INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 17, 2014 and November 18, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Treatment Trends Inc. Keenan House 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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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that all trash, garbage and rubbish was stored in noncombustible, covered containers that prevent the penetration of insects and rodents.
The findings include:
A physical plant inspection was conducted on 11/18/2014 at approximately 12:50 PM.
The two 1.5 yard trash dumpsters on the side of the facility were overfilled with trash and not fully covered.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In response to standard violation 702.0(4),Building Exterior and Grounds, current dumpsters will be locked and signs will be purchased and posted to discourage illegal dumping as discussion with our neighbors has yielded no result. Chaining/locking the dumpsters will be completed by the Treatment Trends maintenance department by December 22, 2014. The trash hauling company will be given a key to assure they have access to the dumpsters at any time.
In addition, the Director of Food Services will meet with staff and residents who are responsible for trash removal to review which dumpsters in the ally belong to Treatment Trends, where the key is located and proper trash management. Training will occur by December 22, 2014. |
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 the review of client records, the facility failed to complete a psychosocial evaluation per facility policy in three of ten client records reviewed.
The findings include:
Ten client records requiring documentation of psychosocial evaluations were reviewed on during the renewal inspection. The facility's policy states that psychosocial evaluations are to be completed within ten days of admission. The facility failed to complete a psychosocial evaluation within ten days of admission in client records # 6, 7 and 9.
Client # 6 was admitted to treatment on 1/14/2014. The client's psychosocial evaluation was completed on 2/4/2014.
Client # 7 was admitted to treatment on 1/22/2014. The client's psychosocial evaluation was completed on 2/10/2014.
Client # 9 was admitted to treatment on 2/26/2014. The client's psychosocial evaluation was completed on 3/12/2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Three out of ten charts reviewed failed to have Psychosocial Evaluations completed within 10 days of admission. This is in violation of licensure standard 709.51(b)(6).
The following shall or did occur:
The Clinical Director reviewed Treatment Trends policy regarding the due date for Psychosocial Evaluation during our regularly scheduled staff meeting on December 1, 2014. Policy states 10 days from admission is our standard.
The Clinical Supervisor will begin utilizing a spread sheet to track due dates for each psychosocial evaluation. this will be completed by December 5, 2014. The Clinical supervisor will review the spreadsheet with clinical staff weekly during our regularly scheduled staff meeting and review charts weekly for appropriate completion of all documentation. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 a review of client records, the facility failed to complete an individual treatment and rehabilitation plan with the client as stated in the agency policy in two of ten client records reviewed.
The findings include:
Ten client records requiring documentation of an individual treatment and rehabilitation plan were reviewed during the renewal inspection. The facility's policy indicates that a comprehensive individual and rehabilitation treatment plan will be developed within ten days of admission. The facility failed to complete a comprehensive individual treatment and rehabilitation plan per the agency's policy in client records 6 and 7.
Client # 6 was admitted to treatment on 1/14/2014. The comprehensive individual treatment and rehabilitation plan documented for client # 6 was completed 1/6/2014.
Client # 7 was admitted to treatment on 1/22/2014. The comprehensive individual treatment and rehabilitation plan documented for client # 7 was completed 1/6/2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Two charts were found to contain Comprehensive Individual Treatment and Rehabilitation plans that were incorrectly dated and not dated within 10 days admission as per agency policy. This is in violation of standard 709.51(b)(6).
To correct, the Clinical Supervisor will review dates during paperwork review process with clinical staff weekly to ensure that the date staff notes on the completed document is accurate. The Clinical Director and Clinical Supervisor reviewed the agency policy with clinical staff on December 1, 2014 during a regularly scheduled staff meeting. Charts will be audited weekly. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document a treatment plan update at least every thirty days in seven of ten client records reviewed.
The findings include:
Ten client records requiring documentation of a treatment plan update were reviewed during the renewal inspection. The facility failed to document a treatment plan update at least every thirty days in client records # 3, 4, 5, 6, 7, 8 and 9.
Client # 3 was admitted on 8/22/2014. A treatment plan was completed for the client on 8/23/2014. The client's first treatment plan update was completed on 10/16/2014.
Client # 4 was admitted on 12/31/2013 and discharged on 6/10/2014. The client's last two treatment plan updates were completed on 5/21/2014 and 4/9/2014.
Client # 5 was admitted on 1/7/2014 and discharged on 4/24/2014. The client's last two treatment plan updates were completed on 3/20/2014 and 2/20/2014.
Client # 6 was admitted on 1/14/2014 and discharged on 4/9/2014. A treatment plan was completed for the client on 1/15/2014. The client's first treatment plan update was completed on 3/23/2014.
Client # 7 was admitted on 1/22/2014 and discharged on 4/4/2014. A treatment plan was completed for the client on 1/23/2014. The client's first treatment plan update was completed on 3/18/2014.
Client # 8 was admitted on 2/18/2014 and discharged on 6/19/2014. A treatment plan was completed for the client on 2/24/2014. The client's first treatment plan update was completed on 4/3/2014.
Client # 9 was admitted on 2/26/2014 and discharged on 7/8/2014. The client's last two treatment plan updates were completed on 6/16/2014 and 5/14/2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Seven records reflected a failure to document a treatment plan update at least every 30 days which violates standard 709.52(b) "Treatment Plan Update".
To ameliorate this violation, the Clinical Director reviewed the Treatment Plan Update Policy with staff during the regularly scheduled staff meeting on December 1, 2014. The policy to update treatment plans at least every 30 days was reviewed.
The Clinical Supervisor will review treatment plans of current clients during weekly staff meetings with staff and will develop a spreadsheet highlighting treatment plans that are due within the week. This spread sheet will be developed and in use by December 4, 2014. Charts will be audited weekly starting 12/4/4. |