INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from January 7-8, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northeast Treatment Centers, 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.
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Plan of Correction
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based upon the physical plant inspection, the facility's intensive outpatient unit failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.
The findings include:
The physical plant inspection was conducted on January 8, 2013, from approximately 1:20 PM to 2:00 PM. The following safety and/or repair concerns were noted within the intensive outpatient unit:
- the cover was missing from a baseboard heater located in IOP group room # 2
- sharp edges and the heating element of the heater referenced above were exposed
- tissue paper and candy wrappers were located within the heating element of the heating unit, which created a fire hazard
The Facility Director was present during the physical plant inspection and the findings were confirmed during the exit interview.
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Plan of Correction
During the onsite inspection, a radiator cover was missing in a group room. STEP 1: The facility will be reviewed by a vendor who will determine the correct solution. STEP 2: Once the consultant determines a solution for the problem, a vendor or maintenance staff will be engaged who will complete the task.
Time line:
STEP 1 Completion: 2/9/2013
STEP 2 Completion: 4/15/2013
Responsible Person(s): Director of NET Maintenance & Facility Director
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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based upon a review of the facility's policy and procedures manual and inpatient client records, the facility failed to provide documentation of a physical examination that was completed by a physician in 8 of 8 client records.
The findings include:
The policy and procedures manual was reviewed on January 8, 2013. The manual specified that client physicals were to be completed within three days of a client's admission.
Eight inpatient client records were also reviewed on January 8, 2013. The facility failed to provide documentation of a physical examination that was completed by a physician within three days of a client's admission in records # 1, 2, 3, 4, 5, 6, 7 and 8.
Client # 1 was admitted on November 9, 2012, and was still an active client on the date of inspection. A physical examination was due no later than November 12, 2012. However, the record contained a physical examination form that did not include documentation of the physician's overall impression of the client. In addition, the physical examination form was not signed or dated by a physician.
Client # 2 was admitted on November 13, 2012, and was still an active client on the date of inspection. A physical examination was due no later than November 16, 2012. However, the record contained a physical examination form that did not include documentation of the physician's overall impression of the client. In addition, the physical examination form was not signed or dated by a physician.
Client # 3 was admitted on November 13, 2012, and was still an active client on the date of inspection. A physical examination was due no later than November 16, 2012. However, the record contained a physical examination form that did not include documentation of the physician's overall impression of the client. In addition, the physical examination form was not signed or dated by a physician.
Client # 4 was admitted on October 19, 2012, and was still an active client on the date of inspection. A physical examination was due no later than October 22, 2012. However, the record contained a physical examination form that did not include documentation of the physician's overall impression of the client. In addition, the physical examination form was not signed or dated by a physician.
Client # 5 was admitted on November 13, 2012, and was still an active client on the date of inspection. A physical examination was due no later than November 16, 2012. However, the record contained a physical examination form that did not include documentation of the physician's overall impression of the client. In addition, the physical examination form was not signed or dated by a physician.
Client # 6 was admitted on October 15, 2012, and was discharged on November 28, 2012. A physical examination was due no later than October 18, 2012. However, the record contained a physical examination form that did not include documentation of the physician's overall impression of the client. In addition, the physical examination form was not signed or dated by a physician.
Client # 7 was admitted on November 6, 2012, and was discharged on December 6, 2012. A physical examination was due no later than November 9, 2012. However, the record contained a physical examination form that did not include documentation of the physician's overall impression of the client. In addition, the physical examination form was not signed or dated by a physician.
Client # 8 was admitted on August 27, 2012, and was discharged on October 16, 2012. A physical examination was due no later than August 30, 2012. However, the record contained a physical examination form that did not include documentation of the physician's overall impression of the client. In addition, the physical examination form was not signed or dated by a physician.
The findings were confirmed by the Clinical Supervisor during the record review.
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Plan of Correction
The following is written in response for the Wharton residential program:
On January 25, 2013 the Wharton Program Director reviewed the Wharton Center's policies regarding physical examinations with staff physicians to ensure that all physical examinations are conducted in the appropriate time frame, includes the physician's signature and the physician's impression of each client.
To ensure ongoing compliance the Wharton Program Director will review all client records weekly to make sure that physical examination meets these standards.
COMPLETION DATE= 1/25/13
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709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based upon a review of inpatient client records and an interview with the clinical supervisor, the facility failed to provide verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan in 5 of 5 client records.
The findings include:
The facility's clinical supervisor confirmed that clients engage in work therapy, which includes work outside of cleaning and maintaining their individual living spaces.
Five client records were reviewed on January 8, 2013. All five records required verification that work done by the client at the project was an integral part of his treatment and rehabilitation plan. However, the facility failed to document work as an integral part of the treatment plan in client records # 1, 2, 3, 4 and 5.
Client # 1 was admitted on November 9, 2012, and was still an active client on the date of inspection. The record contained a treatment plan that was signed and dated by the client on November 14, 2012. However, the treatment plan did not include verification that work completed by the client was an integral part of his rehabilitation plan.
Client # 2 was admitted on November 13, 2012, and was still an active client on the date of inspection. The record contained a treatment plan that was signed and dated by the client on November 16, 2012. However, the treatment plan did not include verification that work completed by the client was an integral part of his rehabilitation plan.
Client # 3 was admitted on November 13, 2012, and was still an active client on the date of inspection. The record contained a treatment plan that was signed and dated by the client on November 19, 2012. However, the treatment plan did not include verification that work completed by the client was an integral part of his rehabilitation plan.
Client # 4 was admitted on October 19, 2012, and was still an active client on the date of inspection. The record contained a treatment plan that was signed and dated by the client on October 24, 2012. However, the treatment plan did not include verification that work completed by the client was an integral part of his rehabilitation plan.
Client # 5 was admitted on November 13, 2012, and was still an active client on the date of inspection. The record contained a treatment plan that was signed and dated by the client on November 16, 2012. However, the treatment plan did not include verification that work completed by the client was an integral part of his rehabilitation plan.
The findings were confirmed by the Clinical Supervisor during the record review.
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Plan of Correction
The following is written in response for the Wharton residential program:
On January 28, 2013 the Wharton Program Director and Wharton Clinical Supervisor met with clinical staff and educated them on the need to ensure that work as treatment should be included as part of the client's treatment plan and documented in the client's record. Clinical staff will document all work therapy that each client completes on a daily basis and this will documented in the client's record.
To ensure ongoing compliance the Wharton Clinical Supervisor will review all client records weekly to make sure that documentation of work therapy is being documented in the client's treatment plan and record.
COMPLETION DATE= 1/28/13
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