INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 29-31, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Insights, 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 August 29, 2008.
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Plan of Correction
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based upon a review of five personnel records on July 29 - 30, 2008, the facility failed to instruct staff in the use of the fire extinguisher within seven days of employment.
Findings:
One of five records reviewed, #3, showed that the staff person had a hire date of 04/07/08 and had not received the required training until 06/17/08.
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Plan of Correction
As stated in our policy and procedures, the staff person assigned to opening the personnel file and providing an office orientation will instruct the new employee on "fire safety". This orientation will include instruction on the use of the fire extinguisher and their assigned tasks during emergencies. The staff designated to provide this instruction is the Facility Office Manager (York) and either the Assistant Director (or) Chief Financial Counsel (Lemoyne). In order to assure compliance with this fire safety instruction for new staff, the Executive Director will confirm that this has occurred with evidence in the personnel file. This will be implemented immediately by the Executive Director as a routine check upon hiring new staff. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based upon a review of five personnel records on July 29 - 30, 2008, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies within seven days of employment.
Findings:
One of five records reviewed, #3, showed that the staff person had a hire date of 04/07/08 and had not received the required training until 06/17/08.
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Plan of Correction
As stated in our policy and procedures, the staff person assigned to opening the personnel file and providing an office orientation will instruct the new employee on "fire safety". This orientation will include instruction on the use of the fire extinguisher and their assigned tasks during emergencies. The staff designated to provide this instruction is the Facility Office Manager (York) and either the Assistant Director (or) Chief Financial Counsel (Lemoyne). In order to assure compliance with this fire safety instruction for new staff, the Executive Director will confirm that this has occurred with evidence in the personnel file. This will be implemented immediately by the Executive Director as a routine check upon hiring new staff. |
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based upon a review of five personnel records on July 29, 2008, the facility failed to maintain written job descriptions for all project positions.
Findings:
One of five records reviewed, #1, lacked a written job description for the position of Project Director.
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Plan of Correction
The overall list of regular duties and responsibilities will be outlined for the Project Director (Executive Director). This outline will then be converted to a formal job description. This task is the responsibility of the Executive Director and will be completed by September 30, 2008. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based upon a review of eleven client records on July 29 - 30, 2008, eight were reviewed for patient confidentiality. Of those eight records, two records were for the partial hospitalization program and six were outpatient records. The facility failed to maintain client confidentiality in two of two partial hospitalization program records reviewed.
Findings:
The facility released client identifying information for urine analysis samples without the benefit of a Quality Service Organization Agreement with the testing laboratory or an informed consent from the client in client records #1 & 2.
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Plan of Correction
When New Insights changed its laboratory services contractor several months ago, it failed to have a new Quality Service Organization Agreement executed with the new testing laboratory. The Executive Director will immediately make contact with AIT Laboratory to arrange for a Quality Service Organization Agreement to be completed no later than August 31, 2008. |
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 upon a review of eleven client records on July 30 & 31, 2008, nine records reviewed were for the outpatient program. Of those nine records, six were reviewed for individualized treatment plans.
Findings:
The facility failed to develop an individualized treatment plan based upon the biopsychosocial evaluation of the client in one of six records reviewed, specifically record #5.
The client was admitted on 06/11/08, the individual treatment plan was completed on 06/11/08 and the biopsychosocial evaluation was not completed until 07/8/08, the date of the client's discharge from treatment. Treatment plans must be based on the evaluation to be individualized.
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Plan of Correction
The clinical supervisor will review with the clinical staff at the staff meeting on 10/1/08 that the master treatment plan can not be affectively developed until the bio-psycho-social evaluation is completed. At the time that each of the clinical staff has the clinical supervisor sign off on the master treatment plan, the clinical supervisor will review the clinical chart to confirm that the bio-psycho-social evaluation has been fully completed. |
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 upon a review of eleven client records on July 30 & 31, 2008, nine records reviewed were for the outpatient program. Of those nine records, two required treatment plan updates .
