INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
|
Observations
Based on the review of the fire drill record, the facility failed to ensure that fire drills were conducted during different times of the day.
The findings include:
The fire drill record was reviewed on July 19, 2013. Twelve months of fire drills were reviewed. The facility's hours of operation are Monday through Thursday 8 am -8 pm, Friday 8 am - 6 pm and Saturday 8 am-1 pm. The facility failed to document fire drills during the evening hours after 3 pm to 8 pm. The following months were reviewed July 2012-June 2013.
|
Plan of Correction
In reference to 705.28(d)(6) Fire Safety drills will take place at alternating times to include evening and weekends; all hours of operation will be represented. Drills will be led under the supervision of the DUI Supervisor and confirmed by the Director. This change will take place by 9/16/13. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in two of two client records reviewed.
The findings include:
Nine client records were reviewed on July 19, 2013. Four of the client records reviewed were for discharged clients. Two of the discharged clients were involuntarily terminated from treatment at the project. The facility failed to notify the clients, in writing, of a decision to involuntarily terminate the clients' treatment at the project, in client record # 7 and 9.
Client # 7 was admitted into treatment on December 13, 2012 and was involuntarily terminated from the project on May 24, 2013. There was no documentation of written notification provided to the client as of the on-site inspection.
Client # 9 was admitted into treatment on December 24, 2012 and was involuntarily terminated from the project on March 15, 2013. There was no documentation of written notification provided to the client as of the on-site inspection.
An interview with the facility director on July 19, 2013 confirmed the findings.
|
Plan of Correction
In reference to 709.33(a) regarding notice of termination, clients will be notified in writing of a decision to involuntarily terminate the client's treatment, the reasons why and the information needed to re-enter treatment if applicable. Notices will be sent by the individual therapist and this will be confirmed by the Clinical Supervisor and Director by random audits. Changes will take place by 9/16/13. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment and/or an evaluation of the counselor's conclusions/impressions of the client.
of the client in seven of nine client records.
The findings include:
Nine client records were reviewed on July 19, 2013. Seven of the nine were reviewed for psychosocial evaluations, #1, 2, 3, 4, 5, 6 and 7.
The psychosocial evaluations in client records #1, 2, 3, 4, 5, 6 and 7 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records #1, 2, 3, 4, 5, 6 and 7 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluations in client records #1, 2, 3, 4, 5, 6 and 7 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records #1, 2, 3, 4, 5, 6 and 7 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluations in client records #1, 2, 3, 4, 6 and 7 did not include an evaluation of the counselor's conclusions/impressions of the client.
An interview with the facility director on July 19, 2013, confirmed the findings.
|
Plan of Correction
In reference to 709.91(b) regarding psychosocial evaluations, client intakes will include a full psychosocial evaluation (to include client's assets/strengths, support systems, client's negative factors, attitude, conclusions/impressions) completed at the time of intake by the intake therapist and confirmed by the Clinical Supervisor. This will take place by 9/3/13 will be overseen by the Clinical Supervisor and Director through random audits. |
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,facility policy and procedures and an interview with the facility director, the facility failed to complete discharge summaries in four of four discharged client records.
The findings include:
Per the facility policy, discharge summaries will be completed within 7 days after the clients discharge date. Discharge summaries are to include the client's reason for treatment, services offered to the client, the client's response to treatment and the client's status at discharge. An interview with the facility director on July 19, 2013 confirmed the policy.
Nine client records were reviewed on July 19, 2013. Of the nine, four were required to show documentation of a discharge summary, #6, 7, 8 and 9. .
Client #6 was admitted on November 14, 2012 and discharged on February 6, 2013. The discharge summary was required to be documented by February 13, 2013. Client #6's discharge summary was completed on February 4, 2013, two days before the client was scheduled to be discharged. The discharge summary failed to include what services were offered to the client.
Client #7 was admitted on December 13, 2012 and discharged on May 24, 2013. The discharge summary was required to be documented by May 31, 2013. Client #7's discharge summary was completed but failed to have a date when it was completed.
Client #8 was admitted on December 24, 2012 and discharged on March 15, 2013. . Client #8's discharge summary failed to include what services were offered to the client.
Client #9 was admitted on July 26, 2012 and discharged on December 13, 2012. The discharge summary was required to be documented by December 20, 2012. Client #9's discharge summary was completed but failed to have a date when it was completed.
|
Plan of Correction
In reference to 709.93(a)(10) regarding discharge summaries: Discharge summaries will be signed/dated by the completing clinical and include services offered to the client. These summaries will be completed within 7 days of client's discharge dates. This plan of correction will be completed by the therapist conducting the discharge and overseen by the Clinical Supervisor through regular audits. Changes will take place by 9/16/13. |