INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 6, 7 and 9, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, JF Kennedy Community MH/MR Center 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 February 7, 2009.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records, the facility failed to document a mechanism to collect feedback on completed training in four of four personnel records.
Findings:
Seven personnel records were reviewed on January 6, 2009. Four personnel records required documentation of feedback. The facility failed to document feedback on completed training in personnel records #1, 2, 3 and 4.
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Plan of Correction
A mechanism to collect training feedback is well established. However, the Division Director will be responsible for ensuring that all staff consistently document feedback on all training completed. This feedback will be maintained in our staff training manual by the Division Director. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document psychosocial evaluations in six of six client records.
Findings:
Nine client records were reviewed on January 8, 2009. Psychosocial evaluations were required in six client records. The facility did not document a clinical assessment of assets/strengths, support systems and negative factors in client records #1, 2, 3, 4, 5 and 6.
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Plan of Correction
By 3/16/09, the Division Director will be responsible for conducting three staff trainings on the proper completion of psychosocial evaluations. Our evaluation form has been recently revised to assist staff to improve their documentation in this area. The Clinic Director is responsible for reviewing each evaluation to ensure compliance. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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
Based on a review of client records, the facility failed to document the completion of the individual treatment plan within the 48 timeframe as per facility policy in three of five client records.
Findings:
Nine client records were reviewed on January 8,2009. An individual treatment and rehabilitation plan was required in six client records. The facility failed to document the completion of the treatment plan within 48 hours as per facility policy in client records # 1, 2 and 3. Client record #1 was admitted on 8/5/08 and the individual treatment plan was completed on 8/15/08. Client record #2 was admitted on 6/12/08 and the individual treatment plan was completed on 7/10/08. Client record #3 was admitted on 6/12/08 and the individual treatment plan was completed on 6/18/08.
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Plan of Correction
This discrepancy has been discussed and corrected with the Clinic Director and our Intake Specialist. The Clinic Director will be responsible for ensuring that each client's admission date is accurately reflected in our records. |
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 a review of client records, the facility failed to document treatment plan updates in nine of nine client records.
Findings:
Nine client records were reviewed on January 8, 2009. Treatment plan updates were required in nine client records. The facility failed to document a review of progress on all goals stated in the prior treatment plans in client records #1, 2, 3, 4, 5, 6, 7, 8 and 9.
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Plan of Correction
By 3/16/09, the Division Director will conduct two staff training sessions to improve their documentation of goals stated in the previous treatment plan. The Clinic Director will review each treatment plan to ensure compliance with this requirement. |