INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on February 14 & 15, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, John F. Kennedy Behavioral Health Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on the review of the "Staffing Requirements Facility Summary Reports" completed by each facility in the Project, the Project failed to ensure that there was one full-time clinical supervisor for every eight full-time equivalent (FTE) counselors in the Project.
The findings include:
The "Staffing Requirements Facility Summary Reports" for each of the two facility's that make up the Project were reviewed from February 13, 2012 through February 16, 2012. The "Staffing Requirements Facility Summary Reports" completed by the facility on 2/13/2012 and signed on 2/13/2012, listed a combined total of 14 counselors who are providing drug and alcohol counseling. The total number of drug and alcohol counseling hours per week provided by the counselors equates to 14 FTE counselors within the project, and therefore the project is required to have at least one full-time clinical supervisor and one part-time clinical supervisor or lead counselor. The "Staffing Requirements Facility Summary Reports" did not identify a full-time clinical supervisor at either of the Project's two facilities.
The facility director confirmed the findings.
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Plan of Correction
Effective 2/17/2012, a full-time clinical supervisor was assigned to this facility. The project director will ensure that a full-time clinical supervisor will be maintained for every 8 FTEs. If the position becomes vacant, the project director will appointment a temporary clinical supervisor until the position is filled. The HR director is responsible for implementing this corrective action. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to ensure that all staff persons and volunteers received a minimum of 6 hours HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
The findings include:
On February 13, 2012 the Staffing Requirements Facility Summary Report was reviewed.
Three employees were required to have documentation of the required HIV/AIDS and TB/STD training. The facility failed to provide documentation of the required HIV/AIDS training for employee # 9, 10, and 11.
Employee # 9 was hired August 2006.
Employee # 9 is a psychiatrist.
HIV/AIDS training was to be completed within the first 2 years of employment, by August 2008.
At the time of review on 2/13/12, the facility failed to document completion of 6 hours HIV/AIDS training for employee # 9.
Employee # 10 was hired May 2009.
Employee # 10 is the security guard.
HIV/AIDS and TB/STD training was to be completed within the first 2 years of employment, by May 2011.
At the time of review on 2/13/12, the facility failed to document completion of 6 hours HIV/AIDS training and 4 hours of TB/STD training for employee # 10.
Employee # 11 was hired September 1977.
Employee # 11 is the medical director.
HIV/AIDS training was to be completed within the first 2 years of employment, by September 1979.
At the time of review on 2/13/12, the facility failed to document completion of 6 hours HIV/AIDS training for employee # 11.
The facility director did not dispute the findings.
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Plan of Correction
By 5/8/2012, all three staff members will fulfill training requirements for HIV/AIDS and TB/STD. The facility director is responsible for arranging the training and ensuring staff compliance with this standard. The HR director will ensure that new staff hires will comply with obtaining this training within the required time frame. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on observation during a physical plant inspection, the facility failed to ventilate bathrooms by exhaust fan or window.
The findings include:
On February 14, 2012 at approximately 12:00 PM and on February 15, 2012 at approximately 9:30 AM, physical plant inspections were conducted.
The facility failed to ventilate bathrooms by exhaust fan or window in one of four bathrooms.
It was observed that the second floor bathroom lacked ventilation by exhaust fan or window. The exhaust fan on the second floor was not operable at the time of inspection.
The facility director confirmed the findings.
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Plan of Correction
On 2/17/2012, the second floor bathroom exhaust fan was replaced with a new exhaust fan and this bathroom is ventilated. The environmental services director will monitor the unit monthly and ensure the restroom fan is operational. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on observation and a physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the nonresidential facility were unobstructed
The findings include:
On February 14, 2012 at approximately 12:00 PM a physical plant inspection was conducted.
It was observed that the door designated as the second floor emergency exit was obstructed.
The second floor emergency exit door was locked and required a key in order to be unlocked.
The facility director confirmed the findings.
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Plan of Correction
On 2/16/2012, the second floor emergency exit door was fitted with a new door handle that does not require a key for passage. This door will remain unobstructed at all times. |
705.28 (a) (1) (iv) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based on observation during a physical plant inspection and an interview with the facility director, the facility failed to clearly indicate exits by the use of signs.
The findings include:
On February 14, 2012 at approximately 12:00 PM a physical plant inspection was conducted.
It was observed that there was no indication of a second emergency exit on the second floor.
The Licensing Specialist asked the facility director where the second exit was located.
The facility director informed the Licensing Specialist that the second exit was located behind the closed and locked door.
The facility director confirmed the findings.
