INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the May 27, 2009 licensure renewal inspection. The follow-up inspection was conducted on November 12, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, New Insights, Inc. 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 December 12, 2009.
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Plan of Correction
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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the facility's fire drill record, the facility failed to conduct fire drills on different times of the day and on different staffing shifts.
Findings:
The fire drill record was reviewed on November 12, 2009 for the months of August, September and October 2009 to ensure compliance of conducting fire drills at different times of the day and on different staffing shifts.
On August 28, 2009 the fire drill was conducted at 9:00 A.M.
On September 17, 2009 the fire drill was conducted at 12:30 P.M.
On October 19, 2009 the fire drill was conducted at 12:30 P.M.
The facility's hours of operation are Monday through Thursday 9 am to 9 PM, Friday 9 am to PM, Saturday 9 am to 1 PM.
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Plan of Correction
On December 17, 2009, an evening fire drill will be conducted at both the Lemoyne and York facilities. The Executive Director will revise the New Insight's policy to require a monthly fire drill to the plan in the evening on a quarterly basis,or every third drill will take place during the evening hours. These fire drills are conducted and documented by the Senior Support Staff person in (Lemoyne), and the Facility Office Manager (York). Upon conducting a fire drill at either facility, a copy of the results recorded in the log will be forwarded to the Executive Director. This copy will provide conformation of the drill being conducted and to review any potential safety issues that may need attention.
The policy will be revised by the Executive Director by December 31, 2009. |
709.92(a) 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:
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Observations
Based upon a review of client records and interviews with the facility owner and the facility's compliance officer on November 12, 2009 the facility failed to develop an individualized comprehensive treatment plans with each client.
The findings were:
Per the facility owner and compliance officer an individual treatment plan is to be developed with the client within 30 days of admission.
Eight client records were reviewed on November 12, 2009. Four of eight records, numbers 2, 3, 4 and 5, contained treatment plans that had nearly identical goals and action steps. Goal #1 Abstinence, Goal #2 Disease Education, Goal #3 Sober Support Network. The treatment plans were not individualized to include individual needs of the clients as identified in the psychosocial histories and psychosocial evaluation.
Client #2 was admitted on 9/29/09. The comprehensive treatment plan was developed on 10/9/09. Client #2 was identified to have problems with isolation and anger as coping mechanisms. These were not addressed as part of the client ' s comprehensive treatment plan.
Client #3 was admitted on 8/25/09. The comprehensive treatment plan was developed on 9/1/09. Client #3 was identified to have problems with depression, legal issues, transportation issues, physical problems, difficulty in managing unstructured time and poor coping skills. These were not addressed as part of the client ' s comprehensive treatment plan.
Client #4 was admitted on 8/20/09. The comprehensive treatment plan was developed within 30 days of admission. Client #4 was identified to have problems with difficulty in managing unstructured time, undiagnosed/untreated mental health issues and poor coping skills. These were not addressed as part of the client ' s comprehensive treatment plan.
Client #5 was admitted on 10/8/09. The comprehensive treatment plan was developed within 30 days of admission. Client #5 was identified to have problems with Post Traumatic Stress Disorder, legal issues, difficulty in managing unstructured time and poor coping skills. These were not addressed as part of the client ' s comprehensive treatment plan.
Client #1 was admitted on September 8, 2009. The treatment plan was to be completed on October 8, 2009. Although unable to review the treatment plan at the time of the client record review a treament plan with a completion date of October 13,2009 was provided for review at the end of the survey.
This was confirmed by the owner and the Compliance Officer.
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Plan of Correction
The Program Director will review with the counseling staff at the staff meeting on December 23, 2009, that the goals and objectives for the initial treatment plan needs to be individualized for each client based on the specific needs of the client. The Program Director will do an in-service training at the staff meeting on how to use the bio-psychosocial profile to determine each client's needs, and how that is translated into the initial treatment plan. The Program Director will sign off on all treatment plans and have the counselors redo them if the treatment plan does not meet the specific needs of the client. The Program Director will also discuss that if specific needs of the client are not going to be addressed during treatment, it will be indicated in the composite. |
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 include one of the goals from the comprehensive treatment plan that was identified as not being completed and needing to be continued on the revised treatment plan.
The findings were:
On November 12, 2009 eight client records were reviewed, one of eight outpatient client records, client record #3, was required to have a treatment plan update.
The treatment plan update summary in client record #3 indicated that goal # 3, developing a sober support network, had not been completed. The clinician indicated that the client had not attended any AA meetings and all objectives were to be continued on the revised treatment plan. The objectives were for the client to attend Alcoholics Anonymous meetings one time per week for a period of 8 - 12 weeks, discuss the pamphlet on sponsorship with the counselor and to identify 5 - 7 sources of sober support.
Goals #1, abstinence, and goal #2, disease education, were both restated on the revised treatment plan. The objective for goal #1 was revised to instruct the client to not have drugs or alcohol in the house. The objectives for goal #2 were revised to instruct the client to read and discuss "Addiction: A Bio-Psychosocial Disease", "DUI" and "The Cost of Addiction".
A new goal, regarding self-care, was added to the revised treatment plan; however, goal #3 was not restated on the revised treatment plan.
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Plan of Correction
The program director will review with the counseling staff at the staff meeting on 12/23/09, that when a treatment plan update is done, it needs to indicate the progress, or lack of progress, that the client has made with each goal and objective. The program director will also review at the same staff meeting that the previous goals and objectives are to be carried forward to the next treatment plan update. If a previous goal or objectives have not been reached as a result of the client's unwillingness, or due to a change in the client's needs; henceforth, the goal and objectives are no longer applicable to the client's treatment. This will be indicated on the treatment plan revision when summarizing the previous treatment plan. In this situation, the clinician will review those previous goals and objectives with the client at the time of doing a treatment plan update to determine their appropriateness or to determine a better way to engage the client in that goal. The program director will sign off on all treatment plan updates and will have the counselor redo them if not compliant with the above. |