INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 23, 2010 through June 24, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHD New Start Ii 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 July 13, 2010.
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Plan of Correction
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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on the tour of the physical plant, the facility exceeded the water temperature past 120F.
The findings include:
The physical plant tour took place on June 24, 2010 at around 9:30am. The first and second floor client restrooms water tested over 120F, at 130F which exceed the required temperature.
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Plan of Correction
The water temperature exceeded 120F. The residential supervisor adjusted the temperture to 115F on 6/25/2010 when tested. The Residential Supervisor will ensure the water temperture is taken weekly and recorded in a log. The Director will review the log monthly to ensure compliance with the standard.The log will start 7/1/2010 and this is the date for full compliance. |
705.10 (d) (7) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
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Observations
Based on the review of the fire drill record, the facility failed to ensure that fire drills are conducted on different times of the day.
The findings include:
The fire drill record was reviewed on June 24, 2010. There were no documentation of a drill conducted on the morning shift. All drills were conducted on either the afternoon, evening or overnight shifts. The following months were reviewed July, 2009, August 2009, September 2009, October 2009, November 2009, December 2009, January 2010, February 2010, March 2010, April 2010, May 2010 and June 2010.
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Plan of Correction
The fire drills were not conducted according to the standard of ensuring that all shifts are covered. The residential supervisor and the facility director will draft a schedule of fire drills for the year to ensure that all shifts have a scheduled miniumum number of fire drills. The residential supervisor will review the log monthly to ensure compliance and report the findings to the director monthly. The director will review the fire drill log quarterly to ensure we are in full compliance. The schedule and subsequent log will begin 7/1/2010 which is our date for full compliance. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on the review of the facility's policy and procedure manual and audit documentation, the facility failed to complete an annual audit by the end of the facility's fiscal year which was June 30, 2009.
The findings include:
The policy and procedure manual was reviewed on June 7, 2010. The annual audit was not made available until June 6, 2010. The documentation was required to be made available prior to the end of their 2009 fiscal year which ended June 30, 2009.
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Plan of Correction
The corporate office did not publish the annual audit within the prescribed timeframe outlined in the policy and procdure manual. In order to comply with the standard RHD central office management will ensure that the annual audit is completed and made available by December 30, 2010. The facility Director will ensure that a copy of the audit is placed in the facility policy and procedure manual. |
709.32(c)(6) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(6) Inventories.
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Observations
Based on the review of the medication record and the facility policy and procedure manual, the facility failed to document medication inventories.
The findings include:
The medication record and the facility policy and procedure manual were reviewed on June 24, 2010. Per the facility policy and procedure manual, medication will be inventoried monthly by the residential counselor. During the review of the medication records there was no documentation of inventories being conducted.
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Plan of Correction
The policy regarding medication inventory was reviewed by the Diretor and Clinical Supervisor and will remain the same. The Residential Supervisor in conjunction with the clinincal supervisor will conduct a medication review and training to ensure that individuals know how to inventory medication. The training will take place on July 23rd and the inventory will be conducted at that time and every month thereafter. The residential supervisor will ensure that the inventory is conducted each month. The Clinical Direcotr will inspect the monthly inventory sheets each quarter and report the results to the director. |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the review of client records, the facility failed to document drug and alcohol histories that included length and patterns of use in four of five client records.
The findings include:
Five client records were reviewed on June 24, 2010. Drug and alcohol histories were required in five client records. The facility did not document drug and alcohol histories that included length and patterns of use in client records # 2, 3, 4, 5 and 6. The drug and alcohol histories only documented the client's recent usage.
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Plan of Correction
After a review of the drug history it was revised by the clinincal team to incorporate detailed lenght and patterns of use. The admended format was revised in record # 2, 3, 4, 5, and 6 as of 7/1/2010. The new form will be utilized facility wide on 7/1/2010. The clinical supervisor will review all forms for completion and accuracy for the month of July. All documents have been fully revisied and to ensure future compliance the clinical supervisor will review all histories bi weekly for content and accuracy. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document complete psychosocial evaluations in four of five client records reviewed.
The finding includes:
Five records were reviewed on June 24, 2010. Psychosocial evaluations were required in four records reviewed.
Client records # 1 failed to document the client's coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions/impressions.
Client records # 2 and 4 failed to document the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions/impressions.
Client records #5 failed to document the client's assets/strengths, coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions/impressions.
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Plan of Correction
After review of the form and the records of each identified client the clinincal team headed by the Clinical supervisor revised the format of the psychosocial evaluation. Each required domain is individually identified and requires a written assessment. The clinincal supervisor and corporate program coordinator will conduct a training session with the clinicans to ensure that the forms are understood, user friendly and comprehensive. The training will take on 7/30/2010. All psychosocials will be reviewed and critiqued by the clinical supervisor for the month of August with full compliance on 9/1/2010. The clinical supervisor in support in the clincal team will ensure future compliance by reviewing all psychosocial evaluations for evaluative content in all domains. Any document that is not complete will not be signed by clinincal supervisor. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 the review of client records, the facility failed to document timely follow-up information in two of three discharged records reviewed.
The findings include:
Five client records were reviewed on June 24, 2010. Follow-up information was required in three discharge records # 3, 4 and 5. Per the facility's policy and procedure all follow-ups will be done within 7 days of a client's discharge if not being referred.
Client record # 3 was admitted on 3/11/10 and discharged on 3/29/10; as of to date no follow-up was documented.
Client record # 4 was admitted on 1/27/10 and discharged on 2/25/10; as of to date no follow-up was documented.
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Plan of Correction
After review of record #3 and #4 the forms were not complete because they did not identify that contact made due to the client being homeless. The Director will ensure that all follow-up is conducted within the 7 day period even if the client is not referred or the client is homeless. The form will indicate that all attempts were made to contact the client and/or their advocate. Full compliance will be on 7/12/2010. |