INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the August 19, 2010 licensure renewal inspection. The follow-up inspection was conducted on February 23, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 and a plan of correction is due on March 30, 2011.
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Plan of Correction
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on the review of fire drill records during the onsite inspection, the facility failed to document the number of participants for each fire drill and the exit used for each fire drill as required.
The findings included:
The fire drill log was reviewed for the past year since the facility was given the approval to commence services. Fire drills were documented monthly as required, however, the fire drill log did not document the number of participants for fire drills conducted on the following dates : 9/10/10; 10/5/10; 11/1/10; 12/29/10; 1/25/11; 2/14/11. The exit used was not documented for fire drills conducted on the following dates: 12/29/10; 1/25/11; 2/ 14/ 11.
The findings were reviewed with a partner in the practice and were not disputed.
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Plan of Correction
The fire drill log sheet will be corrected adding an "exit used" column and a "participants" column. This will be done by 4/10/2011. This will be the duty of the clinical supervisor. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of client records during the onsite inspection, the facility failed to document medical histories which included a personal medical history, family medical history and a review of symptoms and illnesses experienced by the client.
The findings included:
Only one closed client record was available for review from the last year. The record did not include information in the documentation which addressed the family history of illness or a symptoms and illness checklist or narrative.
The findings were reviewed with a partner in the practice and the findings were not disputed.
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Plan of Correction
The clinical supervisor is reviewing a new assessment tool provided the licensing specialist that performed the inspection. The assessment tool contains sections that require input for family history of illness or a symptoms and illness checklist.
The clinical supervisor will implement this tool or create an addendum to the current assessment tool that will address the missing information. |
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 the review of client records during the onsite inspection, the facility failed to document a personal history which included historical and pertinent personal data including: family, sexual, and others where appropriate.
The findings included:
Only one closed client record was available for review from the last year since the facility was opened. The record did not include information in the documentation which addressed the history of family interrelationships in the family of origin and current family constellation or the client's sexual preference, history of abuse or pertinent patterns of sexual behavior. Furthermore the historical data reflected did not connect the impact of D&A abuse to various significant dimensions of the client's life and behavior such as educational, employment, recreational, etc.
The findings were reviewed with a partner in the practice and were not disputed
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Plan of Correction
The clinical supervisor is reviewing a new assessment tool provided the licensing specialist that performed the inspection. The assessment tool contains sections that require input for history of family interrelationships in the family of origin and current family constellation or the client's sexual preference, history of abuse or pertinent patterns of sexual behavior.
The impact of alcohol and other drugs will be documented on each dimension of the client's life as indicated on a new assessment tool.
The clinical supervisor will implement this tool or create an addendum to the current assessment tool that will address the missing information. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records during the onsite inspection, the facility failed to document type and frequency of services to be offered to the client on the treatment plan as required.
The findings included:
Only one closed client record was available for review from the last year since the facility was opened. The record did not include information in the treatment plan documentation which addressed the frequency with which the client would receive services. The record stated only that the client would receive one hour sessions . No indication of the frequency of the sessions was documented ( weekly, bi-weekly, monthly,etc.).
The findings were reviewed with a partner in the practice and were not disputed.
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Plan of Correction
The clinical supervisor will add a section in the individualized treatment plan template that will include line for frequency of sessions. This will be completed by 4/10/2011. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on the review of client records during the onsite inspection, the facility failed to document a record of services which documented the duration of each service provided to the client.
The findings included:
Only one closed client record was available for review from the last year since the facility was opened. The record of services did not include the duration of each service provided to the client. Each of the entries from 2010 ( 9/21, 9/24, 9/29 and 10/1) failed to include the duration of services offered to the client.
The findings were reviewed with a partner in the practice and were not disputed.
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Plan of Correction
The clinical supervisor will change the Service Record to include a column that will require duration of service provided to be recorded. This will be completed by 4/10/2011. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on the review of client records during the onsite inspection, the facility failed to document progress notes which included the dated signature of the individual making each entry.
The findings included:
Only one closed client record was available for review from the last year since the facility was opened. The progress notes did not include the dated signature of the individual making each entry. Each of the entries from 2010 ( 9/21, 9/24, 9/29 and 10/1) failed to include the dated signature of the counselor.
The findings were reviewed with a partner in the practice and were not disputed.
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Plan of Correction
The clinical supervisor will review files monthly to insure all progress notes are signed and dated by the therapist. This has started as of 4/1/2011. |