INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 27, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Colonial House Outpatient was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.27 (4) (i) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of clients and staff to a safe location.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to have a policy in place for staff and clients to following case of an emergency.
The findings include:
The policy and procedure manual was reviewed on April 27, 2012. The facility relocated about two weeks ago and did not have documentation for a disaster plan for the new location. An interview with the facility director on April 27, 2012 confirmed the findings.
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Plan of Correction
On May 29th, 2012, the CEO and facility director meet and created policy for staff and clients to follow inc case of emergency. The plan will be reviewed with staff at the staff meeting on June 4th, 2012. The plan also consisted of placing floor plans in the facility to direct clients and staff on the exit procedure in case of emergency. The facility director will ensure that monthly drills are conducted and it will be documented in the log stating when, what time, what routes and the length of time it takes to complete the drill |
705.27 (4) (ii) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(ii) Assignments of staff during emergencies.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to have a policy in place for staff and clients to following case of an emergency.
The findings include:
The policy and procedure manual was reviewed on April 27, 2012. The facility relocated about two weeks ago and did not have documentation for a disaster plan for the new location.
An interview with the facility director on April 27, 2012 confirmed the findings.
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Plan of Correction
On May 29th, 2012, the CEO and facility director meet and created policy for staff and clients to follow inc ase of emergency. The plan will be reviewed with staff at the staff meeting on June 4th, 2012. The plan also consisted of placing floor plans in the facility to direct clients and staff on the exit procedure in case of emergency. The facility director will be responsible to maintain the policy and ensure that drill are completed. This information will be documented in the log and state length, time, date and number of people in attendance |
705.28 (d) (8) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(8) Prohibit the use of elevators during a fire drill or a fire.
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Observations
Based on a physical plant tour, the building that the facility utilize did not have a sign posted prohibiting the use of the elevator during a fire drill or a fire.
The findings include:
The physical plant tour took place on April 27, 2012 around 9:30 am. It was observed that the elevator that is utilized by the facility failed to have a sign prohibiting the use of elevators during a fire drill or a fire.
An interview with the facility director on April 27, 2012 confirmed the findings.
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Plan of Correction
On May 18th, 2012 the elevator maintance company placed "use steps in case of fire signs on all of the elevators, inside and outside. This was checked by the facility director to ensure that it was completed. The facility director will check for the sign on a monthly basis to ensure that the sign remains intact and dose not recur |
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 provide a psychosocial evaluation that included all assessment components in eight of eight client records.
The findings include:
Eight client records were reviewed on April 27, 2012. A psychosocial evaluation was required in eight of those records, #1, 2, 3, 4, 5, 6, 7 and 8. Psychosocial evaluations were documented in all client records but they did not include an evaluation that included all components of the assessment.
The psychosocial evaluations in client records #1, 5, 6, 7 and 8 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records #1, 4, 5, 6 and 8 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluations in client records #1, 3, 4, 5, 6, 7 and 8 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records #1, 2, 3, 4, 5, 6, 7 and 8 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluations in client records #1 did not include an evaluation of the client's attitude towards treatment and how they would impact treatment.
The psychosocial evaluations in client records #1, 2, 3, 4, 5, 6, 7 and 8 did not include an evaluation of the counselor conclusions/impressions of the client.
An interview with the facility director and clinical supervisor on April 27, 2012 confirmed the findings.
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Plan of Correction
On June 4th, 2012 the clinical supervisor will meet with the clinical team in clinical staff meeting. Results of the inspection, psycho-social evaluation deficiencies will be reviewed again. Training will be provided on assessment of client's assets/strengths, support systems, coping mechanisms, negative factors that could inhibit treatment. Examples of satisfactory psycho-social evaluations and composites will be provided to the clinicians. The clinical supervisor will review at the time of intake for each new client as well as weekly to ensure quality and compliance. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to document support services on three of five client records reviewed.
The findings include:
Eight client records were reviewed on April 27, 2012. Five client records were reviewed for documentation of proposed support services on the client's treatment plan. Client records # 2, 4 and 5 had no documentation of proposed support services on the comprehensive treatment plans.
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Plan of Correction
On June 4th, 2012, the clinical supervisor met with the clinical team in a clinical staff meeting. Education regarding the requirments for treatment planning documentation including proposed support services on the master treatmnet plan was completed. Relevant policy of Colonial House Outpatient amd examples of acceptable treatment plans were copied and reviewed in this meeting. The clinical supervisor will review compliance treatment plans via weekly chart reveiwing and clinical staff meetings as well as individual clinical supervision meetings. |
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 client records, the facility failed to document in the treatment plan updates the client's progress as it related to the goals identified in the individualized treatment and rehabilitation plans.
The findings were:
Eight client records were reviewed on April 27, 2012, five were required to have a treatment plan update, #1, 2, 3, 4 and 5. The facility failed to document in the treatment plan update the client's progress as it relates to the the goals identified in the individualized treatment and rehabilitation plan in client records #2, 3 and 6. In addition, new goals were identified in the treatment plan update without documenting the progress of previous goals identified.
An interview with the facility director and clinical supervisor on April 27, 2012 confirmed the findings
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Plan of Correction
On June 4th, 2012, the clinical supervisor will meet with the clinical team in a clinical staff meeting. Results of the inspection, in particular the lack of documented progress of tretment plan goals on treatment plans were reviewed. Education regarding the purpose, appropriate documentation of new treatment plan goals will be completed. Review of the policy and applicable standards will be reviewed. The clinical supervisor will randomly review treatment plan reviews weekly in clinical staff meeting and monthly in individual clinical supervision meetings. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of the client records, the facility failed to provide a physician signature on treatment plans and treatment plan updates in two of three client records.
The findings include:
Eight client records were reviewed on April 27, 2012. Three client records are medical assistance funded and are required to have a physician review sign the treatment plans and the treatment plan updates. This documentation was missing in records # 4 and 7
Client record # 4 - The client was admitted to treatment January 30, 2012 and the treatment plan was completed on February 30, 2012 and the treatment plan update was completed on March 26, 2012. The physician signature was missing on both treatment plans.
Client record # 5 - The client was admitted to treatment October 20, 2011 and discharged on February 27, 2012. The treatment plan was completed on November 14, 2011 and treatment plan updates were completed on December 8, 2011 and January 23, 2012. The physician signature was missing on all of client # 5's treatment plans.
An interview with the facility director and clinical supervisor on April 27, 2012 confirmed the findings.
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Plan of Correction
The facility director and the CEO spoke to the physican to come to the office on a weekly basis and sign all necessary clinical documentation. the physican now signs all documents every Monday of the week. The facility director will review charts every Monday to insure that the physican is signing these documents in timley manner. |