INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 10 - 11, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Dolminis 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 January 17, 2008.
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Plan of Correction
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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 on December 10, 2007, the facility failed to prepare alternate exit routes to be used during fire drills. A review of the fire drill log revealed that the only exit utilized during fire drills conducted between April 2007 to November 2007 was the exit by the client waiting area.
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Plan of Correction
Facility Director will block client waiting room exit to ensure other emergency means of egress are utilized during the next fire drill. This procedure will be utilized periodically with all exits to ensure that all means of egress will be utilized from time to time by staff and clients during fire and disaster drills. |
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 patient records on December 11, 2007, the facility failed to document a comprehensive drug and alcohol history. A review of six of nine patient records, specifically #2, 3, 4, 5, 10 and 13, revealed that the drug and alcohol history failed to document lengths and patterns of substance abuse related to the patient's progression of use. In addition, the drug and alcohol histories in patient records #1 and 3 were completed late per project policy. Patient record #10 was missing a completion date.
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Plan of Correction
The Brief Psychosocial form containing this information was being completed by the client and the counselors were failing to elaborate on this information. This form is now being completed by the counselor with the client upon intake. The counselors have been trained to gather as much detail as possible concerning the client's drug(s) of use, length and pattern and progression of use. Staff has also been re-educated on the importance of gathering this information at intake and ensuring that the completion date is documented. Four to five Charts are pulled randomly every month for monitoring by the director and a chart monitoring workgroup has been established by staff to ensure compliance. |
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 patient records on December 11, 2007, the facility failed to document a detailed personal history that included family, legal, employment/vocation, education, military, recreational and sexual information. A review of five of nine patient records, specifically #1, 10, 12, 13 and 15, revealed that documentation in the personal history was completed by the patient and often contained one word answers. In addition, questions were left unanswered and it was unclear as to whether the question was addressed with the patient or overlooked. Patient records #1 and 3 were completed late per project policy.
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Plan of Correction
The Brief Psychosocial form containing this information was being completed by the client and the counselors were failing to elaborate on this information. This form is now being completed by the counselor with the client upon intake. The counselors have been trained to gather as much detail as possible concerning the client's personal history to include: family, legal, employment/vocation, education, military, recreational, and sexual information. Staff has been informed to leave no question unanswered. Staff has also been re-educated on how to gather more detailed information from the client that is not readily offered as well as the the importance of gathering this information at intake. Four to five Charts are pulled randomly every month for monitoring by the director and a chart monitoring workgroup has been established by staff to ensure compliance |
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 patient records on December 11, 2007, the facility failed to ensure that the psychosocial evaluation contained a clinical analysis of the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, patient's attitude toward treatment and overall impressions. A review of six of nine patient records, specifically #1, 2, 3, 5, 10 and 15, revealed that the psychosocial evaluation was more historical with patient stated/reported comments rather than the clinician's analysis of the collected historical information.
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Plan of Correction
Facility Director held a training on psychosocial evaluations regarding counselor's analysis of client through information obtained rather than reiterating client's replies to questions. Director also addressed issue of staff's lack of confidence in their capabilities as a clinician to to document their assessment of the client.
Four to five charts are randomly pulled and monitored monthly by Facility Director. A staff workgroup has been implemented to aide with chart compliancy. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of patient records on December 11, 2007, the facility failed to include support services on the individual treatment and rehabilitation plan. A review of two of six patient records, specifically #7 and 8, revealed that support services identified in the history and psychosocial evaluation were not documented as support services on the individual treatment and rehabilitation plan..
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Plan of Correction
Facility Director has re-educated staff on the importance of documenting client support services on the individual treatment and rehabilitation plan. Staff has also been re-educated on the numerous services available that need to be listed as support services. Four to five charts are randomly pulled and monitored monthly by Facility Director. A staff workgroup has been implemented to aide with chart compliancy. |
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 patient records on December 11, 2007, the facility failed to document in the treatment plan update the patient's progress in relationship to the goals in the individual treatment and rehabilitation plan. A review of two of six patient records, specifically #10 and 12, revealed that the documentation in the treatment plan updates did not address the patient's progress of the past 60 days or include revised individual treatment goals. Patient record #13 was missing treatment plan updates for the months of July 22, 2007, September 22, 2007 and November 22, 2007. Patient record #15 failed to document treatment plan updates for the months of July 23, 2007 and September 23, 2007.
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Plan of Correction
Facility Director addressed issue with staff regarding treatment plans and the need to update the client's progress on goals and/or revise treatment plans at least every 60 days.
Director also noted the regulation requiring that all treatment plans are to be updated at least every 60 days.
Four with client to five Charts are pulled randomly every month for monitoring by the director and a chart monitoring workgroup has been established by staff to ensure compliance. |
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 patient records on December 11, 2007, the facility failed to document a discharge summary. A review of two of four patient records, specifically #12 and 15, revealed that the discharge summary did not include the patient's reason for treatment and services provided.
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Plan of Correction
Facility Director instructed/educated staff that they need to include documentation of the client's
reason(s) for treatment and the services provided in the discharge summaries. Four with client to five Charts are pulled randomly every month for monitoring by the director and a chart monitoring workgroup has been established by staff to ensure compliance. |
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 patient records on December 11, 2007, the facility failed to document follow-up information on patients discharged from treatment. A review of four of four patient records, specifically #10, 12, 13 and 15, revealed that no follow-up was conducted on patients discharged from treatment as per project policy.
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Plan of Correction
Facility Director has educated/instructed staff on documenting all follow-up calls and attempts at contacting clients after discharge regardless if contact with the client had been made or not. Staff was also informed as per DOH licensing specialist that calls from family members informing staff that client has been incarcerated can be considered the follow-up contact.
Four to five charts are pulled randomly every month for monitoring by the director and a chart monitoring workgroup has been established by staff to ensure compliance. |