INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 1, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Roxbury Carlisle 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:
|
Plan of Correction
|
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
|
Observations
During a physical plant inspection conducted on February 1, 2019, it was observed that the ventilation system was not operable in the bathroom closest to the counselor's offices.
The findings were discussed with the facility staff during the licensing process.
|
Plan of Correction
The building manager responsible for maintenance was notified regarding the ventilation system issue and acknowledged the repair. The Director of Outpatient Services, or designee, will provide oversight on ensuring compliance with regulation 705.24(5). Compliance will be measured via inspection of all bathrooms and ventilation systems, which will be added to the existing monthly environmental rounding and inspections of the physical plant. Any non-compliance will be immediately reported to both the building manager and Director of Plant Operations to ensure all repairs are identified and completed timely. |
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.
|
Observations
The facility ' s Policy and Procedure for the management of treatment/rehabilitation services for clients states that a treatment plan will be developed with the client within 72 hours of admission. The facility failed to provide documentation that this was completed in 6 of 7 records reviewed.
Client # 1 was admitted on September 12, 2018 and discharged on December 21, 2018. The comprehensive treatment plan was not developed with the client until September 24, 2018.
Client # 2 was admitted on July 9, 2018 and discharged on September 14, 2018. The comprehensive treatment plan was not developed with the client until July 25, 2018.
Client # 3 was admitted on August 9, 2018 and discharged on December 6, 2018. The comprehensive treatment plan was not developed with the client until September 6, 2018.
Client # 4 was admitted on September 25, 2018 and was still an active client at the time of the inspection. The comprehensive treatment plan was not developed with the client until October 8, 2018.
Client #5 was admitted on July 13, 2018 and was still an active client at the time of the inspection. The comprehensive treatment plan was not developed with the client until July 27, 2018.
Client #7 was admitted on August 8, 2018 and was still an active client at the time of the inspection. The comprehensive treatment plan was not developed with the client until September 7, 2018.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
It was determined that 72 hour timeframe for treatment plan initiation found in the Treatment Planning policy was incorrect for the outpatient and intensive outpatient treatment levels of care. The Treatment Planning Policy, specific to outpatient services, has been revised to include the accurate and appropriate timeframes for both initiation and update of the treatment plan. Staff will receive re-education on the new policy and timeframes during team meetings and competency will be assessed via attestation and through chart audits. The Director of Outpatient Services, or designee, will provide oversight on ensuring treatment plan timeframes are met. Compliance will be evaluated by the Director of Outpatient Services on a weekly basis via chart audits and any ongoing issues or trends will be reported in the weekly leadership team meeting. Staff will be re-educated, as necessary, throughout the monitoring process. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
|
Observations
The facility failed to ensure that there was appropriate documentation of written acknowledgment by the client, that the client had been made aware of their rights in client record # 's 1, 2, 3, 4, 5, 6, and 7. The clients rights provided to the client was missing the verbiage "creed, ethnicity, national origin, marital status, sexual orientation, and handicap. "
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The Patient Handbook/Client Rights Notification for outpatient services has been revised to include the verbiage regarding non-discrimination of patients in accordance with regulation 709.30(1). The Director of Outpatient Services, or designee, will provide re-education to staff and perform random weekly checks to ensure compliance. Any issues will be reported in the weekly leadership team meeting. Staff will be re-educated, as necessary, throughout the monitoring process. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
There was no documentation that the clients received counseling services according to their individual comprehensive treatment plan in 6 of 7 charts reviewed.
Client # 1 was admitted on September 12, 2018 and was discharged on December 21, 2018. The comprehensive treatment plan dated September 24, 2018 indicated 1 individual session 1 time a week. The chart's record of service and progress notes indicated that the client had only received an individual session on September 12, 2018.
Client # 2 was admitted on July 9, 2018 and was discharged on September 14, 2018. The comprehensive treatment plan dated July 25, 2018 indicated 1 individual session 1 time a week. The chart's record of service and progress notes indicated that the client had only received an individual session on July 9, 2018.
Client # 3 was admitted on August 9, 2018 and was discharged on December 6, 2018 the comprehensive treatment plan, dated September 6, 2018 indicated 1 individual session 1 time a week. The chart's record of service and progress notes indicated that the client had only received an individual session on August 9, 2018.
Client # 4 was admitted on September 28, 2018 and was still an active client at the time of the inspection. The comprehensive treatment plan dated October 8, 2018 indicated 1 individual session 1 time a week. The chart's record of service and progress notes indicated that the client had only received an individual session on September 28, 2018.
Client # 6 was admitted on October 8, 2018 and was still an active client at the time of the inspection. The comprehensive treatment plan dated October 15, 2018 indicated 1 individual session 1 time a week. The chart's record of service and progress notes indicated that the client had only received an individual session on October 8, 2018.
Client # 7 was admitted on August 8, 2018 and was still an active client at the time of the inspection. The comprehensive treatment plan dated September 7, 2018 indicated 1 individual session 1 time a week. The chart's record of service and progress notes indicated that the client had only received an individual session on August 8, 2018.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The treatment plan forms were revised to include specifics with regard to the required frequency of individual sessions. The Director of Outpatient Services, or designee, will provide re-education to staff during team meetings and competency will be assessed via attestation and through chart audits. The Director will also provide oversight on compliance of patients receiving all necessary services, including individual sessions, as laid out by their treatment plan. Compliance will be evaluated on a weekly basis via chart audits and any ongoing issues or trends will be reported in the weekly leadership team meeting. Staff will be re-educated, as necessary, throughout the monitoring process. |