INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 16-17, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Organization for Women in Early Recovery 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 December 13, 2010.
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Plan of Correction
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705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to ensure all personnel on all shifts were trained to perform assigned tasks during emergencies in three of five personnel records, as required by regulation.
The findings include:
Seven employee records were reviewed on November 16-17, 2010. Five employees were new employees since the last inspection. Per regulation, the residential facility shall ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies. The facility failed to document that emergency training was completed upon employment in employee records # 2, 3 and 7.
Employee # 2 was hired on April 26, 2010. Emergency training was due to be completed no later than May 3, 2010. The facility did not document the completion of emergency training until October 15, 2010.
Employee # 3 was hired on July 19, 2010. Emergency training was due to be completed no later than July 26, 2010. The facility did not document the completion of emergency training until November 3, 2010.
Employee # 7 was hired on October 11, 2010. Emergency training was due to be completed no later than October 18, 2010. The facility did not document the completion of emergency training until November 5, 2010.
On November 17, 2010 the facility director was interviewed and confirmed that emergency training was not completed upon employment for the above noted employees.
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Plan of Correction
The Associate and Clinical Director of POWER became aware that the agency was not documenting the trainings that personnel were receiving during their first week of orientation regarding assigned tasks during emergencies.The Associate and Clinical Director and the Executive Assistant implemented a process to document emergency protocol training in November 2010 and provided a review of the emergency protocols to all staff at that time. The Associate and Clinical Director will provide the needed oversight to ensure that POWER remains in complaince with this regulation. The Associate and Clinical Director will monitor the new process through direct supervision of the Executive Assistant who is responsible to track that staff receive emergency protocol training and through review of personnel records. This plan of correction was implemented on November 5, 2010, prior to the on-site licensure renewal inspection. POWER is in full compliance with this standard effective November 5, 2010. |
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 a review of client records, the facility failed to document an informed and voluntary consent from the client for disclosure of information that included the specific information to be disclosed and the purpose of disclosure in four of five client records.
The findings included:
Seven client records were reviewed on November 16-17, 2010. Five client records required an informed and voluntary consent from the client; including the specific information to be disclosed and the purpose of disclosure. Per regulation, the project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record; including the specific information to be disclosed and the purpose of the disclosure. The facility failed to obtain an informed and voluntary consent from the client; including the specific information to be disclosed and the purpose of disclosure in client records # 1, 2, 3 and 4.
Client #1 was admitted on June 10, 2010. Two consents from the client for the disclosure of information contained in the client record dated June 10, 2010 for third party payers contained an "other" line under the information to be released which had been checked off on the consents. The facility failed to specify what "other" information was to be released.
Client # 2 was admitted on July 9, 2010. Two consents from the client for the disclosure of information contained in the client record dated July 9, 2010 for a third party payer contained an "other" line under the information to be released which had been checked off on the consents. The facility failed to specify what "other" information was to be released.
Client # 3 was admitted on August 12, 2010. One of two consents from the client for the disclosure of information contained in the client record dated August 30, 2010 for a third party payer did not include documentation of the specific information to be released. The second consent from the client for the disclosure of information contained in the client record dated August 30, 2010 for a third party payer did not include documentation of the specific information to be released nor the purpose of the disclosure. A consent from the client for the disclosure of information contained in the client record dated August 12, 2010 for a family member did not include documentation of the specific information to be released.
Client # 4 was admitted on September 14, 2010. One of two consents from the client for the disclosure of information contained in the client record dated September 14, 2010 for a third party payer did not include documentation of the purpose of the disclosure. The second consent from the client for the disclosure of information contained in the client record dated September 14, 2010 for a family member did not include documentation of the specific information to be released.
The facility director and clinical supervisor were interviewed on November 16, 2010 and confirmed the consents noted above were missing the required documentation.
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Plan of Correction
The five client records reviewed that indicated a failure to document an informed and voluntary consent were all completed by the same staff person. The Program Manager/Clinical Supervisor met with the staff person and trained her on how to properly provide and document an informed and voluntary consent. The Program Manager will monitor the staff's adherence to the proper documentaion of informed and voluntary consents during indiviudal supervision. The Program Manager will also train all staff during Team Supervision on how to properly provide and document an informed and voluntary consent. The Program Manager will monitor charts on a consistent basis to ensure proper documentaion of informed and voluntary consents. The Program Manager is responsible for the oversight of the correction of this deficiency. POWER is in full compliance with this standard effective November 19, 2010. |
709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records and an interview with the facility director and clinical supervisor, the facility failed to document the type and frequency of services in the individual treatment and rehabilitation plan in five of five client records.
The findings include:
Seven client records were reviewed on November 16-17, 2010. The type and frequency of services were required in the individual treatment and rehabilitation plan in five client records. The facility did not document the type and frequency of services in the individual treatment and rehabilitation plan in client records # 1, 2, 3, 4 and 7.
Client # 1 was admitted on June 10, 2010. The individual treatment and rehabilitation plan was completed on July 6, 2010. The individual treatment and rehabilitation plan did not include documentation of the type and frequency of services the client was to receive.
Client # 2 was admitted on July 9, 2010. The individual treatment and rehabilitation plan was completed on August 5, 2010. The individual treatment and rehabilitation plan did not include documentation of the type and frequency of services the client was to receive.
Client # 3 was admitted on August 12, 2010. The individual treatment and rehabilitation plan was completed on September 9, 2010. The individual treatment and rehabilitation plan did not include documentation of the type and frequency of services the client was to receive.
