INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 31, 2011 through February 2, 2011 staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Berks Counseling Center 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 March 4, 2011.
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Plan of Correction
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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on the physical plant inspection and interviews with facility staff, the facility failed to ensure that fire extinguishers were inspected annually. Findings: Based on a physical plant inspection completed during the three day survey, an interview with the clinical director on February 2, 2011 and an inspection of the three fire extinguishers located on the second floor, the facility failed to ensure fire extinguishers were inspected and approved annually. Inspection tags on three of three fire extinguishes documented an August 2009 inspection date. Inspection and approval of fire extinguishers were late by six months.
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Plan of Correction
Current fire extinguishers will be inspected and approved by March 11, 2011. Facilities Coordinator will be responsible for checking fire extinguishers quarterly. Housing Director, who supervises Facilities Coordinator, will be responsible to ensure this is completed quarterly.
Effective March 1, 2011
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709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of annual reports and interviews with the project director and clinical director, the governing body failed to make an annual report available to the public for fiscal year 2009/2010.The findings include:The last annual report available for public review was completed for fiscal year June 2008 through July 2009. The facility failed to complete an annual report for fiscal year June 2009 through July 2010. The facility is publicly funded and required to make an annual report available to the public. The 2009 - 2010 fiscal year ended on June 30, 2010. There was no documentation of the annual report as of February 1, 2011.
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Plan of Correction
On October 23, 2010, BCC Executive Director and Board of Directors held the Annual Public Board meeting which is attended by all BCC staff, BCC Board of Directors and is open to the public. BCC's Annual Report is presented as part of this Annual meeting. Notice of this meeting is placed in the Reading Eagle Newspaper the previous week and on BCC's agency website by BCC Office Manager. The newspaper announcement is included below. Proof of Publication of Notice in Reading Eagle is available upon request from Clinical Director. Minutes of this meeting are kept in the Executive Director's office at the 35 N. 6th St. office and are available for review at any time.
NOTICE
The Annual Meeting of the Board of Directors of Berks Counseling Center will be held on Tuesday, November 23rd, 2010 at 8:00 am, at the Inn at Reading, 1040 Park Road, Wyomissing , PA 19610
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709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
Based on an interview with the clinical director and a review of clients records, the facility failed to maintain a data collection and record keeping system that allows for the efficient retrieval of data.The findings include:An interview with the clinical director on February 1, 2011 revealed that the facility was to be utilizing electronic client records by July 2010. A review of client records at a satellite facility on February 2, 2011 and February 3, 2011 revealed that the facility continued to maintain client records utilizing hard copy documents, paper sign-off sheets completed by clients and counselors, counselor log books, hard copy files and scanned documents maintained by counselors and the medical records department. The facility failed in, ten of ten client records reviewed, to utilize the electronic records as indicated during the interview with the Director on February 1, 2011. The facility failed to develop a record keeping system that allowed for efficient retrieval of data and information to measure the facility's performance related to stated goals and objectives.
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Plan of Correction
Our goal continues to be to have a paperless electronic record system. We continue to address barriers that our current electronic system (Quic Doc) presents. The following are the steps we are implementing to meet regulations for electronic record keeping.
1. Deputy Director, Clinical Director, and Director of BCC IT Department are resuming previous weekly meetings to expedite facilitating steps 2&3 effective March 1, 2011.
2.Currently all clinical documents in Quic Doc are either in "Template" format or "Note " format. "Templates "do not have the capability to be electronically signed by clinical personnel where as documents in "Note "format do. All documents in " Template" format, that require clinical personnel signatures, will be reconfigured into a "Note " format to enable clinical personnel to sign document electronically by a committee consisting of Clinical Director, Counselor knowledgeable in IT and IT staff . Clinical Director and Counselor knowledgeable in IT will be responsible for training on use of reformatted documents. Task completion effective by July 1, 2011 or sooner.
3.At least 2 signature pads will be purchased and implemented by Director of IT, to provide a vehicle for client signatures required on documents of the electronic clinical record. Clients will sign each form individually, with the form visually displayed as the client signs the signature pad. This assures the client that the signature is intended for the specific document only. Implementation of the signature pads will eliminate the current procedure of using separate paper signature pages that requires physical scanning and attachment of the paper document to the electronic record. Clinical Director and Counselor knowledgeable in IT will be responsible for training on use of signature pads. Implementation of signature pads effective by July 1, 2011 or sooner.
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