INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on March 28 & 29, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Cove Forge Behavioral Health System at Williamsburg 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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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as cameras were operating in the group counseling rooms identified as group rooms A and B located in Dilbert Hall. This is a repeat citation from the March 29, 2022 licensing inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
These two group rooms are patient lounges that are used for group in the morning. An exemption will be filed on 4/25/23 to request the cameras be open for all activities as a safety measure. The cameras are utilized to monitor patient activities and behavior outside of group times. It was a safety measure that was added several years ago due to the acuity of our patients.
In the even the exemption is not granted, the cameras will be covered with a temporary cover at the start of every group and uncovered upon completion of group.
The facility director and COO will ensure compliance if the exemption is not granted. Compliance will be monitored via those cameras going black during group times. |
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 client record that included a discharge summary within seven days of discharge, per facility policy and procedures, in two out of three applicable discharged records reviewed.Client # 16 was admitted on December 8, 2022 and discharged on March 10, 2023. There was no documentation of a discharge summary in the client record. Client #17 was admitted on January 9, 2023 and discharged on March 10, 2023. A discharge summary was due no later than, March 17, 2023, per facility policy; however, it wasn ' t completed until March 22, 2023. These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
The partial hospital counselors will be re-educated on the importance of completing the discharge summary within 7 days of discharge.
The partial program clinical supervisor will ensure compliance.
The PHP clinical supervisor will audit 5 charts for the next 3 months to ensure compliance. |
709.83(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record that included follow up information within seven days of discharge per facility policy, in two out of three applicable records reviewed.Client # 16 was admitted on December 8, 2022 and discharged on March 10, 2023. There was no documentation of follow up information in the client record. Client #17 was admitted on January 9, 2023 and discharged on March 10, 2023. There was no documentation of follow up information in the client record. This is a repeat citation from the March 29, 2022 licensing inspection. These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
The partial hospital case managers have been re-educated on the importance of conducting follow up calls on clients within seven days of discharge. The two clients who did not receive follow up calls will receive calls within the next 3 business days.
The Case management supervisor will ensure compliance.
The case management supervisor will audit 10 patients for the next 3 months to ensure compliance. |