INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 18, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Behavioral Wellness Center at Girard Torre De La Raza 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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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential 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 all heaters were permanently mounted or installed as there was a space heater located in the nursing examination room #720.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
This finding was reviewed with facility staff during the licensing inspection.
Director of Facility will ensure that all heaters are permanently mounted or installed.
A. Responsible party ?Director
Completion date 11/1/2022
Director will perform monthly facility checks to ensure all heaters are permanently mounted or installed.
A. Responsible party ?Director
Completion date 11/1/2022
Director will address any reported heating problems to realtor to be responded in a timely manner
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709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom disclosure is made on consent to release information forms in seven of seven client records reviewed.
Each client record reviewed contained a release of information form to the "probation and parole department"; however, each form, in every record, did not include the specific name of the person, agency, or organization to whom disclosure would be made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1.The Probation and Parole release will be updated to require the inclusion of the officer's name or the county/state where the probation is in effect.
a. Responsible party -VP Operation?
Completion date ?11-1-2022
2.All staff will receive in-service training on the accurate completion of the form
a. Responsible party -Clinical Supervisor-Completion date- 1-15-2022
3.The clinical supervisor will conduct a
60 day focus review to insure that
4. Upon review of audited chart the participants are discharged |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in one of one applicable client record reviewed.
Client # 6 was admitted on June 16, 2022 and was administratively discharged on June 26, 2022. There was no documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Clinical Supervisor will retrain the staff on the protocol in carrying out an Administrative Discharge i.e. notification of termination. All staff will receive the written policy and will sign the attendance sheet verifying that they were trained in the correct protocol.
a. Responsible party ?Clinical
supervisor
Completion date 11/1/2022
2. Clinical Supervisor will add Discharge Type and Intent to Discharge (If Applicable) to the chart review form that is given to the staff to monitor form completion. This form will be given to the Clinical Supervisor to review during monthly supervision.
a. Responsible party ?Clinical
supervisor
Completion date 11/1/2022
3.Clinical Supervisor will review all Administrative Discharges as they occur to ensure compliance.
a. Responsible party ?Clinical
Supervisor
Completion date 11/1/2022 |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in one of one applicable client records reviewed.
Client # 6 was admitted on June 16, 2022 and was administratively discharged on June 26, 2022. There was no documentation in the record indicating that the client was given the opportunity to request reconsideration of the facility's decision to terminate treatment.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Clinical Supervisor will retrain the staff on the protocol in carrying out an Administrative Discharge i.e. notification of termination. All staff will receive the written policy and will sign the attendance sheet verifying that they were trained in the correct protocol.
a. Responsible party ?Clinical
supervisor
Completion date 11/1/2022
2. Clinical Supervisor will add Discharge Type and Intent to Discharge (If Applicable) to the chart review form that is given to the staff to monitor form completion. This form will be given to the Clinical Supervisor to review during monthly supervision.
a. Responsible party ?Clinical
supervisor
Completion date 11/1/2022
3.Clinical Supervisor will review all Administrative Discharges as they occur to ensure compliance.
a. Responsible party ?Clinical
Supervisor
Completion date 11/1/2022 |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document that treatment plans were reviewed and updated at least every 30 days in three of seven client records reviewed.
Client #1 was admitted August 5, 2022 and was active at the time of inspection. A treatment plan update was completed on September 12, 2022 and the next update was due no later than October 12, 2022. However, the update was not completed at the time of inspection.
Client #2 was admitted August 10, 2022 and was active at the time of inspection. The comprehensive treatment plan was completed on August 19, 2022 and the first update was due no later than September 19, 2022. However, the update was not completed until October 17, 2022.
Client# 3 was admitted August 19, 2022 and was active at the time of inspection. A treatment plan update was completed on September 2, 2022 and the next update was due no later than October 2, 2022. However, the update was not completed until October 13, 2022
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
*Clinical supervisors meet with counselors of client 1,2&3 to review procedures and policy on updating treatment plan least every 30 days completion date 11/1/2022
*Clinical Supervisors will provide an in-service training to all counseling staff regarding importance of treatment plan updating
A.Responsible party ?Clinical
Supervisor
Completion date 11/1/2022
*Clinical Supervisor will conduct random audits of three (3) charts per clinician each month to validate that staff members are correctly updating treatment plans
A.Responsible party ?Clinical
Supervisor
Completion date 11/1/2022
*Clinical Supervisor will document outcome of chart audit in Performance Improvement report quarterly by June 18, 2021.
A.Responsible party ?Clinical
Supervisor
Completion date 11/1/2022
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709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include case consultation notes, in three of seven records reviewed.
Client # 5 was admitted July 12, 2022 and was discharged October 6, 2022.
Client # 6 was admitted on June 16, 2022 and was discharged on June 26, 2022.
Client # 7 was admitted on September 18, 2021 and was discharged on November 19, 2021.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
*Clinical Supervisors will provide an in-service training to all counseling staff regarding completion of client records focusing on case consultation notes
A. Responsible party ?Director
Completion date 11/1/2022
*Clinical Supervisor will conduct random audits of three (3) charts per clinician each month to validate that staff members are documenting case consultation notes
A. Responsible party ?Director
Completion date 11/1/2022
*Clinical Supervisor will document outcome of chart audit in Performance Improvement report
a. Responsible party ?Director
Completion date 11/1/2022
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