INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 30, 2007 through August 1, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, George Junior Republic 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 24, 2007.
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Plan of Correction
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705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based on a physical plant inspection, the facility failed to provide clients with a mattress in good repair. Two mattresses in Prasse Cottage had torn fabric. One pillow was blood stained.
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Plan of Correction
The two mattresses and pillow have been replaced. The Facility Director and Counselor Parents will monitor that mattresses and pillows are in good repair. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on the physical plant inspection, the facility failed to secure client records in a locked container. Closed client records were stored on the floor and on various shelves in a locked closet. The closet was accessible by all staff and used as a multi-purpose storage area that contained items such as paint and paper supplies.
In addition, a counselor at Memorial Cottage stored client records at an office off campus site which has no connection with the facility. While conducting the physical plant inspection, inspectors asked staff if the locked file cabinet was the cabinet where client records were stored. A staff member explained that this was the cabinet for client records, but the records were being stored at an off campus facility.
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Plan of Correction
The files in the closet have been removed and locked in appropriate file cabinets. The files from Memorial cottage have been returned to the locked file cabinet within the cottage. The Facility Director will review policy with all staff and monitor that the files are locked appropriately. |
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 on a review of client records, the facility failed to obtain an informed and voluntary consent to release information. Information was released to the funding source without a signed consent by clients in ten of ten records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10. A general medical consent was utilized which did not include the components of a consent to release form as identified under 709.28 (c)(1-6).
Information was released to Medical Assistance without client consent in two of ten client records reviewed, #3 and 5.
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Plan of Correction
Client consent will be obtained for release of information as identified under 709.28(c)(1-6). A new medical consent form will be developed to include these standards. The Facility Director will monitor compliance. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to comply with state confidentiality laws imposed at 4 Pa. Code 255.5(b). Specific information released to juvenile probation and children, youth and families exceeded that allowed by 4 Pa. Code 255.5(b) in five of ten records reviewed, #1, 2, 3, 6 and 10. Documentation was not provided to indicate that these clients met ACT 126 requirements which allows for additional information to be released.
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Plan of Correction
Documentation will be provided by placing the court order in all client files to indicate that the clients meet ACT 126 requirements. The Facility Director will monitor records to insure that court orders are in the client file and that written informed and voluntary consent for clients are included in the file. |
709.32(c)(4) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
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Observations
Based on a review of client records, the facility failed to document an explanation for missed medication in two of ten records reviewed, #6 and 7.
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Plan of Correction
The Medication Refusal Form policy and form have been revised to insure documentation of explanation for missed medication. The Medical Director and Facility Director will monitor compliance. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. 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 obtain historical and personal data. Personal histories did not include family, legal, employment/vocational, educational, military, recreational, and sexual data in three of eight client records reviewed, #1, 6 and 10.
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Plan of Correction
The Facility Director will review with the Drug and Alcohol Social Workers all areas to be included in the personal history of the client. The Facility Director will monitor compiance. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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 a review of client records, the facility failed to document the type and frequency of treatment services in six of eight records reviewed, # 1, 2, 3, 6, 8 and 10.
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Plan of Correction
The Facility Director will monitor that the type and frequency of services is included on all treatment plans. |
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 review client progress on treatment plan updates. Treatment plan updates failed to include an assessment of progress in relationship to the previously stated gaols in seven of ten records reviewed, #1, 3, 4, 5, 6, 7 and 9.
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Plan of Correction
The Facility Director will monitor treatment goals to insure that client progress is assessed and documented in the individual goals on a monthly basis. The treatment plan updates will be addressed in treatment team meetings and include input from Counselor Parents, the Social Worker, and the Facility Director. |
709.53(a)(5) LICENSURE Progress 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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to document progress notes relative to treatment in six of ten records reviewed, #1, 3, 4, 6, 7 and 8. Progress notes were not documented in two of ten records reviewed, #5 and 10.
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Plan of Correction
The Facility Director will train and monitor Social Workers to address the goals of the client in decomentation of progress notes. Client history will be used to develop goals that are relative to treatment. The Facility Director will monitor the progress notes and files. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document aftercare plans in two of four records reviewed, #2 and 5.
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Plan of Correction
The primary Social Worker will develop an aftercare plan prior to discharge of the client. This plan will be reviewed by the Facility Director and placed in the client file. The Facility Director will monitor that Aftercare plans are included in all client files. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document work therapy on treatment plans in five of eight records reviewed, #1, 3, 5, 6 and 7.
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Plan of Correction
The primary social worker will develop and update monthly a work therapy goal for each client as part of his treatment plan. The Facility Director will monitor for compliance. |