug and alcohol history from a previous provider dated March 27, 2008, however, there was no documentation from the facility that this information was reviewed and updated with the client, who was admitted to the facility on June 12, 2008. In client record #7, there was documentation of a drug and alcohol history from a previous provider dated May 9, 2008, however, there was no documentation from the facility that this information was reviewed and updated with the client, who was admitted to the facility on June 5, 2008.
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Plan of Correction
A formal training on the appropriate protocol for reviewing documentation of a drug and alcohol history that was completed by a previous provider, was facilitated by BCC Clinical Director, on February 4, 2009, during the weekly clinical team meeting.
This protocol stated the previous provider's document, containing the drug and alcohol history, needed to be signed and dated by the BCC therapist upon completion of reviewing the document with the client.
Individual therapists responsible for deficiencies in Chart #1,5 and 7 were addressed individually by BCC Clinical Director, on February 5th, 2009, to ensure their understanding of the protocol.
The BCC Clinical Director, and BCC Clinical Supervisor, will complete weekly random chart reviews, specifically reviewing for evidence of therapist and client review of previous provider's documentation of drug and alcohol history.
Compliance will be evidenced by the therapist signing and dating the end of the document.
BCC's QA (Quality Assurance) Committee will continue to monitor for compliance to this standard as well.
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document a personal history for each client. Findings:Eight client records were reviewed on January 23, 2009. Documentation of a personal history was required in each client record. The facility failed to conduct a personal history and/or document a review of personal histories completed by the previous provider in three out of eight client records, #1, 5, and 7. In client record #1, there was documentation of a personal history from a previous provider dated March 18, 2008, however, there was no documentation from the facility that this information was reviewed and updated with the client, who was admitted to the facility on May 16, 2008. In client record #5, there was documentation of a personal history from a previous provider dated March 27, 2008, however, there was no documentation from the facility that this information was reviewed and updated with the client, who was admitted to the facility on June 12, 2008. In client record #7, there was documentation of a personal history from a previous provider dated May 9, 2008, however, there was no documentation from the facility that this information was reviewed and updated with the client, who was admitted to the facility on June 5, 2008.
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Plan of Correction
A formal training on the appropriate protocol for reviewing documentation of a personal history that was completed by a previous provider, was facilitated by BCC Clinical Director, on February 4, 2009, during the weekly clinical team meeting.
This protocol stated the previous provider's document, containing the personal history, needed to be signed and dated by the therapist upon completion of the document review with the client.
Individual therapists responsible for deficiencies in Chart # 1, 5 and 7 were addressed individually by BCC Clinical Director, on February 5th, 2009, to ensure their understanding of the protocol.
The BCC Clinical Director, and BCC Clinical Supervisor, will complete weekly random chart reviews, specifically reviewing for evidence of therapist and client review of previous provider's documentation of personal history.
Compliance will be evidenced by the therapist signing and dating the end of the document.
BCC's QA (Quality Assurance) committee will continue to monitor for compliance to this standard as well.
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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, the facility failed to document a psychosocial evaluation for each client.Findings:Eight client records were reviewed on January 23, 2009. Documentation of a psychosocial evaluation was required in seven client records. The facility failed to document a psychosocial evaluation in three of seven client records, #1, 5, and 7.
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Plan of Correction
A formal review/training on the appropriate protocol/policy for inclusion of a biopsychosocial /assessment in the client record, including a
biopsychosocial assessment that was completed by a previous provider was facilitated by BCC Clinical Director, on March 11, 2009, during the weekly clinical team meeting.
This protocol /policy states that a completed biopsychosocial assessment is required to be included in every client record, either completed by BCC therapist or by a previous provider. Upon completion of the BCC biopsychosocial assessment, the therapist needs to sign and date the assessment on the last page of the document. If the therapist is reviewing a biopsychosocial completed by a previous provider, the therapist must sign and date at each historical.
section regardless if additional information is added.
The clinical summary / clinical evaluation will be completed by the BCC therapist utilizing the information generated from either BCC's or previous provider's biopsychosocial assessment.
Both a BCC or other provider prior biopsychosocial assessment can be utilized up untill 6 months. A new biopsychosocial needs to be completed after 6 months.
Individual therapists responsible for deficiencies in Chart # 1, 5 and 7 were addressed individually by BCC Clinical Director, on February 5th, 2009, to ensure their understanding of the protocol.
The BCC Clinical Director, and BCC Clinical Supervisor, will complete weekly random chart reviews, specifically reviewing for inclusion of a BCC biopsychosocial assessment or evidence of therapist and client review of previous provider's biopsychosocial assessment. Compliance will be evidenced by the therapist signing and dating the end of the BCC generated document and signing and dating after each historical section of the biopsychosocial assessment generated by a previous provider.
Compliance will also be evidenced by having a new biopsychosocial assessment completed by BCC therapist, in the client record, when client is readmitted after 6 months.
BCC's Quality Assurance/Safety Committee will continue to monitor for compliance to this standard as well
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up, as per facility policy, for each client. The facility's follow-up policy indicates that follow-up for clients successfully discharged from the facility will occur within 30 days of discharge. Findings:Eight client records were reviewed on January 22, 2009. Documentation of follow-up was required in two client records. The facility failed to document follow-up in one of two client records, #8.
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Plan of Correction
A formal review of BCC's follow up policy was conducted by BCC Clinical Director on February 4, 2009, during the weekly clinical team meeting.
Also reviewed was the procedure for filing the completed follow up form in the discharged client record as soon as follow up was completed instead of keeping the completed follow ups in a file in their counseling office.
Individual therapist responsible for deficiency in Client record #8 was addressed individually by BCC Clinical Director, on February 6th, 2009, to ensure their understanding of the policy and procedure for completing follow up and filing completed form.
The BCC Clinical Director, and BCC Clinical Supervisor, will complete weekly random chart reviews of client records that have been successfully discharged at least 30 days previous, specifically reviewing for evidence that a follow up call was completed 30 days post discharge.
BCC's Quality Assurance/Safety Committee will continue to monitor for compliance to this standard as well.
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