INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 18, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Organization for Women in Early Recovery 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 14, 2010.
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Plan of Correction
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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
Based on a review of personnel records and an interview with the facility director, the facility failed to ensure all personnel on all shifts were trained to perform assigned tasks during emergencies in one of one personnel record, as required by regulation.
The findings include:
Five employee records were reviewed on November 16-17, 2010. One employee was a new employees since the last inspection. Per regulation, the residential facility shall ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies. The facility failed to document that emergency training was completed upon employment in employee record # 2.
Employee # 2 was hired on April 26, 2010. Emergency training was due to be completed no later than May 3, 2010. The facility did not document the completion of emergency training until October 15, 2010.
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Plan of Correction
Fire Safety: The Associate and Clinical Director of POWER became aware that the agency was not sufficiently documenting the trainings that personnel were receiving during thier first week of orientation regarding assigned tasks during emergencies. The Associate and Clinical Director and Executive Assistant implemented a process to document emergency protocoal training in November 2010 and provided a review of the emergency protocols to all staff at that time. The Associate and Clinical Director will provide needed oversight to ensure that POWER remains in compliance with this regulation. The Associate and Clincical Director will monitor the new process through direct supervision of the Executive Assistant who is responsible to track that staff receive emergeny protocol training and through review of personnel records. This plan of correction was implemented on November 5, 2010, prior to the on-site licensing renewal inspection. POWER is in full compliance with this standard effective November 5, 2010. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill logs and an interview with the program manager, the facility failed to set off a fire alarm or smoke detector during each fire drill.
The findings include:
The fire drill logs were reviewed on November 18, 2010. Per regulation, the nonresidential facility shall set off a fire alarm or smoke detector during each fire drill. The facility failed to document on the fire drill logs that a smoke detector or fire alarm had been set off during fire drills conducted from January through October 2010.
The program manager was interviewed on November 18, 2010. The program manager confirmed the fire drill logs did not document that a smoke detector or fire alarm had been set off during fire drills. The program manager reported the facility could not set off a fire alarm or smoke detector due to sharing the building with other agencies. The facility did not document a request for an exception to use an alternative means of announcing a fire drill.
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Plan of Correction
Fire Safety-Fire Drills: The Associate and Clinical Director and the Program Manager and Program Supervisor ascertained that the facility does have a fire alarm system that can be checked on a monthly basis by program staff. The fire drill logs will include a column to include documentation that the fire alarm system is checked on a monthly basis. The Program Manager will instruct the Administrative Assistant to reformat the fire drill log to include a column to indicate that the system is checked on a monthly basis and to maintain the monthly logs. The Program Manager will provide the oversight to ensure that the facility is in compliance with this regulation. The Plan of Correction has already been implemented and the facility is in full complaince with this standard effective November 18, 2010. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on the review of client records and interviews with the facility director, the facility failed to date each signature on the treatment and rehabilitation plan updates with the actual date it was signed by the individual in five of five partial hospitalization client records.
The findings include:
Nine client records were reviewed on November 18, 2010. Five client records were reviewed as partial hospitalization clients. Treatment plan updates were reviewed in five client records. Per the Licensing Alert dated May 2005, the date that must appear in the client record is the date the update is signed. When more that one signature is required, each signature should be dated with the actual date it is signed by that individual. The facility did not document dated signatures in treatment plan updates in client records # 1, 2, 3, 6 and 7.
Client # 1 was admitted on July 8, 2010. The treatment and rehabilitation plan was completed on August 5, 2010. Treatment and rehabilitation plan updates completed in September, October and November 2010 did not include documentation of the actual date of each individual's signature on the treatment and rehabilitation plan updates.
Client # 2 was admitted on August 18, 2010. The treatment and rehabilitation plan was completed on September 21, 2010. Treatment and rehabilitation plan updates completed in October and November 2010 did not include documentation of the actual date of each individual's signature on the treatment and rehabilitation plan updates.
Client # 3 was admitted on September 3, 2010. The treatment and rehabilitation plan was completed on October 1, 2010. The treatment and rehabilitation plan update completed in November, 2010 did not include documentation of the actual date of each individual's signature on the treatment and rehabilitation plan updates.
Client # 6 was admitted on July 20, 2010 and discharged on October 15, 2010. The treatment and rehabilitation plan was completed on August 20, 2010. The treatment and rehabilitation plan update completed in September, 2010 did not include documentation of the actual date of each individual's signature on the treatment and rehabilitation plan updates.
An interview with the facility director on November 18, 2010, confirmed the treatment plan updates noted above did not document the actual date of each individual's signature.
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Plan of Correction
Treatment and Rehab Services: The Program Manager and Clinical Supervisor will educate all staff about the frequency that treatment plans are to be reviewed and updated. This training and education will take place during team supervision and will be reinforced during individual supervision. Staff will be educated about dating their signatures on the actual date they signed the treatment plan updates. The Associate and Clinical Director will revise the treatment plan forms to include a place for the date on the signature lines as a prompt for staff to date their signature. The Porgram Manager will provide eversight to ensure this standard is met via individual and team supervision and chart reviews. The facility will be in full compliance with this standard effective November 24, 2010. |
709.83(a)(4) LICENSURE Client records
709.83. 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:
(4) Case consultation notes.
