INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 29-30, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Allied Addiction Recovery, LLC 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:
|
Plan of Correction
|
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
The fire drill logs were reviewed on May 29, 2013. The time period reviewed was September 2012 through May 2013. The facility did not document any alternate exits used during fire drills. The main hallway stairs was the exit route used during every fire drill that took place during this time period.
An interview was conducted with the project/facility director on May 29, 2013 at which time the aforementioned information was confirmed.
|
Plan of Correction
Facility Director met with staff involved in fire drill documentation on 6/1/13. Staff was directed to alternate exits used and to accurately document this alternation in the Fire Drill log. Reports will be placed in the Facility Directors mailbox and they will monitor the alternation of exits and documentation. |
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
|
Observations
Based on a review of personnel records, the facility failed to document a written job description which contained the employee's and supervisor's dated signatures in one of three personnel records.
The findings include:
Three personnel record was reviewed on May 29, 2013. All three personnel records required a job description which was signed by the employee and supervisor. The facility did not document a signed job description in personnel record #3.
Employee #3 was hired as a full time counselor on February 7, 2013. There was no signed job description documented in employee #3's record, only a contract from when she was a contracted employee.
An interview with the project / facility director took place on May 30, 2013 at which time it was confirmed that there was no signed job description for employee #3.
|
Plan of Correction
Facility Director met with newly hired Office Manager on 6/1/13. The Office Manager will maintain Personnel records ongoing and has included the siging of Job Descriptions into new employee orientation. Current staff were met with on 6/1/13 and Job Descriptions were signed and added to personnel records. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
|
Observations
Based on personal observation, the facility failed to maintain the confidentiality of client identity and records.
The findings include:
On May 30, 2013, at approximately 1:30 PM, the licensing inspector observed a sign in sheet on the table in the waiting area. Upon closer inspection, it was observed that clients and visitors were signing their first and last names on the sign in sheet upon entry. This sign in sheet is accessible to anyone who enters the facility.
An interview with the project/facility director took place on May 30, 2013 at which time the aforementioned information was confirmed.
|
Plan of Correction
Sign in sheet was removed from the facility on 5/30/13. Staff has been briefed as to the reasons why and the sign in sheet will not be used in the future. |
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.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates that included an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in one of one client records.
The findings include:
Eight client records were reviewed on May 29-30, 2013. Treatment plan updates were due to be completed in one of the client records reviewed. Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days. The treatment plan update documented in client record # 4 did not contain an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.
Client #4 was admitted on March 1, 2013. The comprehensive treatment and rehabilitation plan was developed on March 25, 2013. A treatment plan update was due to be completed on May 25, 2013. A treatment plan update was completed; however, the treatment plan update did not include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment and rehabilitation plan.
An interview with the project/facility director took place on May 30, 2013 at which time the aforementioned information was confirmed.
|
Plan of Correction
Facilty Director met with staff on 6/1/13 and reviewed the Treatment Plan Update process and the proper filling out of the document. Staff reported an understanding of the need to document progress toward treatment plan goals in the section marked Progress toward treatment plan goals. Facility Director will receive TPUs in his mailbox to review and ensure compliance. |
709.93(a)(10) LICENSURE Client records
709.93. 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:
(10) Discharge summary.
|
Observations
Based on a review of client records, the facility failed to document a complete discharge summary that included the client's reason for treatment, services offered, response to treatment and client's status upon discharge in three of four client records.
The findings include:
Eight patient records were reviewed on May 30, 2013. Four client records were reviewed for discharge summaries. Client records #6, 7 and 8 did not include documentation of discharge summaries that included all required components.
Patient # 6 was admitted on February 1, 2013 and discharged on March 23, 2013. The discharge summary did not include documentation of the client's reasons for treatment and the client's status upon discharge.
Patient # 7 was admitted on January 18, 2013 and discharged on February 28, 2013. The discharge summary did not include documentation of the client's reasons for treatment.
Patient # 8 was admitted on December 17, 2012 and discharged on February 11, 2013. The discharge summary did not include documentation of the client's reasons for treatment and the client's status upon discharge.
An interview with the project/facility director took place on May 30, 2013 at which time the aforementioned information was confirmed.
|
Plan of Correction
Facility reviewed requirements with staff involved in the writing of discharge summaries on 06/1/13. Required information including the reason for treatment, response to treatment, and client's status upon discharge were emphasized. Office Manager will review discharge summaries for these components and forward records to the Facility Director for final review before they are placed in inactive storage. |
709.93(a)(11) LICENSURE Client records
709.93. 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:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to document follow up information in three of four client records.
The findings include:
Four discharged outpatient client records were reviewed on May 30, 2013. Follow up contact after discharge was due to be completed in three client records. Follow up contact after discharge was not documented in client records #5, 7 and 8.
Client #5 was admitted on February 1, 2013 and discharged on February 28, 2013. The follow up contact documented in client record #5 was conducted on February 25, 2013, three days prior to discharge.
Client #7 was admitted on January 18, 2013 and discharged on February 28, 2013. The follow up contact documented in client record #6 was conducted on February 25, 2013, three days prior to discharge.
Client #8 was admitted on December 17, 2012 and discharged on February 11, 2013. The follow up contact documented in client record #8 was conducted on February 11, 2013, the same day as discharge.
An interview with the project/facility director took place on May 30, 2013 at which time the aforementioned information was confirmed.
|
Plan of Correction
Facility Director met with staff involved in follow up contacts on 6/1/13. The Office Manager will review files for release of information and then attempt follow up within 7 days of discharge. They will forward the discharged record to the Facility Director for final review before inactive storage. |