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Plan of Correction
On 2/17/2012, an emergency exit sign was placed above and outside of the second floor exit doorway. The environmental services director will monitor the unit of a monthly basis and be responsible for ensuring that all emergency signs are posted. |
705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on observation during a physical plant inspection, the facility failed to light interior exits and stairs at all times.
The findings include:
On February 15, 2012 between 9:30 AM and 10:15 AM a physical plant inspection was conducted.
It was observed at 10:15 AM that the second floor emergency exit was dark.
The facility director confirmed the findings.
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Plan of Correction
On 2/17/2012, the second floor interior exit and stairs are lit and will remain on 24 hours/day and 7 days/week. The light circuit in this area has been redesigned by our electrician to remain in the 'On' position. |
705.28 (b) (1) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(1) Maintain a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
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Observations
Based on observation during a physical plant inspection, the facility failed to maintain a minimum of one operable smoke detector on each floor.
The findings include:
On February 15, 2012 at approximately 12:30 PM a physical plant inspection was conducted.
It was observed by the Licensing Inspector that the smoke detector on the second floor was inoperable when the maintenance man tried to activate the smoke detector during the physical plant inspection, as the battery needed to be replaced.
The maintenance man confirmed the findings.
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Plan of Correction
On 2/15/2012, the battery was replaced in the second floor automatic smoke detector and the smoke detector is operable. The environmental services director will monitor the unit monthly and ensure all smoke detectors are operational. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document fire extinguisher training upon staff employment in one of eight records.
The findings include:
On February 13, 2012, eight personnel records requiring documentation that staff had been instructed in the use of a fire extinguisher upon employment were reviewed.
The facility failed to document the completion of fire extinguisher training upon staff employment in one of eight records reviewed, record #1.
Employee # 1 was hired April 1985 and the training was required to be documented upon employment. The training was not documented at the time of review on February 13, 2012.
The human resource director confirmed the findings.
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Plan of Correction
On 2/16/2012, the employee hired in April 1985 received instruction in the use of the fire extinquisher. This instruction has been documented by the facility. The facility director is responsible for ensuring that all new employees receive this training within seven days of their employment. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies.
The findings include:
On February 13, 2012, eight personnel records requiring documentation that staff had training for emergencies prior to working any shift were reviewed. The facility failed to document the completion of training for emergencies prior to working any shifts in one of eight records reviewed, record #1.
Employee # 1 was hired April 1985 and the training was required to be documented prior to working any shift. The training was not documented at the time of review on February 13, 2012.
The human resource director confirmed the findings.
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Plan of Correction
On 3/14/2012, the employee hired in April 1985 was trained to perform assigned tasks during emergencies. This training has been documented in facility records. The HR director will review all personnel files and will ensure that no employee will go to the unit without having satisfied this requirement. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and a review of the facility's policy and procedure manual, the facility failed to document a psychosocial evaluation per policy.
The findings include:
The facility's policy titled "Intake and Admission" states:
A Psychosocial Evaluation will be completed by the therapist within 30 days of intake/admission. The evaluation will provide a composite picture of the client in relationship to his/her psychosocial history to identify possible relationships, conditions and underlying causes leading to the client ' s current situation.
Psychosocial evaluations include but not limited to:
a clear description of the client ' s presenting and underlying problems, client needs or problems that can or cannot be resolved through treatment or that might inhibit treatment, client assets, strengths or other factors that can contribute to the resolution of identified problems, the potential or available client support systems, negative factors that might affect treatment, the client's preferred coping mechanisms, conclusions regarding the client's appearance, behavior and reactions during the intake process, conclusions regarding the client's attitude toward and ability to participate in the treatment process.
On February 14 - 15, 2012, twelve client records requiring documentation of a psychosocial evaluation were reviewed. The facility failed to document an evaluative psychosocial assessment per policy in twelve of twelve records reviewed, # 1, 2, 3, 4, 5, 6, 11, 12, 13, 14, 15, and 16.
Client # 1 was admitted to the program on 11/29/11.
The psychosocial evaluation was to be documented within 30 days of intake/admission.
The psychosocial evaluation did not have a completion date.
Client # 2 was admitted to the program on 12/2/11.
The psychosocial evaluation was to be documented within 30 days of intake/admission.
The psychosocial evaluation did not have a completion date.
Client # 3 was admitted to the program on 10/18/11.
The psychosocial evaluation was to be documented within 30 days of intake/admission.
The psychosocial evaluation did not have a completion date.
In addition, the facility failed to document an evaluative psychosocial assessment which included an assessment regarding the client's assets/strengths and support systems.
Client # 4 was admitted to the program on 12/1/11.
The psychosocial evaluation was to be documented within 30 days of intake/admission.
The psychosocial evaluation did not have a completion date.
In addition, the facility failed to document an evaluative psychosocial assessment which included an assessment regarding the client's assets/strengths and negative factors.
Client # 5 was admitted to the program on 7/19/11.
The psychosocial evaluation was to be documented within 30 days of intake/admission.
The psychosocial evaluation did not have a completion date.
In addition, the facility failed to document an evaluative psychosocial assessment which included an assessment regarding the client's problems/needs, assets/strengths, coping mechanisms, and negative factors. Furthermore, the evaluation failed to include the client's attitude toward treatment.
Client # 6 was admitted to the program on 1/18/12.
The psychosocial evaluation was to be documented within 30 days of intake/admission.
The psychosocial evaluation did not have a completion date.
In addition, the facility failed to document an evaluative psychosocial assessment which included an assessment regarding the client's problems/needs, assets/strengths, support systems, and negative factors.
Client # 11 was admitted to the program on 8/23/11.
The psychosocial evaluation was documented on 8/23/11.
However, the facility failed to document an evaluative psychosocial assessment.
The facility failed to document an assessment regarding the client's support systems, coping mechanisms, and negative factors.
In addition, the evaluation failed to include the client's attitude toward treatment.
Client # 12 was admitted to the program on 8/23/11.
The psychosocial evaluation was documented on 8/29/11.
However, the facility failed to document an assessment regarding the client's support system.
Client # 13 was admitted to the program on 10/4/11.
The psychosocial evaluation was documented on 10/4/11.
However, the facility failed to document an evaluative psychosocial assessment regarding the client's assets/strengths, support systems, coping mechanism, and negative factors.
In addition, the evaluation failed to include the client's attitude toward treatment.
Client # 14 was admitted to the program on 11/14/11.
The psychosocial evaluation was documented on 11/14/11.
However, the facility failed to document an evaluative psychosocial assessment regarding the client's assets/strengths, support systems, coping mechanisms, and negative factors.
Client # 15 was admitted to the program on 11/9/11.
The psychosocial evaluation was to be documented within 30 days of intake/admission.
The psychosocial evaluation did not have a completion date.
In addition, the facility failed to document an assessment regarding the client's assets/strengths, support systems, coping mechanisms, and negative factors.
Client # 16 was admitted to the program on 8/23/11.
The psychosocial evaluation was to be documented within 30 days of intake/admission.
The psychosocial evaluation did not have a completion date.
In addition, the facility failed to document an assessment regarding the client's assets/strengths, coping mechanisms, and negative factors.
The facility director did not dispute the findings.
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Plan of Correction
By 4/30/2012, the facility director will conduct 2 staff trainings to improve documentaion of psychosocial evaluations. This training will focus on client assets/strengths, support systems, negative factors, coping mechanisms and problems/needs. In addition, the psychosocial evaluation format will be revised to include documentation of the client's attitude towards treatment. A completion date will be added to the bottom of all pages of the document. The clinical supervisor will review psychosocial evaluations to ensure compliance with this standard. |
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 and a review of the facility's policy and procedure manual, the facility failed to document a treatment plan update per policy.
The findings include:
The facility's policy titled "Treatment/Rehabilitation Services" states:
Treatment Plan Updates will be completed by the therapist at least every 60 days.
On February 14 - 15, 2012, eleven client records requiring documentation of a treatment and rehabilitation plan updates were reviewed.
The facility failed to document a treatment and rehabilitation plan update per policy in six of eleven records reviewed, # 1, 3, 4, 5, 12, and 16.
Client # 1 was admitted to the program on 11/29/11, and is still an active client.
The comprehensive treatment plan was documented on 11/29/11.
Treatment Plan Updates will be completed by the therapist at least every 60 days.
The facility failed to document a treatment plan update for client # 1 at the time of review on 2/14/12.
Client # 3 was admitted to the program on 10/18/11, and is still an active client.
The comprehensive treatment plan was documented on 10/18/11.
Treatment Plan Updates will be completed by the therapist at least every 60 days.
The facility documented a treatment plan update on 2/2/12 and a late update on 12/30/11.
Client # 4 was admitted to the program on 12/1/11, and is still an active client.
The comprehensive treatment plan was documented on 12/1/11.
Treatment Plan Updates will be completed by the therapist at least every 60 days.
The facility failed to document a treatment plan update for client # 4 at the time of review on 2/14/12.
