INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 1 - 2, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Another Way, 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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709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
Based on a review of the policy and procedure manual, medication inspection logs and an interview with the facility director, the facility failed to document inspections of the medication storage area every three months, as per facility policy.
The findings include:
On August 1, 2011, the policy and procedure manual was reviewed. Per the agency policy, an inspection of the medication storage area will be completed every three months. Inspections were reviewed for the months of August 2010 through August 2011. Inspections of the medication storage area were conducted by the facility on the following dates: 9/14/10, 10/27/10, 6/20/11 and 7/25/11. No inspections were documented between 10/27/10 and 6/20/11. Based on the facility policy, inspections of the medication storage area should have been conducted no later than 1/27/11 and 3/27/11.
The facility director was interviewed on August 1, 2011 at approximately 10:30 AM and confirmed that medication storage area inspections were not documented every three months, as required by agency policy.
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Plan of Correction
Due to staff changes the medication inspection log was missed for the periods documented. The Counselor Assistant that monitors the medication room was completing the medication inspection log at the time of our annual survey. We are in full compliance as of 8/15/11. The Counselor Assistant will continue to complete the logs and the Facility Director will monitor that it is being completed as directed by policy. |
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
Based on a review of client records and an interview with the facility director, the facility failed to document individual counseling sessions on the record of services provided in two of five client records.
The findings include:
Five client records were reviewed on August 1 - 2, 2011. The record of services provided was required in five client records. The facility did not document the individual counseling sessions on the record of services provided in client records # 3 and 5.
Client # 3 was admitted to treatment on April 20, 2011. The record of services provided did not include documentation of the individual counseling sessions provided to the client. Progress notes documented that individual counseling sessions occurred on the following dates: April 25, April 27, May 2, May 9, May 16 and May 26, 2011. None of these individual sessions were documented on the record of services provided, at the time of the review, on August 1 - 2, 2011.
Client #5 was admitted to treatment on February 1, 2011 and discharged on July 21, 2011. The record of services provided did not include documentation of the individual counseling sessions provided to the client. Progress notes documented that individual counseling sessions occurred on the following dates: February 1, February 7, February 14, February 21, February 28, March 7, March 14, March 21, March 28, April 4, April 11, April 18 and April 25, 2011. None of these individual sessions were documented on the record of services provided, at the time of the review, on August 1 - 2, 2011.
The facility director was interviewed throughout the licensing process and confirmed that individual sessions were not documented on the record of services provided, in client records # 3 and 5.
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Plan of Correction
Another Way did not check the activity logs to ensure that the individual sessions were logged. The behavioral techs log the individual sessions on a weekly basis and did not correctly log the individual sessions. The Facility Director will assign one Behavioral Tech to monitor the Activity Logs to ensure all individual sessions are logged correctly. The facility Director will then review the logs by the end of the month before they are filed to confirm it was logged correctly. We are in full compliance by 8/15/11 |