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Observations
Based on the review of client records and interviews with the facility director, the facility failed to date each signature on the case consultation notes with the actual date it was signed by the individual in three of three partial hospitalization client records.
The findings include:
Nine client records were reviewed on November 18, 2010. Five client records were reviewed as partial hospitalization clients. Case consultation notes were reviewed in three client records. Per the Licensing Alert dated May 2005, the date that must appear in the client record is the date the update is signed. When more that one signature is required, each signature should be dated with the actual date it is signed by that individual. The facility did not document dated signatures in case consultation notes in client records # 1, 6 and 7.
Client # 1 was admitted on July 8, 2010. The case consultation note dated October 10, 2010 did not include documentation of the actual date of each individual's signature on the case consultation note.
Client # 6 was admitted on July 20, 2010 and discharged on October 25, 2010. The case consultation note dated October 21, 2010 did not include documentation of the actual date of each individual's signature on the case consultation note.
Client # 7 was admitted on May 24, 2010 and discharged on September 14, 2010. The case consultation note dated July 20, 2010 did not include documentation of the actual date of each individual's signature on the case consultation note.
An interview with the facility director on November 18, 2010, confirmed the case consultation notes noted above did not document the actual date of each individual's signature.
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Plan of Correction
Client Records: The Program Manager and Clinical Supervisor will train all staff about the need to sign and date all case consultations they are invovled with. Training will take place during team supervision and will be reinforced durign individual supervision. The Associate and Clinical Director will revise the forms used for case consultations to include a place for the date on the signature line to prompt consultation participants to date their signatures. The Program Manager will provide oversight to ensure this standard is met via individual and team supevision and chart reviews. The facility will be in full compliance with this standard effective November 24, 2010. |
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
Based on the review of client records and interviews with the facility director, the facility failed to date each signature on the treatment and rehabilitation plan updates with the actual date it was signed by the individual in two of two outpatient client records.
The findings include:
Nine client records were reviewed on November 18, 2010. Four client records were reviewed as outpatient clients. Treatment plan updates were reviewed in two client records. Per the Licensing Alert dated May 2005, the date that must appear in the client record is the date the update is signed. When more that one signature is required, each signature should be dated with the actual date it is signed by that individual. The facility did not document dated signatures in treatment plan updates in client records # 4 and 5.
Client # 4 was admitted on July 14, 2010. The treatment and rehabilitation plan was completed on August 1, 2010. Treatment and rehabilitation plan updates completed in September, October and November, 2010 did not document the actual date of each individual's signature on the treatment and rehabilitation plan updates.
Client # 5 was admitted on August 9, 2010. The treatment and rehabilitation plan was completed on September 3, 2010. Treatment and rehabilitation plans updates completed in October and November, 2010 did not document the actual date of each individual's signature on the treatment and rehabilitation plan updates.
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Plan of Correction
Treatment and Rehabilitation Services: The Program Manager and Clinical Supervisor will educate all staff about the frequency that treatment plans are to be reviewed and updated. This training and education will take place during team supervision and will be reinforced during individual supervision. Staff will be educated about dateing their signatures on teh actual date they signed the treatment plan. The Associate and Clinical Director will revise the treatment plan forms to include a place for the date on the signature lines as a prompt for staff to date their signature. The Program Manager will provide oversight to ensure this standard is met via individual and team supervision and chart reviews. The facility will be in full compliance with this standard effective November 24, 2010. |
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
Based on the review of client records and an interview with the facility director, the facility failed to date each signature on the case consultation notes with the actual date it was signed by the individual in two of two outpatient client records.
The findings include:
Nine client records were reviewed on November 18, 2010. Four client records were reviewed as outpatient clients. Case consultation notes were reviewed in two client records. Per the Licensing Alert dated May 2005, the date that must appear in the client record is the date the update is signed. When more that one signature is required, each signature should be dated with the actual date it is signed by that individual. The facility did not document dated signatures in case consultation notes in client records # 4 and 5.
Client # 4 was admitted on July 14, 2010. The case consultation note dated October 6, 2010 did not document the actual date of each individual's signature on the case consultation note.
Client # 5 was admitted on August 9, 2010. The case consultation note dated October 5, 2010 did not document the actual date of each individual's signature on the treatment and rehabilitation plan updates.
An interview with the facility director on November 18, 2010, confirmed the case consultation notes noted above did not document the actual date of each individual's signature.
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Plan of Correction
Case Consultation Notes: The Program Manager and the Clinical Supervisor will train all staff about the need to sign and date all case consultations they are involved with. Training will take place during team supervision and will be reinforced during individual supervision. The Associate and Clinical Director will revise the form used for case consultations to include a place for the date on the signature line to prompt consultation participants to date their signatures. The Program Manager will provide oversight to ensure this standard is met via individual and team supervision and chart reiveiws. The facility will be in full compliance with this standard effective November 24, 2010. |