INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on, January 26, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Treatment Treads 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of employee training records, the facility failed to assure that each employee received a written individual training plan in one of seven personnel records.
The findings include:
Seven employee training records, were reviewed on January 26, 2012. Personnel record #1 ( Project Director) failed to include a written individual training plan. The last developed plan staff #1 was in November 2010.
The Project Director confirmed this finding.
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Plan of Correction
In response to deficiency: 704.11(b)(1) LICENSURE
Individual training plan.: The following plan of correction will be implemented. Within thirty days from the date of submission of this plan, the Chairman of the Board of Directors will complete an evaluation of Employee #1. This will be done annually from here forward.
The Chairman of the Board has been informed of the licensing requirements of BDAP and will adhere to them.
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709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel files and administrative policies and procedures the facility failed to meet the requirements of this regulation as evidenced by the absence of annual performance reviews in one of seven personnel records.
The findings include:
Seven personnel files were reviewed on January 17, 2012. Staff #1 has not received an
individual performance evaluation since November 2010.
The Project Director confirmed this finding.
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Plan of Correction
In response to deficiency: 709.26(d)(5)(i) LICENSURE
Personnel Management:
709.26.
The following plan of correction will be implemented following date of submission:
Within thirty days from this date the Chairman of the Board of Directors will complete an evaluation of Employee #1. This will be done annually from here forward.
The Chairman of the Board has been informed of the licensing requirements of BDAP and will adhere to them.
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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 and an interview with the project director, the facility failed to complete the histories before the psychosocial evaluation was completed in two of fifteen client records.
The findings include:
Fifteen client records were reviewed on January 26, 2012. A psychosocial evaluation was required all of the client records.
Client records #8 and #15 provided documentation that revealed the client histories were completed before the psychosocial evaluation had be documented..
Client #8 was admitted on 10-25-2011. The medical, personal and drug and alcohol histories were completed on 11-30-11. The psychosocial evaluation was completed on 11-24-2011. The histories were completed six days after the psychosocial evaluation.
Client # 15 was admitted on 9-20-2011. The personal history was completed on 10-17-2011 and the psychosocial evaluation was completed on 10-11-2011. The history was completed six days after the psychosocial evaluation.
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Plan of Correction
The following deficiency: 709.91(b)(6) will be addressed as follows. The corrective action will include an all-staff training to be held no later than 30 days from the date of survey, to address appropriate date sequencing of intake history and subsequent psychosocial evaluation. Staff will review the proper timeframes of intake paperwork and psychosocial evaluation, with an emphasis on ensuring the histories are completed prior to the evaluation being developed.
In addition, the clinical supervisor will review at least 3 random files per month to ensure proper dating is documented. |
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 15 client records, it was determined that the facility failed to complete the treatment plan update.
The findings include
Fifteen client records were reviewed on January 26, 2011. Client record #2 was admitted on 6-30-2011. The comprehensive treatment plan was completed on 7-22-2011. The treatment plan update was due on 9-22-2011. The client was discharged on 10-11-2011 and the facility failed to complete the update as per policy.
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Plan of Correction
The following deficiency is being addressed: 709.92(b) LICENSURE
Treatment and rehabilitation services:
709.92. as follows: The clinical staff will meet in a training to review the appropriate dating of treatment plans,including preliminary, master and updated plans.
The clinical supervisor will randomly select three client files monthly to review and ensure treatment plans are being completed in a timely manner.
In addition, the Program Director will review three of the Clinical Supervisor's client files monthly to ensure the treatment plans are dated appropriately and in a timely manner. |