INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on September 11-13, 2019, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, Treatment Trends Inc. Keenan House, was found to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this investigation.
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Plan of Correction
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705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
The facility failed to have furniture in good repair. The wooden frame on the couch in the third floor lounge was broken and the cushions on the chairs were stained and two of the chairs had rips in the fabric.
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Plan of Correction
To correct the violation of standard 704.11(b)(1, all furniture will be inspected by the Clinical Director to determine which pieces need to be replaced. A suggested schedule of purchase shall be submitted to the TTI Executive Director by October 21, 2019. For furniture in good repair, a schedule of cushion replacement shall be submitted to the Executive Director of TTI by October 24, 2019. All furniture and cushions will be ordered by October 27th. Furniture and cushions shall be in place by November 5, 2019. The Maintenance crew, and senior supervisory staff will inspect each piece of furniture monthly to ensure all furniture and cushions are in good repair and submit a request to the clinical Director for review/purchase. |
709.24 (a) (1) MEMO 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:
(1) Definition of the target population toward whom facility services are directed.
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Observations
The facility failed to adhere to procedures for providing access to physical healthcare services.
*Facility incident reporting policy states that an incident report must be filed by the end of the shift during which the incident is observed or reported.
Records reviewed indicated that a client, was admitted to the facility on 1/29/18 and discharged 4/3/18. An injury occurred on 2/13/18 and the client reported the incident and was sent to the ER on that date, however there was no documentation of the incident until 2/28/18 which lists the client ' s injury and ER admit on 2/13/18; there was also discharge paperwork and prescriptions which were dated 2/13/18 that were attached to the report.
Additionally, a client was admitted on 6/19/19 and was still active at the time of the investigation. This client was injured and was taken to the ER on 9/10/19 however there was no written incident report prior to his leaving the facility, as per policy, and the facility was unable to verify with certainty the date of the injury as no incident report was found at the time of the investigation.
This information was shared with the facility staff in order to mitigate the dangerous condition.
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Plan of Correction
Standard 709.24 will be addressed in Clinical Staff meeting by 10/7/2019 and in Clinical Tech meeting during their monthly meeting by 10/15/2019. In both meetings, the following policies and procedures will be reviewed by the Clinical Director for clinicians and the clinical technician supervisor for techs:
1) Incident reports must be completed by end of shift
2) All injuries are to be noted in the staff log.
3) All prescriptions are given to the Service Coordinator office upon return from any medical appointment.
AS of October 7, 2019, Keenan House has a full time nurse who is responsible that all injuries are documented in an Incident Report, medications are faxed to the pharmacy (the original stays in the chart)and notation in the log about any incident involving staff or clientele. These tasks shall be completed by October 14, 2019.
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709.28 (c) 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.
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Observations
The facility failed to ensure the confidentiality of counseling sessions.
The lounge area on the third floor had a video camera mounted on the ceiling. According to facility staff the lounge area is also utilized for conducting group counseling sessions.
Additionally, there were cameras throughout the facility and some of these were located in areas that were utilized for counseling sessions.
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Plan of Correction
AT present, we are seeking an exception due to contractual obligations with the DOC and PREA (Prison Rape Elimination Act) requirements. Request is being made by the Associate Executive Director and should be responded to by November 20, 2019.
Until the waiver/exception is decided upon, the camera's will be turned off during all group events and individual sessions will be strictly held in the counselor booths that do not have camera's. The Program Director will be responsible to ensure the IT department concludes its programing by December 2nd to ensure cameras are no live during group times via pre-programed scheduling.
Should the exception/waiver fails to be approved by DDAP, the cameras will be removed from rooms used for group sessions by maintenance personnel. |
709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
The facility failed to ensure that treatment plans were developed with the client.
Client #1 was admitted on 1/29/18 and discharged on 4/3/18. The comprehensive treatmewnt plan was signed by the counselor on 2/7/19 but was not signed until 3/6/18 by the client.
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Plan of Correction
Correction of standard 709.52 will take place by the following intervention:
Treatment plan development procedures will be reviewed by the Clinical Director during the weekly clinical staff meeting by October 7, 2019. The policy and procedure will be presented by the Clinical Director. Highlighted will be the importance of inclusion of client collaboration in development of the Treatment plan and proper signature of documents by both staff and clientele.
The Clinical Director will review each Treatment Plan during individual staff supervision to ensure client and counselor are developed together beginning October 21, 2019. |