INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 19 and 20, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Renewal Treatment, Inc., 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 23, 2009.
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Plan of Correction
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705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of the facility's fire drill log, the facility failed to document that alternate exit routes were used during fire drills.
Findings:
The fire drill log was reviewed on February 19, 2009 for fire drills conducted between March of 2008 and January of 2009. There was no documentation that alternative exit routes were used. The exit route documented in all fire drills conducted during this time was the front exit.
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Plan of Correction
Renewal Treatment Inc. (RTI) shall use the alternative route during the completion of monthly fire drills. The Security Supervisor will ensure that the staff and clients use both the primary evacuation route and secondary evacuation route (rear fire tower) during the completion of the required drills. The Security Supervisor shall document the means of egress on the fire drill report form. The Director of Program Compliance will review the fire drill log on a quarterly basis to ensue that the secondary means of egress is utilized. RTI will put this plan of correction into place effective immediatley. |
709.22(e)(2) 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:
(2) A financial statement of income and expenses.
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Observations
Based on the review of the annual report, the facility failed to document that the annual report which was made available to the public, included a financial statement of income and expenses.
Findings:
The annual report for the fiscal year ending June 30, 2008 did not document the income and expenses of the program. The annual report documented a pie chart with percentages as to how the money was used. There was no documentation in the annual report that specified an amount of the income and program expenses.
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Plan of Correction
Renewal Treatment Inc. (RTI) will document the income and expenses of the program. RTI will use dollar amounts on the pie charts in the annual report to show income and expenses for each subsequent fiscal year. The Director of Finance will provide the financial information (dollar amounts) to be used for the pie charts documenting income and expenses during completion of the annual report. The CEO and Director of Program Compliance will ensure that this information is included in the annual report prior to its approval and distribution. This will take place during the completion of the annual report for fiscal year ending June 30, 2009. The facility will have the annual report completed for fiscal year 2008-2009 in November 2009. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. 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 document psychosocial evaluations that contained clinical assessments of the clients' support systems, coping mechanisms and overall conclusions and impressions in eight of nine client records.
Findings:
Twelve client records were reviewed on February 19-20, 2009. Nine client records were required to have a psychosocial evaluation.
The facility did not document a psychosocial evaluation that included the client's support systems in client records # 2, 3, 4, 6, 7, 8 and 9. The clients' support systems were not addressed.
The facility did not document a psychosocial evaluation the included the clients' coping mechanisms in client records # 1, 2, 3, 4, 6, 7 and 8. The clients' coping mechanisms were not addressed.
The facility did not document a psychosocial evaluation the included a clinical assessment of the counselors' conclusions and impressions in client records # 2, 6, 7, and 9. The information was historical and did not include clinical conclusions and impressions of the client.
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Plan of Correction
The Project Director and Clinical Supervisor will provide training to the counseling staff on the proper completion of psychosocial evaluations. The training will cover how to document clinical assessments of client's problems/needs, support systems, coping mechanisms and overall conclusion. The Project Director and Clinical Supervisors are requiring the counseling staff to complete practice psychosocial evaluations for the purpose of skill evaluation. Additional training will be provided to treatment staff based on their assessed skill level. A narrative description and outline of the psychosocial evalation will be included in each client's file to aid the counseling staff in the completion of all required areas of documentation when completing the evaluations. The documentation of psychosocial evaluation shall be reviewed by the Clinical Supervisors during monthly chart reviews, this review shall ensure the proper documentation of all required areas. RTI will be in full compliance by March 13, 2009. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan in nine of nine client records.
The findings include:
Twelve client records were reviewed on February 19-20, 2009. The facility was required to assure that counseling services were provided according to the treatment and rehabilitation plan in nine client records reviewed. The facility did not provide counseling services according to the treatment and rehabilitation plan in client records # 1, 2, 3, 4, 5, 6, 7, 8 and 9. The clients did not receive the 8 hours per week of group counseling as required by the treatment plan.
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Plan of Correction
RTI shall assure that counseling services are provided according to the individual treatment plan. The groups have been restructured to ensure that there are typically eight clients in a group and never more than twelve. The group counseling sessions have been increased from one hour to one and one-half hour. The groups will now have an assignment review as part of the group. The Program Director and Clinical Supervisor shall regularly attend live groups to ensure compliance with group size, length and content. The Project Director and Clinical Supervisors will review each clients record during monthly chart reviews and ensure that all services are being provided according to the treatment plan. This plan of correction is effective immediatley. |
709.53(a)(5) LICENSURE Progress Notes
709.53. 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:
(5) Progress notes.
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Observations
Based on the review of client records, the facility failed to document progress notes on individual clients that included information relative to the client's involvement with the project in four of nine records.
Findings:
Twelve client records were reviewed on February 19-20, 2009. Nine were reviewed for progress notes. The facility did not document group progress notes that included information relative to the client's involvement with the project in client records # 5, 6, 7 and 8. The assessment of the client's involvement with the group was a generic statement that was copied and placed in all attendees of the group.
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Plan of Correction
RTI shall document group notes that contain information relative to each client's involvement with the project. The Program Director and Clinical Supervisor shall provide training on the proper documentation of group notes to the treatment staff. Group notes will contain an individualized assessment of each client's involvement in the group. Clinical Supervisors will review group notes during monthly file reviews to ensure that the documented note contains the required individualized assessment documentation. This plan of correction has been undertaken and is effective immediatley. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document follow-up information in two of four client records.
The findings include:
Twelve client records were reviewed on February 19-20, 2009. Follow-up information was required in four client records. The facility did not document follow-up information in client records # 10 and 12.
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Plan of Correction
RTI's Program Director and Clinical Supervisors shall ensure that follow-up information is documented in client records. The Program Director and Clinical Supervisor will retrain the treatment staff on the follow-up requirements. The Clinical Supervisor will ensure that follow-up takes place by the treatment staff within seven days of the outpatient appointment. The follow-up will be documented in the client record by using a case note. The Clinical Supervisors will perform supervisory follow-up during monthly file reviews to ensure compliance with this standard. This plan of correction is effective immediatley. |