INITIAL COMMENTS
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This report is a result of a complaint investigation conducted on August 12, 2020, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site investigation, Treatment Trends 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 investigation and a plan of correction is required.
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Plan of Correction
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709.24 (a) LICENSURE Treatment/rehabilitation Management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
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Observations
As a result of an incident that occurred at the facility on July 11, 2020, that resulted in a fatality, an investigation was initiated by the Department. Based on a conversation with facility staff and a review of administrative documentation, resident monitoring is to be conducted, in part, by a staff member who is stationed at the front desk of the facility, adjacent to the video monitor screens. During the course of the investigation it was discovered that no staff was in this position from 11:30 pm to 12:00 am on the night of the incident.
A high level of traffic was also observed in and around the room of client #1 during this time, which went unobserved due to the lack of staff in their designated location.
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Plan of Correction
A dedicated team member will be stationed at all times in the reception area or 3rd floor security station to continuously monitor video screens. Traditionally, this will be a non-clinical support staff member, but a clinical or leadership staff member may be asked to fill the role when needed in order to assure continuous coverage at monitoring stations. The behavioral technician supervisor or other leadership team member will conduct random video reviews weekly to assure staff compliance with this policy. Each team member will be oriented to this process at the time of hire. A policy update will be circulated and require sign-off by all team members.
A checkpoint system has been installed that allows for a wand to scan RFID chips and electronically record team rounds. Thirty-nine monitoring points have been established that assures rounds cover internal and external points, common areas, bathrooms, kitchen, and bedrooms. A daily monitoring report will be checked each morning by the behavioral technician supervisor or other leadership team member to confirm rounds are being completed regularly and correctly. All current team members will be trained on the process which will be verified by a sign off. New team members will be oriented to the process at time of hire. Training will be conducted by the behavioral technician supervisor. Our security policy will be updated to match the current system/procedures and will be forwarded to DDAP after approval from the Board.
All above stated actions will be completed by October 1, 2020.
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709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
The facility failed to document a record of medication administration for client #1.
Based on a review of administrative documentation, including the client record, it was observed that no Medication Administration Record (MAR) was documented in the record of client #1 for the month of July, 2020. Client #1 had been prescribed the medication, olanzapine, which was documented in the MAR from his admission date through June 30, 2020.
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Plan of Correction
A copy of the MAR will kept in the client file. The original MAR will be kept in MAR binder accompanied by a photograph of each client which will be housed in the medication room. The nurse or service coordinator will be responsible for receiving medications, comparing them to physician prescriptions for accuracy and logging each medication with dosages and time of administration correctly in the MAR. A staff member who is trained to dispense medications will monitor client self-administration of medications and notate the observation of each self-administered dosage. A copy of a completed MAR will be placed in the client chart at the conclusion of each month by the service coordinator.
The nurse, program director, or clinical director will assure all new team members in relevant positions will be oriented to this procedure at the time of hire. The Policy and Procedure was updated on 9/15/2020 and sent to all employees via email; this expectation was added under Procedure #1.
All above stated actions will be completed by October 1, 2020.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
The facility failed to provide treatment according to the treatment plan for client #1.
Based on a review of administrative documentation, including the client record, it was observed that no clinical services were documented from July 1-July 6, 2020. A treatment plan dated June 26, 2020 stipulated the client would attend (1) individual session per week, (3) primary groups per week and (1) men ' s group per week.
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Plan of Correction
Counselors will develop treatment plans collaboratively with the client and accurately indicate type and frequency of treatment contacts. Each contact will be recorded on the record of service and have an accompanying progress note. The Clinical and Program Directors will have a in house treatment plan training to review expectations regarding identifying of therapeutically appropriate interventions and the necessity to have accompanying documentation confirming client participation in each therapeutic contact. The Clinical Director will provide regular supervision and chart audits to confirm these practices are occurring. New clinicians will be oriented to these practices at the time of hire.
All above stated actions will be completed by October 1, 2020.
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709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
The facility failed to document a record of service for client #1.
Based on a review of administrative documentation, including the client record, it was observed that no record of service was documented.
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Plan of Correction
A record of service (ROS) will be completed and contained in each client file that summarizes all individual sessions, primary groups, and psycho-educational group contact. The ROS will capture therapeutic contacts for a client over the span of a month and subsequently have a new ROS completed each month. Each item captured on the ROS will have a supporting progress note. Each counselor will be responsible to update the ROS regularly for each client on their caseload. Completion of ROS will be monitored by the Clinical Director through a combination of supervision and chart audits. An in-house training conducted by the program director and clinical director of the process will be completed for current staff during a weekly staff meeting on 9/29/20. New clinicians will be oriented to these practices at the time of hire.
All above stated actions will be completed by October 1, 2020.
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