INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 17, 18, and 19, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, WES Corporation 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 October 10, 2007.
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Plan of Correction
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on review of the documented fire drills and staff interview, the facility failed to document that a fire alarm or smoke detector was activated during each drill, and there was no documentation that the Department had approved an alternative procedure.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 the review of administrative records and staff interviews, the facility failed to complete an annual report and make it available to the public.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on review of administrative documentation and staff interview, the facility failed to ensure that the project director presented project goals and objectives to the governing body for the fiscal year in review, 2007/2008.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on random record review, the facility failed to obtain a voluntary and informed consent to release information to Philadelphia DHS for one of eight client records reviewed, #11. In addition, the facility failed to ensure the proper completion of the consent to release form which continued to contain the wording "release/obtain" without specifying the consent was for the release of information in four of eight client records reviewed, #1, 2, 6 and 9.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on random record review, the facility failed to document the length and patterns of substance use as well as failed to include the client's perception of the impact of substance use on the social, physical and mental state of the client in eight of eight client records reviewed, #1, 3, 4, 5, 6, 9, 10 and 12.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a random review of client records, the facility failed to meet the requirements for this regulation because histories in records # 1, 3, 4, 5, 6, 10 and 11 lacked detail on family dynamics/interactions. Details were lacking in records # 1, 3, 4, 11 and 12 on legal involvement. Details were also lacking on employment and vocation in records # 1, 6, 9, 10, 11 and 12. Details were lacking on recreational activity in records #1, 4, 5, 6, 9, 10, 11 and 12. Details were lacking on sexual histories in files # 1, 5, 6, 10 and 11.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 random record review, the facility failed to meet the requirements for this regulation because eight of eight evaluations were missing in full or in part, # 1, 3, 4, 5, 6, 10, 11 and 12. The client records that contained the integrative summary failed to provide a clinical evaluation, rather documented a repeat of the data obtained in the history.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.92(a) 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:
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Observations
Based on random client record review, the facility failed document treatment plans in three of four records, # 5, 7 and 9. In addition, client # 4 had a signed but blank treatment plan in the client chart.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 random client record review, the facility failed to document proposed support services in four of six records reviewed, #3, 10, 12 and 13.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 random client record review, the facility failed to document treatment plan updates in three of four client records, # 4, 7, 11 and 13, and the fourth record, client #10, did not document progress related to the prior stated goals and objectives.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on random client record review, the facility failed to document case consultations three of four client records, #4, 5, and 11.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on random client record review, the facility failed to develop a complete aftercare plan. One of two client records, # 2 and 7, contained only the preliminary plan that is developed on admission to address what will be accomplished after they leave formal treatment.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 random client record review, the facility failed document a discharge summary for client # 7, and clients # 1 and 5 discharge summary did not include the reasons for the client entered treatment when they did, # 5 failed to include the services offered during the treatment or the status of the client upon discharge, and #1, 2 and 5 did not describe the client's response to the treatment.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on random client record review, the facility failed document follow-up contact in three of three client records, # 5, 6 and 7.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |