INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 18, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Colonial House Outpatient was found to be not 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the facility's Staffing Requirements Facility Summary Report, personnel records and a conversation with the clinical director, the facility failed to ensure that the counselor assistant received the required supervision.
Employee #7 was hired on 10/3/16 with a GED and was required to receive 3 months of direct observation.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will review policy and procedure related to supervision of counselor assistants, and will maintain adherence to the policy and procedure through provision of direct supervision for the counselor assistant with HS diploma or GED for the first 3 months of his/ her employment and submission of documentation of the supervision sessions, co-signing of notes, client records of services. Employee # 7 will continue with direct supervision from 5/2017 through 8/2017. Facility will monitor for compliance through submission of clinical supervision notes on a bi-weekly basis to Personnel to be maintained in employee records. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection on May 18, 2017, the facility failed to ensure that the water temperature was below 120 degrees.
Men's restroom water was measured at 124.3 degrees.
Men's restroom water was measured at 123.6 degrees.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Director of program contacted building maintenance who adjusted water temperature to 120 degrees on 5/18/17. Director of program will monitor water temperature monthly to ensure that it does not exceed 120 degrees. |
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 a physical plant inspection conducted on May 18, 2017, the facility failed to have the fire extinguishers inspected annually.
Fire extinguishers located throughout the facility had not been inspected since April 2016.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Fire extinguishers were inspected on 5/25/17 as follow up to the deficiency received the previous week. Maintenance Manager will schedule yearly extinguisher inspection appointment, and document the appointment in maintenance log in addition to notifying Director of facility of the scheduled appointment. Scheduling and documentation of appointment will be done by first week of February of each year. Director of facility will ensure that the appointment for inspection of extinguishers are scheduled by first week of February of each year, and completed by the end of May of each year. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Seven client records were reviewed on May 18, 2017, the facility failed to document a preliminary treatment plan during intake in client records, #3, 4, & 6.
Client #3 was admitted on 11/10/16 and was an active client at the time of the licensing inspection.
Client #4 was admitted on 11/10/16 and was discharged on 5/5/17.
Client #6 was admitted on 8/26/16 and was discharged on 3/28/17.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Staff will be retrained in the intake and orientation process, to include training in development of initial treatment plans and will maintain knowledge regarding policy and procedure related to intake as a result of the retraining. Clinical Supervisor and Lead Counselor will review all paperwork related to the intake and admission appointments within 7 days of initial treatment appointment to ensure that initial treatment plans are being completed with the client. Staff retraining began on 6/22/17, and will be completed by 7/13/17. |
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
Seven client records were reviewed on May 18, 2017, the facility failed to update the treatment plan every 60 days in client records, #4, 5, & 6.
Client #4 was admitted on 11/10/16 and was discharged on 5/5/17. A comprehensive treatment plan was created on 12/1/16; a treatment plan update was due by 2/1/17 but was not documented until 3/7/17.
Client #5 was admitted on 8/16/16 and was discharged on 1/5/17. A comprehensive treatment plan was created on 8/16/16; a treatment plan update was due by 10/16/16 but was not documented until 12/8/16.
Client #6 was admitted on 8/26/16 and was discharged on 3/28/17. A comprehensive treatment plan was created on 11/28/16; a treatment plan update was due by 1/28/17 but was not documented until 2/13/17.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Staff will be retrained beginning 6/29/17 on treatment and rehabilitation services, to include initial treatment planning. Retraining will include initial treatment planning process, and the review of treatment plans in accordance with policy and procedure. Staff will maintain knowledge regarding policy and procedure related to treatment and rehabilitation services. Corrective action will be completed on 7/13/17. Adherence to treatment plan updates (every 60 days) will be monitored through chart audits, and in clinical supervision with Lead Counselor and Clinical Supervisor. Active charts will be reviewed to ensure that treatment plan updates have been completed every 60 days in supervision with lead counselor and Clinical Supervisor and through the use of peer chart reviews beginning on 7/3/17. |