INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 18, 2012 to April 19, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Guidance for Growing, LLC 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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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill records, the facility failed to provide documentation that the facility's fire alarm is in working order.
The findings include:
Fire drill records were reviewed on April 17, 2012. The records were reviewed for the period covering December 2011 to April 2012. The facility was granted an approval on September 7, 2010 to the Physical Plant Standards for Nonresidential Facilities, Chapter 705.28 (d) (7), relative to activating a fire alarm or smoke detector during a fire drill. As a result of the approval, the facility was required to provide documentation that their fire alarm is in working order. Documentation that the facility's fire alarm is in working order was not presented for review.
The findings were confirmed during an ongoing dialogue with the project director on April 18, 2012 from approximately 8:30 A.M. to 12:00 P.M.
This is a repeat citation. The facility was cited on October 25, 2011 and April 12, 2011 for noncompliance with this standard.
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Plan of Correction
The project director will put in a written request to the building owner requesting written confirmation the fire alarm is in working order. The project director will set a yearly schedule of contacting the building owner to obtain proof that the fire alarm is functioning. This contact will be made in December of each year to ensure that proof of a working fire alarm is readily available at the time of inspection. A calender reminder will be set in the project director's calender to prompt him to put a written request to the building owner. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. 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 a review of client records, the facility failed to review and sign off on a drug or alcohol history completed within six months prior to admission by the SCA or other D & A treatment facility.
The findings include:
The facility's policy titled: "Treatment/rehabilitation management," states:
"When treatment begins, the therapist is responsible for the development and maintenance of the case file. A bio-psychosocial assessment will be completed by the therapist within a 2-week period from the initial assessment. The bio-psychosocial assessment will include histories on:
Medical History: Documents the client's personal medical history, family medical history, history of illness, symptoms, and any medication currently being taken ... ....
Drug and alcohol History: A history documenting the substances most frequently abused the length and patterns of use, prior treatment episodes. Included is the client's perception of their effect on his/her social, physical, or mental state. If there is any substance abuse history within the family or significant others, it is noted here."
On April 19, 2012, three client records requiring documentation of a drug and/or alcohol history were reviewed. The facility did not have documentation of a signature and date from the facility staff and client indicating a drug or alcohol history from a licensed drug and alcohol treatment provider or the Single County Authority was reviewed by both facility staff and client in two of three records reviewed, specifically, client records # 2 and 5.
Client # 2 was admitted on February 16, 2012. The drug or alcohol history was completed by another D & A treatment facility within six months prior to client # 2's date of admission and was received by the facility on February 22, 2012. However, the drug or alcohol history did not include documentation of a signature from the facility staff and client indicating the drug or alcohol history was reviewed by both facility staff and client as of April 18, 2012.
Client # 5 was admitted December 7, 2011. The drug or alcohol history was completed by another D & A treatment facility within six months prior to client # 5's date of admission and was received by the facility on January 5, 2012. However, the drug or alcohol history did not include documentation of a signature from the facility staff and client indicating the drug or alcohol history was reviewed by both facility staff and client as of April 18, 2012.
The findings were confirmed during an ongoing dialogue with the project director on April 18, 2012 from approximately 9:00 A.M. to 12:00 P.M.
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Plan of Correction
The therapist will not continue with a client's treatment or will re-assess the client if a history is not obtained from a state approved alcohol and other drug treatment agency within 2 weeks of the client's initial intake. If a client's history is obtained from another state licensed agency within 6-months of the initial history, the therapist and the client will sign and date the history indicating that the history was reviewed by both the therapist and the client. The histories of both client #2 and #5 were signed off on and dated by the client and therapist. The project director will be responsible for ensure this procedure is followed. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. 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 client records, the facility failed to review and sign off on a personal history completed within six months prior to admission by the SCA or other D & A treatment facility.
The findings include:
The facility's policy titled: " Treatment/rehabilitation management," states:
"When treatment begins, the therapist is responsible for the development and maintenance of the case file. A bio-psychosocial assessment will be completed by the therapist within a 2-week period from the initial assessment.
