INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 13, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Central Behavioral Health 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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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
A physical plant inspection was conducted on September 13, 2016 at 2:50 PM. Based on this inspection, the facility failed to ensure the grounds were in good repair as there was a 7 feet by 4 inch section of eroded cement on the sloped, cement apron leading into the parking lot behind the facility. The depth of the erosion varied between 2 - 5 inches throughout the length of the section.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The erosion of the cement at the entrance to the parking lot off of Basin Street has been addressed. On October 3rd JH Greene & Son, LLC removed the old entrance debris and installed a new concrete apron. This had been planned for some time but was delayed due to issues obtaining permits. Pictures of the completed work along with a copy of the invoice are available.
Facility director will complete a monthly check of facility grounds, make note of any issues that need to be addressed, and work with program director and maintenance staff to ensure that the appropriate repairs/replacements are made. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
The facility's administrative records were reviewed prior to the onsite inspection. The facility is publicly funded. Based on this review, the facility failed to disclose the names of the board of directors within the 2015 annual report.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will create an annual report consisting of information regarding the program in the past year along with a list of the current members of the agency's board of directors. This will be completed and presented to the board of directors on October 27th 2016.
Facility director will coordinate with program director regularly in order to ensure that any changes to the board of directors are documented so that they can be reflected in future annual plans.
Facility director will review the DDAP website weekly in order to identify any future licensing alerts that would be cause for changes in the facility's documentation and operation. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Two personnel records were reviewed on September 13, 2016. Based on this review, the facility failed to document an annual performance evaluation in personnel records #1 and #5.
Employee # 1 was promoted to project director on 1/5/2015. There were no performance evaluations on file for this employee.
Employee # 5 was hired as the medical director on 7/2/2014. There were no performance evaluations on file for this employee for 2015 and 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director and project director will ensure that Employee #1 and Employee #5 receive performance evaluations by November 30th 2016. The facility director and project director will work with the human resources department to ensure that performance evaluations are completed on an annual basis for all staff members.
The facility's human resources department maintains a timetable of when performance evaluations are due for other agency programs and facility director and program director will ensure that the CORE staff are added to this list.
Both Employee #1 and Employee #5's evaluations must be completed by the board of directors so their evaluations must be made an agenda item at the monthly board meeting. Project director will ensure that the evaluations of Employee #1 and Employee #5 are added to the board's agenda before the annual evaluations are due. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Two client records requiring written notification to the client of the facility's decision to involuntarily terminate the client's treatment were reviewed on September 13, 2016. Based on this review, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment in client records #9 and #10.
Client # 9 was admitted into treatment on 6/24/2015 and was involuntarily terminated from the facility on 12/4/2015. There was no documentation of written notification of the facility's decision to involuntarily terminate the client's treatment as of the on-site inspection.
Client # 10 was admitted into treatment on 2/8/2016 and was involuntarily terminated from the facility on 7/6/2016. There was no documentation of written notification of the facility's decision to involuntarily terminate the client's treatment as of the on-site inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director has created an outreach letter template to inform clients of their involuntary discharge from treatment based on the client's lack of response to earlier outreach. Facility director has met with staff to introduce them to this letter as well as instruct them on using it when discharging a client who has not responded to outreach.
As of 10/12/16 both Client #9 and Client #10 have been sent this letter, reflecting that they have been involuntarily terminated from services.
The facility director has updated the facility's policy and procedures manual to reflect that when a client no longer presents for treatment and does not respond to phone outreach, a letter of outreach will be sent by the counselor or facility director with a request for contact back within two weeks, otherwise the client will be involuntarily terminated from the program. A copy of this letter will be kept in the client's chart. If no contact is made after those two weeks the counselor or facility director will send a letter reflecting that the client has been discharged from the program involuntarily. A copy of this letter will be kept in the client's chart.
Facility director will do a monthly review of client charts to ensure that this procedure is being upheld for client's who are not engaging in services. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
The facility's administrative records were reviewed prior to the onsite inspection. Based on this review, the facility failed to develop policies and procedures to respond to all of the unusual incidents listed in 709.34(a)(1-8):
sexual assault by staff or a client.
death or medication error.
significant disruption of services due to a disaster which closes the facility for more than 1 day.
theft, burglary, break-in or similar incident at the facility.
fire or structural damage to the facility.
event requiring the presence of police, fire or ambulance personnel.
outbreak of a contagious disease requiring Centers for Disease Control notification.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project director and facility director will meet to review and revise the facility's existing policy in order for it to comply with 709.34 (a) (1). This revised policy will be presented to the facility's Quality Improvement committee for review. This will be completed and presented to the committee on December 5th 2016. |
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
The facility's administrative records were reviewed prior to the onsite inspection. Based on this review, the facility failed to develop policies and procedures that include all of the content listed in 709.34(b)(1-5):
prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
of a timely and appropriate corrective action plan, when indicated.
monitoring of the corrective action plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project director and facility director will meet to review and revise the facility's existing policy in order for it to comply with 709.34 (b) (2). This revised policy will be presented to the facility's Quality Improvement committee for review. This will be completed and presented to the committee on December 5th 2016. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Ten client records were reviewed on September 13, 2016. Based on this review, the facility failed to document the type and frequency of treatment services on the individual treatment and rehabilitation plans in client records #1, #3, and #10.
Client # 1 was admitted to treatment on 5/9/2016. The client's individual treatment and rehabilitation plans dated 9/6/2016 and 7/26/2016 did not specify the type and frequency of counseling therapy.
Client # 3 was admitted to treatment on 7/23/2013. The client's individual treatment and rehabilitation plans dated 9/1/2016 and 7/12/2016 did not specify the type and frequency of counseling therapy.
Client # 10 was admitted to treatment on 2/8/2016 and discharged on 7/6/2016. The client's individual treatment and rehabilitation plans dated 6/17/2016 and 4/22/2016 did not specify the type and frequency of counseling therapy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director and counselors in the program have updated the existing treatment plan update form to include frequency and duration of counseling therapy for each treatment goal. Facility director has presented this new form to all staff members, immediately began the use of this form for all future treatment plan updates, and destroyed earlier versions of the form.
Facility director will ensure that the amended treatment plan update form is being used through monthly supervision meetings and chart reviews.
Both clients #1 and #3 are active. Facility director has instructed client #1 and client #3's counselor to update the treatment plan using the new form and to review this with the clients during their next scheduled session. |