INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 22, 2008 and April 23, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Stairways Behavioral Health Outpatient Drug and Alcohol Program 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 May 19, 2008.
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Plan of Correction
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection and conversations with the Facility Director and Quality Assurance Coordinator to verify where counseling services are offered the facility failed to provide privacy so that counseling session cannot be seen by persons not in the treatment session. The project provides group and individual sessions in rooms with windows where sessions can be seen by other facility staff and clients.
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Plan of Correction
If needed we will install blinds in the therapists door windows to meet the requirement of this section. We will install window blinds immediately to insure confidentiality if that is your decision.
However, we request that this current set-up remain as is. Our reasons include that we employ 2 female therapists; their offices are in the far back right corner of the clinic with minimal traffic; we have a large forensic population within the D&A program and the MH clinic in general - and the forensic office is located next to both D&A therapists offices. We believe it is in the best interests/safety of our female therapists that appropriate staff can verify their safety as needed via the small door window. |
709.93(a)(2) LICENSURE Client records
709.93. 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:
(2) Medication records.
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Observations
Based on a review of client records, the facility failed to document medication dose and frequency of use of medications. Three of five client records reviewed on April 22, 2008 did not include documentation of medication dose and the frequency of use. Client record #1 documented that the client was admitted on February 4, 2008. The psychosocial history completed on February 27, 2008. Medications taken by client are listed ,however, dosage and dosage frequency was not documented in the record. Client record #2 documented that the client was admitted on February 7, 2008 and the psychosocial history was completed on March 7, 2008. Medications taken by client were listed , however, the dose and frequency of use was not documented in the record. Client record #3 documented that the client was admitted on March 3, 2008 and the psychosocial history was completed on March 25, 2008. Medications taken by the client are listed .however, the dose and frequency of use was not documented in the record.
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Plan of Correction
As noted in Observation #1893, we were in partial compliance with this standard. Therapists are aware of the proper procedure, they simply didn't comply in all cases reviewed. This writer has verbally reminded all staff of the requirement to document medication dose and frequency. Staff were also provided a written copy of this citation. The issue will also be discussed next Wednesday (5-7-08)during group therapist supervision with this writer. This writer and the corporate compliance officer will monitor therapist chart documentation immediately and into the future to insure therapists are documenting medication dose and frequency as required. Any compliance issues will be discussed with staff during weekly therapist supervision with this writer. |
709.93(a)(10) LICENSURE Client records
709.93. 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary which included services provided to the clients. Three of three client records reviewed on April 23, 2008 failed to include services offered or provided to the client in the discharge summary. Client record #6 documented that the client was admitted on November 2, 2007 and discharged on February 7, 2008. The discharge summary completed on February 7, 2008 failed to include a summary of services provided or offered to the client. Client record #7 documented that the client was admitted on October 15, 2007 and discharged on December 11, 2007. The discharge summary completed on December 11, 2007 failed to include a summary of services provided or offered to the client. Client record #8 documented that the client was admitted on September 18, 2007 and discharged December 12, 2007. The discharge summary completed on December 11, 2007 failed to include a summary of services provided or offered to the client.
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Plan of Correction
Therapists are aware of this requirement but were not in compliance in 3 records reviewed. They were reminded verbally of the requirement by this writer. They were also provided a written copy of this citation. This issue will also be discussed with them again on 5-7-08 during group therapist supervision time with this writer. They will correctly document services offered in the D/C summary to include: individual counseling, group counseling, referrals, services offered which were accepted or declined etc. and frequency as appropriate. This writer and the compliance officer will immediately monitor therapist compliance with documentation both now and into the future. |