The bio-psychosocial assessment will include histories on:
Medical History: Documents the client's personal medical history, family medical history, history of illness, symptoms, and any medication currently being taken ... ....
Personal History: This section documents historical and pertinent personal data, including: Family, legal, sexual, employment/vocational, educational, military, recreational."
On April 19, 2012, three client records requiring documentation of a personal history were reviewed. The facility did not have documentation of a signature and date from the facility staff and client indicating a personal history from a licensed drug and alcohol treatment provider or the Single County Authority was reviewed by both facility staff and client in two of three records reviewed, specifically, client records # 2 and 5.
Client # 2 was admitted February 16, 2012. The personal history was completed by another D & A treatment facility within six months prior to client # 2's date of admission and was received by the facility on February 22, 2012. However, the personal history did not include documentation of a signature from the facility staff and client indicating the personal history was reviewed by both facility staff and client as of April 18, 2012.
Client # 5 was admitted December 7, 2011. The personal history was completed by another D & A treatment facility within six months prior to client # 5's date of admission and was received by the facility on January 5, 2012. However, the personal history did not include documentation of a signature from the facility staff and client indicating the personal history was reviewed by both facility staff and client as of April 18, 2012.
The findings were confirmed during an ongoing dialogue with the project director on April 18, 2012 from approximately 9:00 A.M. to 12:00 P.M.
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Plan of Correction
The therapist will be responsible for completing a bio-psycho-social assessment only after a history is completed either by an outside agency or by Guidance for Growing. If an assessment from an outside agency is not completed, Guidance for Growing will re-assess the client before completing a bio-psycho-social assessment.
The therapist will not continue with a client's treatment or will re-assess the client if a history is not obtained from a state approved alcohol and other drug treatment agency within 2 weeks of the client's initial intake. If a client's history is obtained from another state licensed agency within 6-months of the initial history, the therapist and the client will sign and date the history indicating that the history was reviewed by both the therapist and the client. The histories of both client #2 and #5 were signed off on and dated by the client and therapist and clinical summaries have been completed. The project director will be responsible for ensuring this procedure is followed. |
709.91(b)(6) LICENSURE Intake and admission
709.91. 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 comply with intake and admission relating to documentation of psychosocial evaluation.
The findings include:
On April 19, 2012, three client records requiring documentation of a psychosocial evaluation were reviewed. The facility did not document a psychosocial evaluation upon review of a drug or alcohol history and personal history from another licensed drug and alcohol treatment provider by both facility staff and client in two of three records reviewed, specifically, client records # 2 and 5.
Client # 2 was admitted February 16, 2012 and the psychosocial evaluation was completed December 17, 2011. The drug or alcohol history and personal history were completed by another D & A treatment facility within six months prior to client # 2's date of admission and were received by the facility on February 22, 2012. However, the drug or alcohol history and personal history did not include documentation of a signature from the facility staff and client indicating the drug or alcohol history and personal history were reviewed by both facility staff and client as of April 18, 2012.
Client # 5 was admitted December 7, 2011 and the psychosocial evaluation was completed December 22, 2011. The drug or alcohol history and personal history were completed by another D & A treatment facility within six months prior to client # 5's date of admission but were not received by the facility until January 5, 2012. Also, the drug or alcohol history and personal history did not include documentation of a signature from the facility staff and client indicating the drug or alcohol history and personal history were reviewed by both facility staff and client as of April 18, 2012.
The findings were confirmed during an ongoing dialogue with the project director on April 18, 2012 from approximately 9:00 A.M. to 12:00 P.M.
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Plan of Correction
The project director, who is the govering body, will add to the agency policy manual that psychosocial evaluations will completed within 14 days of receipt of AOD and personal history from outside agencies. This will be completed by 05/25/2012.
The therapist will be responsible for completing the psycho-social history within the 14 days of receipt of history for an outside agency. The therapist will sign and date the psycho-social, which will be inspected by the project director confirming that it was completed in the 14 day period. The project director will approve the new policy. |