INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 1-2, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, DARS, Inc. Supervised Independent Living 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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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least once every six months and did not set off an alarm or smoke detector with every fire drill.
The findings include:
The facility's fire drill logs were reviewed on August 27, 2015 as part of an administrative review. The fire drill logs were reviewed for the time period covering August 2014 to August 2015. Drills were conducted during sleeping hours on August 27, 2014 and July 30, 2015. This timeframe exceeded a six month period for sleeping hours drills.
Additionally, the was no documentation in the fire drill log that a fire alarm had been set off for fire drills during October 2014 through February 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will schedule a fire drill to occur during sleeping hours at a minimum of one time every five months. These drills will be unannounced to all clients and staff with the exception of the night shift supervisor and the Facility Director. These drills will follow the approved policy of informing the local fire department of the test and setting off the fire alarm system during each drill.
The fire drill log will be reviewed by the Facility Director the day following the sleeping hours drill. If there is a need for the fire drill to be repeated, an overnight drill will be conducted the following month to ensure compliance. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of inpatient client records, the facility failed to document a drug and alcohol and personal history at intake.
The findings include:
Ten client records were reviewed for intake documentation which included a drug and alcohol history and personal history on September 2, 2015. Three out of ten client records lacked documentation of historical information, specifically client records 1, 2, and 3.
Client #1 was admitted on June 10, 2015; however there was no documentation of a drug and alcohol history or personal history for client #1.
Client #2 was admitted on April 30, 2015; however there was no documentation of a drug and alcohol history or personal history for client #2.
Client #3 was admitted on December 12, 2014; however there was no documentation of a drug and alcohol history or personal history for client #3.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Within three days of transition from the DARS, Inc. Manos House program into the DARS, Inc. Supervised Independent Living program, the primary therapist will review the existing Bio/Psycho/Social summary and indicate any updates to the provided information that may have occurred during treatment in Manos House. The counselor will sign and date the interview sheet below the previous counselor's signature and will indicate if any information was updated.
The new counselor will continue to generate an addendum to the Interviewer's Assessment section of the Bio/Psycho/Social, which will identify any adjustments to the clients treatment plan that are warranted due to the completion of residential treatment and the entry into Supervised Independent Living. This addendum will follw the approved policy regarding collection of client personal history.
The Clinical Supervisor will be responsible for verifying that the required information has been updated and will sign and date the document. The Clinical Supervisor will review all client records for a period of three months to ensure compliance and will conduct ongoing random sampling thereafter to ensure continued compliance. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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
Based on a review of inpatient client records, the facility failed to document treatment plans to include the type and frequency of treatment and rehabilitation services.
The findings include:
Ten client records were reviewed for comprehensive treatment plans, which included the type and frequency of treatment and rehabilitation services on September 2, 2015. Three out of ten client records lacked documentation of a treatment plan that included a type and frequency of treatment services, specifically client records 2, 3, and 6.
The comprehensive treatment plan for client #2 was documented on May 15, 2015; however it did not include the type and frequency of treatment services in for client #2
The comprehensive treatment plan for client #3 was documented on January 5, 2015; however it did not include the type and frequency of treatment services in for client #3.
The The comprehensive treatment plan for client #6 was documented on December 3, 2014; however it did not include the type and frequency of treatment services in for client #6
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All treatment plan updates will include descriptions of the type of treatment performed, and the frequency in which the treatment will be provided.
The type and frequency can be changed during subsequent treatment plan updates as treatment progress permits.
All treatment plan updates will continue to be signed by the client, the primary therapist, and the clinical supervisor. The clinical supervisor will ensure that type and frequency of treatment is clearly identified on each treatment plan update prior to signing the document. |