INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on Sept. 21-22, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Rehabilitation Services, Inc. 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
|
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
|
Observations
Based on the review of staff records the facility failed to document that a Counselor Assistant was under the Direct Observation of the Clinical Supervisor or a trained counselor, as required by the regulation.
The findings included:
On 9/21/11 one personnel record for a counselor assistant, employee #4, was reviewed for documentation that the clinical supervisor provided direct observation of counseling sessions.
The counselor assistant, a bachelor's level degreed employee with no previous clinical experience was hired on 4/11/11. While there were weekly supervisory meetings documented in the personnel file there was no documentation to support that the Counselor Assistant was directly observed by the clinical supervisor while they were providing clinical services to clients.
The Facility Director confirmed the findings.
|
Plan of Correction
The clinical director will provide direct observation of all counselor assistants and document these observations. The goal is to observe at least one therapeutic session per week, which shall be included in the weekly consultation notes prepared by the clinical director. |
705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
|
Observations
Based on the physical plant inspection conducted on 9/22/11, the facility failed to maintain all structures so as to be free from any danger to health or safety.
The findings included:
The physical plant inspection was conducted on 9/22/11 approximately between the hours of 11:30 AM and 1:00 PM , with the facility director present.
During the inspection of the client sleeping areas on the 2nd floor, two of the vents in the front sleeping are had condensation dripping onto a bed and dresser below. Additionally, the duct that was dripping water onto the bed beneath was also discharging dust and debris.
Ceiling vents in 4 out of 5 sleeping areas on the 2nd floor and the ceiling vent at the top of the stairs on the 3rd floor had a heavy presence of dust and dirt build-up on the vent covers.
There were 2 ceiling tiles in the middle bedroom on the 2nd floor that were bowed and sagging.
There were 2 ceiling tiles in the office area on the first floor that were bowed and sagging. One was in the Facility Director's Office and the other was in the adjacent office.
There were two finials on the central staircase that were loose and were able to be removed easily. One was at the first floor level and the other was at the third floor level.
During the exit interview, the facility and program director did not dispute the findings. They advised that maintaining the facility and furnishings is difficult when dealing with adolescent clients.
|
Plan of Correction
All vents covers were cleaned and/or replaced. Air filters, which are routinely replaced monthly, will be examined more frequently to insure that dust is filtered prior to entering the ductwork. Client beds were moved from under vents to insure condensation cannot drip onto mattresses in the future. The condensation present was due to the air conditioning unit being off and then being turned on to a lower temperature. This caused moisture to condensate in the vents. We have been advised to maintain a constant temperature which will alleviate this issue. The sagging ceiling tiles, that were bowed, were replaced and the duct work above was reinforced, which was causing the issue. The finials were removed from the staircase.
The facility director will directly monitor these facility issues to ensure continuous compliance.
|
705.5 (a) (2) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(2) A pillow and bedding appropriate for the temperature in the facility.
|
Observations
Based on the physical plant inspection conducted on 9/22/11, the facility failed to provide pillows and mattresses to the clients that were clean and in good condition.
The findings included:
A physical plant inspection was conducted on 9/22/11 approximately between the hours of 11:30 AM and 1:00 PM , with the facility director present.
During the inspection of the client sleeping areas on the 2nd floor, it was noted that 4 out of 7 pillows inspected were stained. In addition, 3 out of 7 mattresses inspected were in need of replacement as evidenced by the existence of sagging areas, burn holes and tears.
These findings were not disputed by the facility director or project director.
|
Plan of Correction
On September 28, the mattresses cited in the report and all other mattresses of similar condition were replaced. In the future, the facility director will ensure that mattresses are repaired and/or replaced more expeditiously. On September 29, all client pillows were replaced with new pillows. The program assistant will issue a new pillow to all clients entering into the program. The facility director will monitor to ensure compliance. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
Based on direct observation on 9/21/11, upon entering the facility, the facility failed to ensure that only permanently mounted or installed heating units were present in the facility.
The findings included:
Upon entering the facility on 9/21/11, to begin the on-site inspection, it was noted that a portable/moveable space heater was present in the facility director's office.
