INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 8-11, and 14-15, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Care Center dba SPHS Care Center 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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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on observation and a physical plant inspection, the facility failed to provide an unobstructed exits from all exits.
The findings include:
A physical plant inspection was conducted on May 15, 2012. A double key deadbolt is located on all exits. This does not provide for unobstructed exits at all times.
The finding was reviewed with the facility director and was not disputed.
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Plan of Correction
The Facility Director notified the landlord in writing on May 16, 2012 that the locks and or doors on the facility entrance need changed. The landlord has indicated that he is checking on a contractor and supplies for the work to be completed. The Director will continue to maintain contact with the landlord until the doors and/or locks are brought into compliance. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to provide counseling to a client on a regular and scheduled basis including individual counseling, at least twice weekly in four of the five records reviewed in the partial hospitalization activity.
The findings include:
Five client records from the partial hospitalization activity were reviewed on May 10, 2012. All five records were required to include documentation of individual counseling at least twice weekly. Four of the five records did not document individual counseling at least twice weekly. Client records # 2, 3, 24, and 25 did not include two individual sessions per week.
The findings were reviewed with the facility director and the clinical supervisor and were not disputed.
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Plan of Correction
The Clinical Supervisor has met with all partial hospitalization staff and has reviewed the requirement of providing two individual sessions per week with clients enrolled in partial hospitalization with these staff. The Supervisor will also review the documentation to indicate if a client has cancelled or no showed their scheduled appointment.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly clinical and chart supervision.
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709.83(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete discharge summary in one of one applicable records reviewed in the partial hospitalization activity.
The findings include:
Five client records from the partial hospitalization activity were reviewed on May 10, 2012. One record was required to include documentation of a discharge summary. The facility failed to document a complete discharge summary.
Client record # 2 was admitted on 2-13-2012 and discharged on 3-15-2012. The documented discharge summary did not include the reason for treatment, services offered, or the clients response to treatment.
The findings were reviewed with the facility director and the clinical supervisor and were not disputed.
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Plan of Correction
The Clinical Supervisors shall review the requirement to include detailed information regarding the client's referral, progress, goals and discharge status in the discharge summaries with clinical staff. This remediation will occur at staff meetings on May 31, 2012 and June 7, 2012. The clinical supervisor will have a follow up note placed in the client record expanding the information that was deficient in the identified client record for future reference.
It shall be the responsibility of the Clinical Supervisors to insure ongoing compliance with this regulation through weekly clinical and chart supervision.
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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 provide an informed consent from the client for the disclosure of information.
The findings include:
1.) Release of information forms were missing the purpose for the release of information on consent to release information forms in client records # 1, 2, 3, 5 and 6.
2.) A release of information form included a list of the specific information to be released that exceeded the the limitations imposed at 4 Pa. Code subsection 255.5 (b) on consent to release information forms documented in client record #3. A consent to release information form for a release of information to a third party payer failed to identify the specific information to be disclosed in client record #10.
3.) A release of information form was not signed by the client and information was disclosed to a laboratory in client record #4.
The findings were reviewed with the facility director and the clinical supervisor and were not disputed.
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Plan of Correction
Facility will obtain appropriate Consents to Release Information for clients #1,2,3,4,5,6,10 where obtaining the consents is possible and remains relevant. The Clinical Supervisors will develop a training update of the accurate and appropriate completion of consents to release information by June 30, 2012 and present the training to all staff during July 2012 staff meetings and clinical supervision. Information to be covered will include appropriate purpose and appropriate choice of information to be released, at a minimum.
It shall be the responsibility of the Clinical Supervisors to insure ongoing compliance with this regulation through weekly chart and clinical supervision.
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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 document a treatment plan update in one of one client record.
The findings include:
Eleven client records were reviewed on May 10-11, 2012. One client record was required to include documentation of a treatment plan update.
Client record #11 included documentation of a treatment plan update on 4-12-2012 which included new goals and objectives, but failed to include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.
The findings were reviewed with the facility director and the clinical supervisor and were not disputed.
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Plan of Correction
The Clinical Supervisors shall review the requirement to include an assessment of client's progress on treatment goals in the treatment plan update with clinical staff. This remediation will occur at staff meetings on May 31, 2012 and June 7, 2012. The D/A supervisory staff will review the format of the treatment plan update and determine a format that enhances the documentation regarding assessment and progress in a clear, prompted area on the form for the counselor to complete.
It shall be the responsibility of the Clinical Supervisors to insure ongoing compliance with this regulation through weekly clinical and chart supervision.
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