INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 18-19, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The CARE Center -Washington 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 June 11, 2009.
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Plan of Correction
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705.28 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18 inch drop with a well-secured railing.
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Observations
Based on a physical plant inspection, the facility failed to provide a well secured handrail for all interior and exterior ramps.
The findings include:
A physical plant inspection was conducted on May 19, 2009. The interior exit ramp located at the rear of the building had a loose railing. The exterior handrail located at the rear of the building also had a loose railing.
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Plan of Correction
The facilty director has notified the building owner/landlord of the deficiency and has recieved assurances that the loose railing will be repaired and made secure. The facility director will monitor the landlord's progress with regard to this matter regularly to insure it is completed by August 1, 2009. |
709.83(a)(5) LICENSURE Client records
709.83. 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) Medication records.
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Observations
Based on client record review, the facility failed to document medication records including dosage and frequency of medication in one of two client records.
The findings include:
Thirteen client records were reviewed on May 18-19, 2009. Four client records were reviewed for the partial hospitalization program. Documentation of medications including dosage and frequency was required in two client records. The facility did not document the frequency of medication in client record # 3.
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Plan of Correction
The clinical supervisor will conduct a staff in-service on documentation of medications. Emphasis will be given to the issues of accuracy and thoroughness, including doseage and frequency documentation.
Compliance will be reviewed by the clinical supervisor and facility director during regular chart review and individual staff supervision. |
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 client record and letters of agreement review, the facility failed to document informed consent or a qualified service agreement when sending urine results to an outside agency in one of one client records.
The findings include:
Thirteen client records were reviewed on May 18-19, 2009. Urine samples were sent to an outside agency in one record. Client record # 5 did not include a signed release of information nor was a qualified service agreement in place for the outside agency.
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Plan of Correction
The clinical supervisor shall provide direct supervision to this staff person regarding confidentiality with particular attention given to properly obtaining consent and release forms. Additionally, the clinical supervisor will conduct an in-service for all staff regarding these issues.
Ongoing compliance will be the joint responsibilty of the clinical supervisor and facilty director and shall be accomplished through regular chart review and staff supervision. |
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 a review of client records, the facility failed to provide written documentation of the type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plans, in two of six client records.
The findings include:
Nine outpatient client records were reviewed on May 18-19, 2009. The individual treatment and rehabilitation plans were required to document type and frequency of treatment and rehabilitation services in six client records. The facility did not document support this information in client records #7 and 13.
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Plan of Correction
The clinical supervisor and facility director will conduct an in-services training in July, 2009 regarding the appropriate development and documentation of individual treatment and rehabilitation plans, with specific attention to the type and frequency of treatment and rehabilitation services.
Plans shall be reviewed by the clinical supervisor during individual supervision to assure compliance. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to provide written documentation of the proposed type of support services in the individual treatment and rehabilitation plans, in two of six client records.
The findings include:
Nine outpatient client records were reviewed on May 18-19, 2009. The individual treatment and rehabilitation plans were required to document support services in six client records. The facility did not document support services in client records # 7 and 13.
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Plan of Correction
The clinical supervisor and facility director will conduct an in-service training in July, 2009 regarding the appropriate development and documentation of treatment and rehabilitation plans, with specific attention given to the identification and documentaion of the type of support services to be included in individual treatment and rehabilitation plans.
Plans shall be reviewed by the clinical supervisor during individual staff supervision to insure complaince. |
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 on a review of client records, the facility failed to complete sixty day treatment plan updates in one of three client records.
The findings include:
Nine outpatient client records were reviewed on May 18-19, 2009. Sixty day treatment plan updates were required in three client records. The facility did not document treatment plan updates every sixty days in client record # 7.
Client # 7 was admitted on December 30, 2008 and the comprehensive treatment plan was completed on January 8, 2009. A treatment plan update was due by March 8, 2009; it was not completed until April 20, 2009.
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Plan of Correction
The clinical supervisor and facility director will conduct an in-service training in July, 2009 regarding the required updating of treatment and rehabilitation plans. This training will include emphasis on the update timeframes and procedures required by individual treatment and rehabilitation plans.
Plans shall be reviewed by the clinical supervisor during individual staff supervision to insure complaince. |