INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the May 27, 2010 licensure renewal inspection. The follow-up inspection was conducted on November 12, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Conewago Snyder 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 December 10, 2010.
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Plan of Correction
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709.28(c)(5) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
Based on a review of client records and an interview with the Facility Director, the facility failed to insure that a dated witness signature was affixed to each consent to release information document in each of the client records reviewed.
The findings included:
Three client records were reviewed during the unannounced inspection on 11/12/2010. The facility failed to insure that a dated witness signature was documented on each of the consent to release information forms filed in each record as required. An interview with the Facility Director revealed a misunderstanding about this requirement . The facility uses a proprietary software package for electronic record keeping. Each person logging into this electronic system is pre-approved. When the person logs into the electronic record and develops a new form with a client, the staff person's name is pre-populated on the signature line as part of the log in process. Staff are not placing an actual dated witness signature on each consent to release information as required by this regulation. This omission was noted in three of three applicable records reviewed.
Client record # 1- This individual was admitted on 9/14/10. Consents to release information were documented in the record which permitted disclosures to other treatment providers, family members and a local pharmacy. No dated witness signature was documented on consent to release information forms completed on 10/15/10, 11/2/10 and 11/7/10.
Client record # 2- This client was admitted on 11/1/10. Consents to release information were documented in the record which permitted disclosures to local medical service providers, government agencies and a local pharmacy. No dated witness signature was documented on consent to release information forms completed on 11/1/10, 11/3/10, 11/4/10, 11/5/10 and 11/8/10.
Client record # 3- This client was admitted on 10/8/10. Consents to release information were documented in the record which permitted disclosures to other treatment providers, third party payers, government agencies and a personal contact. No dated witness signature was documented on these consent to release information forms completed on 10/8/10 and 10/12/10.
An ongoing dialogue was held with the Director throughout the course of the inspection and she did not dispute the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based a review of client records and agency policy during the onsite inspection the facility failed to document personal histories which included family interrelationships, work history and educational history. Histories were not consistently documented within the three day timeframe as required in facility policy.
The findings included:
A plan of correction follow up inspection was conducted on 11/12/10. Three client records were reviewed. Three of three client records failed to include documentation of complete personal histories. One of three failed to include documentation that the personal history was completed within three days of admission as required by facility policy.
Client record # 1- This individual was admitted on 9/14/10. The personal history was completed on 9/19/10. This record did not include documentation of a complete personal history as it was missing family interrelationships, an employment history and an educational history.
Client record # 2- This client was admitted on 11/1/10. The record did not include documentation of a personal history which included family interrelationships, employment history and an educational history.
Client record # 3- This individual was admitted on 10/8/10. The client record did not include documentation of a personal history which included a complete employment history and family interrelationships.
All findings were discussed with the Facility Director throughout the inspection . She did not dispute the accuracy of the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.52(a)(3) LICENSURE Support service type
709.52. 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:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to document the type of support services proposed for each client on the comprehensive treatment plan in three of three client records.
The findings included:
Three client records were reviewed during the plan of correction follow up inspection of 11/12/10. Three of three applicable records failed to document support services on the treatment plan.
Client record # 1- The client was admitted on 9/14/10. The treatment plan was formulated on 9/21/10. The treatment plan failed to include documentation of the type of support services to be offered to the client.
Client record # 2- The client was admitted on 11/1/10. The treatment plan was formulated on 11/8/10. The treatment plan failed to include documentation of the type of support services to be offered to the client.
Client record # 3- The client was admitted on 10/8/10. The treatment plan was formulated on 10/15/10. The treatment plan failed to include documentation of the type of support services to be offered to the client.
The findings were reviewed with the Facility Director throughout the course of the inspection and were not disputed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(3) LICENSURE Records of Service
709.53. 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:
(3) Record of services provided.
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Observations
Based on the review of client records during the unannounced inspection, the facility failed to document a complete record of services in three of three client records.
The findings included:
Three client records were reviewed during the unannounced plan of correction follow up inspection of 11/12/10. Three of three client records contained records of services which failed to include documentation of the duration of each service on the record of service document.
Client record # 1- This client was admitted on 9/14/10. The record of service did not include the duration of each service provided on the record of services.
Client record # 2- This client was admitted on 11/1/10. The record of service did not include the duration of each service provided on the record of services.
Client record # 3- This client was admitted on 10/8/10. The record of service did not include the duration of each service provided on the record of services.
The findings were reviewed throughout the course of the inspection with the Facility Director and were not disputed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(5) LICENSURE Progress Notes
709.53. 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:
(5) Progress notes.
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Observations
Based on the review of client records, the facility failed to document dated signatures on progress notes as required. Group notes failed to include documentation of each individual's response or participation in the group process.
The findings included:
Three client records were reviewed during the unannounced plan of correction follow up inspection 11/12/10. Three of three client records failed to include documentation of support services on the treatment plan.
Client record # 1- The client was admitted on 9/14/10. The individual progress notes in the client record were not written in the "Data Assessment Plan" format. The group notes in the record did not document each individual's participation or response in the group session. Progress notes were not signed and dated.
Client record # 2- The client was admitted on 11/1/10. The individual progress notes in the client record were not written in a "Data Assessment Plan" format. The group notes in the record did not document each individual's participation or response in the group session. Progress notes were not signed and dated.
Client record # 3- The client was admitted on 10/8/10. The individual progress notes in the client record were not written in a "Data Assessment Plan" format. The group notes in the record did not document each individual's participation or response in the group session. Progress notes were not signed and dated.
The findings were reviewed with the Facility Director throughout the course of the inspection and were not disputed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(12) LICENSURE Work as treatment
709.53. 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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on the review of three client records and interviews with two clients, the facility failed to document the use of work as treatment on each individual treatment plan as required.
The findings included:
Three client records were reviewed during the unannounced plan of correction follow up inspection of 11/12/10 and two clients were interviewed. Interviews with two of two clients revealed that part of their daily routine is to complete "details" which include such tasks as mopping floors around the facility, cleaning bathrooms and wiping furniture down. These "work details" are completed by each client as part of the day's activities.
Client record # 1 - This individual was admitted on 9/14/10. At the time of the record review on 11/12/10, there was no documentation of work therapy on the treatment plan or in the client record.
Client record # 2 - This individual was admitted on 11/1/10. At the time of the record review on 11/12/10, there was no documentation of work therapy on the treatment plan or in the client record.
Client record # 3 - This individual was admitted on 10/8/10. At the time of the record review on 11/12/10, there was no documentation of work therapy on the treatment plan or in the client record.
The findings were reviewed with the Facility Director. She did not dispute that this practice occurs.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |