INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 30, 2007 through July 31, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Holcomb Associates, 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 and a plan of correction is due on August 30, 2007.
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Plan of Correction
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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
The facility failed to ensure space heaters were not within the facility. A space heater was viewed in office #10.
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Plan of Correction
The space heater has been removed from the office. Staff have been formally reminded that space heaters are prohibited. Support staff to conduct random inspections of offices to ensure compliance with agency policy. |
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
The facility failed to document that personnel were trained to perform assigned tasks during emergencies for four of six employees reviewed, #3, 4, 5, and 6.
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Plan of Correction
The Facility Director reviewed the documentation requirements with the HR staff regarding the need for compliance with documentation of staff's ability to perform assigned tasks during emergencies. HR will conduct spot-checks to ensure compliance with this standard. |
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.
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Observations
The facility failed to document that alternate exit routes were used during fire drills.
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Plan of Correction
The Facility Director reviewed with the agency's Director of Facility Management the requirement that fire drills document use of alternate exit routes. Future fire drills will be conducted in rotating manner to include all possible exit routes. Documentation will be maintained of use of these alternate routes. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
The facility failed to include available resources for the 2007 - 2008 project goals and objectives.
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Plan of Correction
The Facility Director and Project Director will collaborate on the Project's Goals and Objectives report to ensure that available resources are sufficiently documented. The 2007-2008 report will be updated to include this information. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
The facility failed to include the date that the annual work performance evaluation was completed for three of four employees reviewed, #2, 3 and 4.
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Plan of Correction
The HR department has revised the Annual Performance Evaluation form to require documentation of the evaluation period. Supervisory staff have been instructed to complete the form in its entirety, including the evaluation period. |
709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
The facility failed to provide an accurate data collection and record-keeping system on July 31, 2007. The client list included two mental health clients who were identified as active drug and alcohol clients and one closed mental health client identified as a closed drug and alcohol client.
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Plan of Correction
The Facility Director and the Director of Clinical Support Services will review the MIS system to determine if a systemic problem exists in the mis-classification of client status. Any systemic problem will be corrected when identified. Periodic spot-checks will be conducted to ensure that data entry is accurate and timely. |
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
The facility failed to document the treatment plans updates in two of two client records reviewed, #1 and 2.
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Plan of Correction
Agency policy regarding the review and updating of treatment plans was reviewed with the Clinical Supervisor and clinicians. The Clinical Supervisor will conduct spot-checks 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
The facility failed to document case consultations, according to the time frame identified in the project's policy, in two of two client records reviewed, #1 and 2.
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Plan of Correction
Agency policy regarding the frequency and content of case consultations was reviewed with the Clinical Supervisor. The Facility Director will conduct periodic reviews to ensure compliance with this standard. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
The facility failed to complete the aftercare plan when the client was discharged after successfully completing treatment in one of two records reviewed, #1.
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Plan of Correction
Policy regarding the time frame and content of aftercare plans was reviewed with the Clinical Supervisor and clinicians. The MIS system will be used to trigger prompts to staff regarding completion of aftercare plans. The Clinical Supervisor to conduct periodic chart reviews to determine 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
The facility failed to document a complete discharge summary in one of two client records reviewed, #2. The discharge summary did not include the reason for treatment, response to treatment plan goals, services offered and client status upon discharge.
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Plan of Correction
The Clinical Supervisor was reminded of agency policy regarding the time frame and required content of discharge summaries. Staff to be trained and monitored on their compliance with this standard. |
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.
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Observations
The facility failed to document follow-up information in two of two client records reviewed, #1 and 2.
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Plan of Correction
Agency policy regarding follow-up documentation was formally reviewed with the Clinical Supervisor. The supervisor will conduct formal monitoring, based on MIS triggers, to ensure compliance. |