Findings:
The facility failed to complete a treatment plan update in one of two records requiring an update, specifically record #4.
The client was admitted on 04/30/08, the individual treatment plan was completed on 05/08/08 and as of the date of the licensing inspection no treatment plan update had been completed.
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Plan of Correction
The clinical supervisor will review with the clinical staff at the staff meeting on 10/1/08 the required time frames for the development of the master treatment plan, and treatment plan updates; for clients in outpatient, intensive outpatient, and partial hospitalization levels of care. The clinical supervisor will develop a spread sheet that each clinician can keep their active client list on that reflects the client's name, date the master treatment plan is due and done, and the date treatment plan updates are due and done. This will be presented to the clinical staff at the staff meeting on 10/1/08. The clinical supervisor will randomly review one chart of each clinician at the time of their supervision every 2 weeks to monitor for compliance with treatment plan updates. |
709.93(a)(2) 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:
(2) Medication records.
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Observations
Based upon a review of eleven client records on July 30 & 31, 2008, nine records reviewed were for the outpatient program. Of those nine records, five required documentation for medications as identified in the medical history portion of the client records.
Findings:
The facility failed to properly document medications listing the name of the medication, dosage and/or frequency of use in three of the five records reviewed, specifically records #4, 6 & 7.
Client record #4 lacked the dosage for the medication Effexor, record #6 simply listed a medication as a "Cholesterol Pill" and failed to list the dosage and record #7 failed to document any medications even though the response to the question, are you taking any over the counter or prescribed medications, was yes.
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Plan of Correction
The clinical supervisor will review with the clinical staff and front office staff, at the staff meeting on 10/15/08 that a complete and accurate medication list is required for all clients being admitted into treatment. The front office staff will review the medical history form after completion by the client, at the time of the initial assessment. If medication names, doses, or frequency of use is not completed, the front office staff will ask the client to bring in the additional information by the second session. The clinician will also review the medical history form at the time of the initial assessment and will question the client if there is incomplete medication information and ask for the remaining medication information to be brought in by the next session. The clinical supervisor will randomly review one chart from each clinician at the time of clinical supervision every 2 weeks to monitor for 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 upon a review of eleven client records on July 30 & 31, 2008, nine client records reviewed were for the outpatient program. Of those nine records, four required discharge summaries.
Findings:
The facility failed to complete discharge summaries in two of four records reviewed. Specifically #8 & 10.
Client #8 was discharged on 04/01/08 and client #10 was discharged on 07/02/08. Neither record had a discharge summary as of the date of the licensing inspection.
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Plan of Correction
The clinical supervisor will review with the office staff at the staff meeting on 10/1/08 that the charts of all clients that have been discharged will be audited by the front office staff to assure that discharge summaraies have been completed by the clinician. Any closed out chart that does not have a completed discharge summary will be brought to the attention of the clinical supervisor for him to address with the clinician. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on an interview with the facility director and a review of the compliance plan along with the list of active clients presented by the facility director on July 30, 2008, it was determined that the facility was over capacity.
Findings:
The facility had a census of 98 outpatient drug-free clients, but is only licensed for a capacity of 80 outpatient drug-free clients.
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Plan of Correction
The Executive Director will immediately put a hold on admissions to the Lemoyne outpatient program. This hold will be enforced until the current census can be reduced to the approved capacity of (80). The total outpatient census will be monitored at both sites on a weekly basis by the Accounts Manager. Whenever the census at either site would exceed the set capacity, the Executive Director will be notified to make immediate adjustments. When the census is below capacity at either site, the Accounts Manager will inform the Support Staff at the respective facility of the available outpatient openings to be filled. This task is the prime responsibility of the Executive Director. The Accounts Manager will have a major responsibility in monitoring and communicating the necessary adjustments at both facilities. The weekly monitoring and reporting system by the Accounts Manager will be in place by August 15, 2008. |