INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on September 8 - 9, 2010 by staff from the Division of Drug and Alcohol Program Licensure.
Based on the findings of the on-site inspection, Holcomb Associates, 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 October 13, 2010.
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Plan of Correction
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705.28 (b) (3) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(3) Repair inoperable smoke detectors or fire alarms within 48 hours of the time the detector or alarm is found to be inoperative.
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Observations
Based on the review of the fire drill log, administrative documentation, and an interview with the clinical manager, the facility failed to repair inoperable smoke detectors or fire alarms within 48 hours of the time the detector or alarm was found to be inoperative.
The findings include:
On September 8 - 9, 2010 the facilities fire drill log and administrative documentation was reviewed.
The log documented on 5/5/10 and 6/12/10 that a manual alarm via intercom was used.
The log documented on 7/7/10 and 7/13/10 that the alarm system was in the process of repair...a manual system was temporarily implemented until repair was complete.
The log documented on 8/17/10 that a manual alarm system was used. The log also documented under problems or training needs observed "system inspected and the mother board needs to be replaced. The part was ordered and repair scheduled."
A review of the facilities administrative documentation noted that on September 1, 2010 the inoperable smoke detectors or fire alarms were serviced and operable.
An interview was conducted with the facilities clinical manager on September 9, 2010, and she confirmed that repairs were not done within 48 hours of the time the detector or alarm was found to be inoperative.
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Plan of Correction
The Clinical Supervisor will set off the fire alarm at each monthly fire drill. At that time if the alarm has malfunctioned in any way, repair services will be sought immediately. The management staff will ensure the alarm is fixed within 48 hours of the time it was found inoperable.
This will ensure Holcomb Behavioral Health Systems' compliance with Licensure Standard 705.28 (b) (3).
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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records and a review of the facility's policies and procedures manual, the facility failed to complete a preliminary treatment and rehabilitation plan.
The findings include:
The facility's policy states:
28.13 A preliminary treatment plan will be developed by the counselor and client within 7 days of the initial clinical assessment.
28.13.1 Preliminary treatment plans will document critical problems areas and strategies for addressing these issues.
28.13.2 Barriers to treatment will be listed on plan and considered in the development of goals and objectives.
Seven active and three closed client records were reviewed on September 9, 2010 for the completion of a preliminary treatment and rehabilitation plan.
The facility failed to complete a preliminary treatment plan within seven days of the initial clinical assessment per policy in three of seven client records, specifically records # 2, 5, and 6.
Client # 2 was admitted to the program on 8/4/10.
The preliminary treatment plan was due on 8/11/10 within 7 days of the initial clinical assessment.
The facility failed to document a preliminary treatment plan at the time of review on 9/9/10.
Client # 5 was admitted to the program on 7/21/10.
The preliminary treatment plan was due on 7/28/10 within 7 days of the initial clinical assessment.
The facility failed to document a preliminary treatment plan at the time of review on 9/9/10.
Client # 6 was admitted to the program on 7/27/10.
The preliminary treatment plan was due on 8/3/10 within 7 days of the initial clinical assessment.
The facility failed to document a preliminary treatment plan at the time of review on 9/9/10.
This is a repeat deficiency from the April 23, 2010 inspection.
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Plan of Correction
Clients 2, 5, and 6 have documented treatment plans as of 10/13/10.
All current staff will be trained in the completion and timeliness of the Preliminary Treatment and Rehabilitation Plans on October 25, 2010. All clinical staff will fill this form out upon admission at the first face to face contact.
The Clinical Supervisor will conduct regular chart reviews for the next 4 weeks to ensure compliance. When all charts are in compliance the Clinical Supervisor will conduct random monthly chart reviews to ensure compliance with Licensure Standard 709.91 (b)(7), as well as facility policies 28.13, 28.13.1, and 28.13.2
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709.93(a)(10) LICENSURE Client records
709.93. 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 the review of client records and the facility's policies and procedures manual, the facility failed to document a complete client record which included a discharge summary.
The findings include:
The facility's policy states:
28.23 Discharge summaries will be completed within 7 days of the client's discharge.
28.23.1 Discharge summaries will document, at minimum:
28.23.1.1 the reason for referral/services
28.23.1.2 a summary of services provided
28.23.1.3 a summary of the client's response to services
28.23.1.4 the client's clinical status/condition at discharge
28.23.1.5 the discharge diagnosis
28.23.1.6 aftercare recommendations
Three closed client records were reviewed on September 9, 2010 for discharge summaries.
The facility failed to document a discharge summary per policy in one of three client records reviewed, specifically, client record # 10.
Client # 10 was admitted to the program on 2/16/10 and discharged on 6/29/10.
The discharge summary was completed on 8/4/10.
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Plan of Correction
All current staff will be trained in the completion and timeliness of the Discharge Summary on October 25, 2010. All clinical staff will fill this form out upon admission at the first face to face contact.
The Clinical Supervisor will conduct regular chart reviews for the next 4 weeks to ensure compliance. When all charts are in compliance the Clinical Supervisor will conduct random monthly chart reviews to ensure compliance with Licensure Standard 709.93 (a) (10), as well as facility policies 28.23, 28.23.1, 28.23.1.1, 28.23.1.2, 28.23.1.3, 28.23.1.4, 28.23.1.5, 28.23.1.6. |