Client # 4 was admitted on September 14, 2010. The individual treatment and rehabilitation plan was completed on October 11, 2010. The individual treatment and rehabilitation plan did not include documentation of the type and frequency of services the client was to receive.
Client # 7 was admitted on February 2 , 2010 and discharged on August 8, 2010. The individual treatment and rehabilitation plan was completed on March 5, 2010. The individual treatment and rehabilitation plan did not include documentation of the type and frequency of services the client was to receive.
The facility director and clinical supervisor were interviewed on November 17, 2010 and confirmed the type and frequency were not documented on the individual treatment and rehabilitation plans noted above.
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Plan of Correction
The Program Manager/Clincal Supervisor will educate the Therapists regarding the regulation to include the type and frequency of treatment and rehabilitation services, specifically type and frequency of individual and group therapy. Education and training will take place during team supervision. The Therapists are responsible to develop the individual treatment and rehabilitation plan with the client, which is to include the type and frquency of services. The Porgram Manager will provide oversight to ensure adherence to this regulation via individual supervision and chart monitoring. POWER will be in full compliance with this standard for any treatment and rehabilitation plans developed on or after November 24, 2010. |
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 the review of client records and interviews with the facility director and clinical supervisor, the facility failed to date each signature on the treatment and rehabilitation plan updates with the actual date it was signed by the individual in five of five client records.
The findings include:
Seven client records were reviewed on November 16-17, 2010. Treatment plan updates were reviewed in five client records. Per the Licensing Alert dated May 2005, the date that must appear in the client record is the date the update is signed. When more that one signature is required, each signature should be dated with the actual date it is signed by that individual. The facility did not document dated signatures in treatment plan updates in client records # 1, 2, 3, 4 and 7.
Client # 1 was admitted on June 10, 2010. The treatment and rehabilitation plan was completed on July 6, 2010. Treatment and rehabilitation plans completed in August, September, October, and November 2010 did not include documentation of the actual date of each individual's signature on the treatment and rehabilitation plan updates.
Client # 2 was admitted on July 9, 2010. The treatment and rehabilitation plan was completed on August 5, 2010. Treatment and rehabilitation plans completed in September, October and November 2010 did not include documentation of the actual date of each individual's signature on the treatment and rehabilitation plan updates.
Client # 3 was admitted on August 12, 2010. The treatment and rehabilitation plan was completed on September 9, 2010. Treatment and rehabilitation plans completed in October and November 2010 did not include documentation of the actual date of each individual's signature on the treatment and rehabilitation plan updates.
Client # 4 was admitted on September 14, 2010. The treatment and rehabilitation plan was completed on October 11, 2010. The treatment and rehabilitation plan completed in November 2010 did not include documentation of the actual date of each individual's signature on the treatment and rehabilitation plan updates.
Client # 7 was admitted on February 2, 2010 and discharged on August 28, 2010. The treatment and rehabilitation plan was completed on March 5, 2010. The treatment and rehabilitation plans completed in April, May, June, July and August 2010 did not include documentation of the actual date of each individual's signature on the treatment and rehabilitation plan updates.
An interview with the facility director and clinical supervisor on November 18, 2010, confirmed the treatment plan updates noted above did not document the actual date of each individual's signature.
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Plan of Correction
The Program Manager/Clinical Supervisor will educate all staff about the frequency that treatment plans are to be reviewed and updated. This training and education will take place during team supervision and will be reinforced during individual supervision. Staff will be educated about dating their signatures on the actual date they signed the treatment plan. The Associate and Clinical Director will revise the treatment plan forms to include a place for the date on the signature lines as a prompt for staff to date thier signature. The Program Manager will provide oversight to ensure this standard is met via individual and team supervision and chart reviews. POWER will be in full compliance with this standard effective November 19, 2010. |
709.53(a)(8) LICENSURE Case Consultation 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:
(8) Case consultation notes.
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Observations
Based on the review of client records and interviews with the facility director and clinical supervisor, the facility failed to date each signature on the case consultation notes with the actual date it was signed by the individual in four of four client records.
The findings include:
Seven client records were reviewed on November 16-17, 2010. Case consultation notes were reviewed in four client records. Per the Licensing Alert dated May 2005, the date that must appear in the client record is the date the consultation occurred. When more that one signature is required, each signature should be dated with the actual date it is signed by that individual. The facility did not document dated signatures in case consultation notes in client records # 1, 2, 3 and 7.
Client # 1 was admitted on June 10, 2010. The case consultation note dated September 10, 2010 did not include documentation of the actual date of each individual's signature on the case consultation note.
Client # 2 was admitted on July 9, 2010. The case consultation note dated October 6, 2010 did not include documentation of the actual date of each individual's signature on the case consultation note.
Client # 3 was admitted on August 12, 2010. The case consultation note dated November 10, 2010 did not include documentation of the actual date of each individual's signature on the case consultation note.
Client # 7 was admitted on February 2, 2010 and discharged on August 28, 2010. The case consultation notes dated May 5, 2010 and June 10, 2010 did not include documentation of the actual date of each individual's signature on the case consultation note.
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Plan of Correction
The Program Manager/Clinical Supervisor will train all staff about the need to sign and date all case consultations they are involved with. Training will take place during team supervision and will be reinforced during individual supervision. The Associate and Clinical Director will revise the form used for case consultations to include a place for the date on the signature line to prompt consultation participants to date their signatures. The Program Manager will provide oversight to ensure this standard is met via individual and team supervision and chart reviews. The facility will be in full compliance with this standard effective November 19, 2010. |