INITIAL COMMENTS
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This report is a result of a supervisory review of the written report of the findings of an on-site licensure renewal inspection that was conducted on February 7, 2014 and February 10, 2014, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the supervisory review of findings from the on-site inspection, ADAPPT House 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 supervisory review.
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Plan of Correction
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document the instruction of staff in the use of a fire extinguisher upon staff employment, in two of three personnel records reviewed.
The findings included:
Four personnel records were reviewed. Three records contained documenation of newly hired staff and required documentation that fire extinguisher training had been provided in accordance with the standard. The facility failed to document the completion of fire extinguisher training upon employment in personnel records # 2 and 3.
Employee # 2 was hired on September 24, 2013. The training was not documented until October 7, 2013.
Employee # 2 was hired on January 2, 2014. The training was not documented until January 15, 2014.
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Plan of Correction
The H.R. Specialist/designee and Training Coordinator shall ensure that all new hires receive "fire extinguisher" training within seven days of employment.
The H.R. Specialist/designee and Training Coordinator shall meet on a weekly basis to ensure and coordinate the timely occurrence of trainings.
A certificate of completed "fire extinguisher" training shall be placed in the individual's training file. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to document the training of staff in assigned tasks during emergencies upon staff employment, in two of three personnel records reviewed.
The findings included:
Four personnel records were reviewed. Three records included documentation for newly hired staff and required documentation that training in emergencies had been provided in accordance with the standard. The facility failed to document the completion of training upon employment in personnel records # 2 and 3.
Employee # 2 was hired on September 24, 2013. The training was not documented until October 8, 2013.
Employee # 2 was hired on January 2, 2014. The training was not documented until January 15, 2014.
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Plan of Correction
The H. R. Specialist/designee and Training Coordinator shall ensure that all new hires receive "Emergency" training within seven days of employment.
The H.R. Specialist/designee and Training Coordinator shall meet on a weekly basis to ensure and coordinate the timely occurrence of trainings.
A certificate of completed "Emergency Plan" training shall be placed in the individual's training file. |
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 the review of patient records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in eight of eight records.
The findings included:
Eight patient records were reviewed during the on-site inspection. The facility failed to ensure that an informed and voluntary consent to release information was obtained in all records. The records contained a release for the attending physician. The information to be released included only whether the client is or is not in treatment, the prognosis of the client, the nature of the project, a brief description of the progress of the client and a short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse. The purpose stated for the release of information stated "conducting medical examination, medical care and medical monitoring." The information to be released was too specific for the purpose identified.
Additionally, patient record # 5 contained a consent to release information that had a patient signature which was not dated by the patient.
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Plan of Correction
Going forward, the "release of information" form referred to in the deficiency listing will be replaced with a revised release form; whereby the disclosure clearly responds to the purpose.
The Clinical Supervisor and Facility Director shall ensure that the appropriate "release of information" forms are in use, signed, and dated. |
709.51(b)(3)(i) LICENSURE Medical histories
709.51. 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, the facility failed to document a detailed history that included medical, drug or alcohol history, and personal history in two of seven records reviewed.
The findings included:
Eight client records were reviewed during the on-site inspection. Seven records were reviewed for client histories. The facility failed to document a medical history, drug and alcohol history and personal history in patient records # 2 and 5.
Client record # 2 contained a medical history, drug and alcohol history and personal history from a prior admission on June 11, 2013. The documentation was not updated for the most recent admission.
Client record # 5 contained a history documented without a date for verification of timely completion.
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Plan of Correction
1. For all clients being re-admitted, the clinical supervisor will determine the date of the bio-psycho-social evaluation (BPS) that was completed during the most recent prior admission.
2. When the BPS due date of the current admission is 6 months or less from the completion date of the BPS that was completed during the most recent prior admission:
a. The clinical supervisor will obtain a copy of the prior BPS from the file for the client's previous admission.
b. A counselor/counselor assistant will update the prior BPS making all changes in red and recording "No Change" in red for all prior information where that applies.
c. Counselor/counselor Asst. will complete a new BPS summary based on the updated information.
3. When the BPS due date of the current admission is more than 6 months after the completion date of the BPS that was completed during the most recent prior admission, a new BPS will be completed.
4. To ensure that no prior BPS will be updated if it is more than 6-months old, the clinical supervisor alone will have access to the closed files and will not make available to counselors / counselor assistants any BPS that is more than 6-months old.
5. The clinical supervisor will inform all counselors / counselor assistants of this citation, explain the reason for it and explain the plan of correction.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based upon a review of patient records, the facility failed to document a psychosocial evaluation that included an assessment of the patient's problems/needs, support systems, coping mechanisms, negative factors, the patient's attitude toward treatment and counselor conclusions in four of seven records.
The findings included:
Eight patient records were reviewed during the on-site inspection. Seven records were reviewed for psychosocial evaluations. Four records failed to include all areas in a psychosocial evaluation, # 1, 2, 5 and 7.
Patient # 1 was admitted on November 19, 2013. The psychosocial evaluation dated November 26, 2013, failed to document an assessment by the counselor that included the support system, coping mechanisms, negative factors, patient's attitude toward treatment and counselor's conclusions. The documentation did not include an evaluation by the clinician for the required components.
Patient # 2 was admitted on October 8, 2013. The psychosocial evaluation dated October 14, 2013, failed to document an assessment by the counselor that included the patient problems/needs. The documentation did not include an evaluation by the clinician for the required components.
Patient # 5 was admitted on January 27, 2014. The psychosocial evaluation dated February 3, 2014, failed to document an assessment by the counselor that included the patient problems/needs and coping mechanisms. The documentation did not include an evaluation by the clinician for the required components.
Patient # 7 was admitted on January 13, 2014. The psychosocial evaluation dated January 21, 2014, failed to document an assessment by the counselor that included the patient problems/needs and coping mechanisms. The documentation did not include an evaluation by the clinician for the required components.
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Plan of Correction
1. Train program staff in developing psychosocial evaluations that contain all the elements specified by BDAP regulations.
2. Provide staff with written guidelines that include all the elements specified by BDAP regulations for use in writing psychosocial evaluations.
3. Clinical Supervisor will use BDAP regulation based guidelines as standard when reviewing psychosocial evaluations for his/her signature.
4. Clinical Supervisor will monitor psychosocial evaluations for compliance with BDAP regulations as part of monthly chart audit.
5. Report on the compliance with BDAP regulations of psychosocial evaluations supervision sessions with counselors.
6. Hold program staff accountable for compliance with BDAP regulations in the completion of psychosocial evaluations.
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709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based upon a review of patient records, the facility failed to document a complete patient record that included record of services in five of eight records reviewed
The findings included:
Eight patient records were reviewed during the on-site inspection. All records were reviewed for a record of service. Five patient records, # 2, 4, 5, 6, and 7 failed to include individual sessions in the services identified.
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Plan of Correction
1. An up to date chronological record of services (CRS) will be maintained in a computer file for each client [as has been and will be done].
2. A hardcopy printout of the complete CRS will be included in the case file of each client upon their discharge.
3. A hardcopy printout of an up to date CRS will be included in the case file of each active client that is submitted to the DDAP auditor during the licensing inspection.
4. The clinical supervisor will, as part of monthly chart review, monitor the up to date maintenance and final completion of record of service for compliance with BDAP standards. |