Client # 5 was admitted to the program on 7/19/11, and is still an active client.
The comprehensive treatment plan was documented on 7/19/11.
Treatment Plan Updates will be completed by the therapist at least every 60 days.
The facility documented one treatment plan update for client # 5 on 1/17/12.
Client # 5 was required to have treatment plan updates on 9/19/11 and 11/19/11.
Client # 12 was admitted to the program on 8/23/11, and is still an active client.
The comprehensive treatment plan was documented on 8/29/11.
Treatment Plan Updates will be completed by the therapist at least every 60 days.
The facility documented a treatment plan update on 10/24/11 and a late update on 1/12/12.
Client # 16 was admitted to the program on 8/23/11, and is still an active client.
The comprehensive treatment plan was documented on 8/8/11.
Treatment Plan Updates will be completed by the therapist at least every 60 days.
The facility documented a treatment plan update on 10/8/11 and a late update on 1/23/12.
The facility director did not dispute the findings.
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Plan of Correction
By 4/30/2012, the facility director will conduct one staff training to improve timely documentaion of treatment plan updates. The clinical supervisor will monitor client charts on a weekly basis to ensure compliance with this standard. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records and a review of the facility's policy and procedures manual, the facility failed to document a complete client record which included a case consultation.
The findings include:
The facility's policy titled "Client Records" states:
Case consultation notes will be completed by the therapist at least every 90 days for the initial year of treatment and at least bi-annually thereafter.
On February 14 - 15, 2012, nine client records were requiring documentation of a case consultation were reviewed. The facility failed to document a case consultation note per policy in five of nine records reviewed, # 3, 5, 12, 13, and 16.
Client # 3 was admitted to the program on 10/18/11, and is still an active client.
A case consultation was due to be completed by 1/18/12; however at the time of review on 2/14/12 the facility failed to document a case consultation.
Client # 5 was admitted to the program on 7/19/11, and is still an active client.
A case consultation was due to be completed by 10/19/11 and 1/19/12; however at the time of review on 2/14/12 the facility failed to document a case consultation.
Client # 12 was admitted to the program on 8/23/11, and is still an active client.
A case consultation was due to be completed by 11/23/11; however at the time of review on 2/14/12 the facility failed to document a case consultation.
Client # 13 was admitted to the program on 10/4/11, and is still an active client.
A case consultation was due to be completed by 1/4/12.
The facility documented a late case consultation on 1/9/12.
Client # 16 was admitted to the program on 8/23/11, and is still an active client.
A case consultation was due to be completed by 11/23/11; however at the time of review on 2/14/12 the facility failed to document a case consultation.
The facility director did not dispute the findings.
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Plan of Correction
By 4/30/2012, the facility director will conduct one staff training on the timely completion of case consultations. The clinical supervisor will monitor client charts weekly to ensure compliance with this standard. |
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.
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Observations
Based on a review of client records and a review of the facility's policy and procedure manual, the facility failed to document a discharge summary per policy.
The findings include:
The facility's policy titled "Discharge Summary" states:
It is the policy of the Center to complete a discharge summary for all clients who terminate treatment/services. The primary therapist will complete the discharge summary within one week after discharge. This summary will be a stand alone document reflecting the following aspects of treatment.
1. reason for admission
2. services provided
3. summary of response to treatment
4. status at discharge
5. recommendations
On February 14 - 15, 2012, four client records requiring documentation of a discharge summary were reviewed. The facility failed to document a discharge summary per policy in four of four records reviewed, # 7, 8, 9, and 10.
Client # 7 was admitted to the program on 10/6/1980 and discharged on 7/18/11.
The discharge summary was documented on 7/18/11; however, it did not include the client's reason for treatment or services offered.
Client # 8 was admitted to the program on 7/15/2010 and discharged on 11/5/11.
The discharge summary was documented on 11/5/11; however, it did not include the client's status, reason for treatment, or services offered.
Client # 9 was admitted to the program on 1/7/2011 and discharged on 8/1/11.
The discharge summary was documented on 8/1/11; however, it did not include the client's reason for treatment or services offered.
Client # 10 was admitted to the program on 4/13/1972 and discharged on 8/31/11.
The discharge summary was documented on 8/31/11; however, it did not include the client's response to treatment or services offered.
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Plan of Correction
Effective 4/2/2012, the discharge summary will be revised to be a stand alone document and it will contain all required elements. The facility director will conduct a staff training on the proper completion on the revised form. The clinical supervisor will review discharge summaries to ensure compliance with this standard. |