INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 11, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Women's Institute of Family Health 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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709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
The facility failed to document that an annual report for 2023 was made available to the public.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will assure that the annual report for Women's Institute for Family Health will be made available to the public each year prior to the date of the meeting. The Project Director will place an ad in a local newspaper to announce the date, time and location of the annual report. The notice will be placed in a newspaper at least 30 days prior to the presentation of the annual report. |
709.24 (a) (3) 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:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the project's policy manual and discussion with staff, the facility failed to ensure that the written procedures for the management of treatment/rehabilitation services included timeframes for when documentation related to the completion of progress notes was to be completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director shall develop a written procedure for the management of treatment/rehabilitation services that will include the time frame for the completion of progress notes. The policy will be revised by 8/21/2024 |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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:
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Observations
Based on a review of seven client records and the facility's policies and procedures, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client within four weeks of admission, per the facility policy, in five records reviewed.
Client # 3 was admitted on January 10, 2024 and was discharged on May 13, 2024. The individual treatment and rehabilitation plan was due to be completed by February 7, 2024; however, it was not documented as completed until March 7, 2024.
Client # 4 was admitted on January 10, 2024 and was discharged on March 28, 2024. The individual treatment and rehabilitation plan was due to be completed by February 7, 2024; however, it was not documented as completed until May 17, 2024.
Client # 5 was admitted on January 4, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by February 1, 2024; however, it was not documented as completed until February 9, 2024.
Client # 6 was admitted on May 9, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by June 6, 2024; however, it was not completed until June 19, 2024.
Client # 7 was admitted on January 11, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by February 8, 2024; however, it was not documented as completed until March 28, 2024.
This is a repeat citation from the July 6, 2023 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director shall assure that individual treatment and rehabilitation plans are developed with the client within four weeks of admission. The Project Director will forward reminder notices to counseling staff alerting them to upcoming deadlines for treatment plans at three weeks and the Project Director will also review client records on a weekly basis to assure that individual treatment plans are completed within four weeks of admission. The Project Director will maintain a calendar notification system to alert her to all upcoming deadlines for clinical documentation. A calendar alert system will be implemented by 8/21/24 |
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.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed updated at least every 60 days in three of five applicable records reviewed.
Client # 3 was admitted on January 10, 2024 and was discharged on May 13, 2024. The individual treatment and rehabilitation plan was completed on March 7, 2024, and a treatment plan update was due to be completed by May 7, 2024; however, the treatment plan update was not documented as complete until June 19, 2024.
Client # 5 was admitted on January 4, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on February 9, 2024, and a treatment plan update was due to be completed by April 9, 2024; however, the treatment plan update was not documented as complete until May 23, 2024.
Client # 7 was admitted on January 11, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on March 28, 2024, and a treatment plan update was due to be completed by May 28, 2024; however, the treatment plan update was not documented as completed until June 7, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director shall assure that treatment and rehabilitation plans are reviewed and updated at least every 60 days. The Project Director will forward reminder notices to counselors at 53 days to alert them to the upcoming deadline for updates. The Project Director will review client records on a weekly basis to assure that updates are completed within 60 days of admission. The Project Director will develop a calendar alert system to keep her informed of all upcoming deadlines for clinical documentation. The calendar alert system will be implemented by 8/21/24 |