INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 19, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Treatment Trends Inc. Confront 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 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that all trash, garbage and rubbish was stored in noncombustible, covered containers that prevent the penetration of insects and rodents. The findings include:A physical plant inspection was conducted on 11/19/2014 at approximately 10:45 AM.The two 30 gallon trash receptacles on the side of the facility by the handicap accessible exit were overfilled with trash and uncovered. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The proper garbage cans with lids were ordered by the time of the verbal licensing review at the end of the visit. Adherence to this regulation will occur immediately and as part of the monthly building inspections conducted by the administrative assistant or program director. This will become part of the monthly building check off. In addition, all staff will be asked to communicate about the missing lides on a Tuesday or a Friday morning following the garbage pick up the previous night. This expectation will be reviewed in staff meeting by December 8th. |
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
Based on a review of client records, the facility failed to document the frequency of treatment services on the individual treatment and rehabilitation plan in five of eleven client records reviewed.The findings include:Eleven client records requiring documentation of the frequency of treatment services on the individual treatment and rehabilitation plans were reviewed during the renewal inspection. The individual treatment and rehabilitation plans contained in client records # 2, 3, 5, 8 and 11 did not include the frequency of treatment services.Client # 2 was admitted to treatment on 1/27/2014. The client's individual treatment and rehabilitation plan dated 2/25/2014 did not specify the frequency of individual counseling therapy. Client # 3 was admitted to treatment on 1/28/2014. The client's individual treatment and rehabilitation plan dated 3/5/2014 did not specify the frequency of individual counseling therapy. Client # 5 was admitted to treatment on 5/5/2014. The client's individual treatment and rehabilitation plan dated 6/9/2014 did not specify the frequency of individual counseling therapy. Client # 8 was admitted to treatment on 1/15/2014. The client's individual treatment and rehabilitation plan dated 2/11/2014 did not specify the frequency of primary group counseling therapy.Client # 11 was admitted to treatment on 4/16/2014. The client's individual treatment and rehabilitation plan dated 9/10/2014 did not specify the frequency of individual and primary group counseling therapy. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be emailed about this deficiency with instructions to always include the frequency of treatment to be designated as "weekly", "biweekly", or "monthly" as is appropriate. In addition, this information will be reviewed at staff meeting by 12/8/14 and will be reviewed individually with eaqch counselor at the next supervision session all occurring before December 20, 2014. Last, when reviewing the treatment plan and updates, for supervisor signature, this particular point will be reviewed more closely as an ongoing management tool with corrections being asked of the counselors if there is a deficiency in this area. This is an ongoing process of oversight. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document a treatment plan update at least every sixty days in two of four client records reviewed. The findings include: Four client records requiring documentation of a treatment plan update were reviewed during the renewal inspection. The facility failed to document a treatment plan update at least every sixty days in client records # 4 and 9.Client # 4 was admitted on 1/29/2014 and discharged on 5/7/2014. A comprehensive treatment plan was completed for the client on 2/26/2014. There were no treatment plan updates documented in the client's record. Client # 9 was admitted on 10/23/2014 and discharged on 1/21/2014. A comprehensive treatment plan was completed for the client on 11/13/2014. There were no treatment plan updates documented in the client's record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Documentation requirements and time frames will be reviewed at the next staff meeting by December 10, 2014. In addition, all staff will reviewe this material in individual supervision by December 20. The following will be the specifics of the review: All staff will review the requirements for treatment plans to be updated every 60 days and informed how to document when a client is not attending sessions that will meet this time frame. In the case of a client who is missing sessions, thereby preventing the treatment plan to be done in a timely fashion, staff will write out a blank Updated Treatment Plan form with the intended/required date on the top. In addition the counselor will explain the reasons why this form is not done in a timely manner. The staff will sign this form and have it signed by the supervisor. |