At the time of the inspection the facility director confirmed the findings.
|
Plan of Correction
The facility director removed the space heater from the building during the licensing visit. The facility director sent a memorandum to all staff to ensure no one brings a space heater to the building. This memorandum made it clear to all employees that space heaters are not permitted in the facility at any time. Also, facility director will monitor through monthly facility checks, as well as through staff meetings. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
|
Observations
Based on the review of the facility Policy and Procedures Manual the facility 's policy in regard to Confidentiality failed to address all of the relevant components of Confidentiality as well as 4 PA Code 255.5.
The findings include:
The Confidentiality policy reviewed on 9/22/11 failed to address 4 PA Code, 255.5 (a) (1-10). , pertaining to conditions under which the disclosure of client information can be made.
The Confidentiality policy permits the release of information, without consent, but failed to specify the correct condition under which it can be done. Specifically, the facility policy states: e. " Release of information adheres to the following guidelines: Without Consent. Consent is not required for medical emergencies. " 4 PA Code 255.5 (a)(9) requires that disclosure without consent can only be made " where the client ' s life is in immediate jeopardy. " Medical emergencies alone are not the basis for disclosure without consent.
The facility's Confidentiality policy was reviewed with the program and project directors, both of whom confirmed that the facility's policy on Confidentiality does not fully reference 4 PA Code 255.5.
|
Plan of Correction
DARS, Inc. added to existing Confidentiality Policy 4 Pa. Code subsection 255.5(a)(1-10). Also included was language pertaining to the release of information for medical emergencies, which was clarified as an immediate life threatening emergency. The updated policy also addressed who specifically would maintain client records, which has been designated to the facility director.
|
709.28(a)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(2) Staff access to client records.
|
Observations
A review of the facility Policy and Procedures on Confidentiality revealed that the facility failed to provide a procedure by which staff members can access client records.
The findings included:
The Confidentiality policy identified by title those staff members who have access to client records but failed to describe the process by which those staff members are to gain access to client records.
The program director and project director confirmed the findings.
|
Plan of Correction
All active client records will be kept in a file cabinet in a locked closet located in the Clinical Supervisor's office. In addition to the closet door being kept locked, the door to the office will be kept locked when the Clinical Supervisor is not in the office. All clinical staff, to include the Clinical Supervisor, Senior Counselor, Counselor Assistants, Facility Director and Project Director will have a key to the closet as well as the door to the office. The closet door will be kept locked at all times other than when staff are actually retrieving or returning records. Staff needing access to the client records, will gain access by unlocking the door to the Clinical Supervisor's office when the Clinical Supervisor is out and then unlocking the closet door to access the file cabinet. Upon retrieving or returning the client record, the staff will immediately lock the closet door, and the office door, if the supervisor is out of the office. This procedure will be added to the policy and procedure.
|
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
|
Observations
Based on a review of client records, the facility failed to ensure that client physical examinations and/or physical reviews were completed as per the timeframes listed in the facility policy and procedures. The facility also failed to ensure that each client record included documentation from the physician in regard to the client's general appearance.
The findings included:
The facility policy requires that upon admission all clients receive a physical or have a previous physical reviewed within 48 hours (preferable) to 7 days (maximum). The policy allows for the physician to review and sign off on a physical that was completed by another physician as long as it was completed within the previous 12 months.
Five client records requiring documentation of physical examinations were reviewed on 9/21/11. The facility failed to complete physical examinations, reviews and/or include general appearance comments in five out of five records reviewed, records # 1-5.
Client record #1: This client was admitted on 1/04 /11. The record contained a physical from another facility that had been completed within the previous 12 months. However, the record did not include any documentation to show that the facility physician had reviewed the findings of the previous physical.
Client record #2: This client was admitted on 3/16/11. A physical examination was due to be completed on 3/23/11; however the physical examination was not completed until 3/30/11. Additionally, the physical examination lacked comments regarding the client ' s general appearance.
Client record #3: This client was admitted on 5/23/11. The record contained a physical from another facility that had been completed within the previous 12 months. However, the record did not include any documentation to show that the facility physician had reviewed the findings of the previous physical.
Client record #4: This client was admitted on 8/24/11. The record contained a physical that lacked documentation regarding the client ' s general appearance.
Client record #5: This client was admitted on 4/18/11. The record contained a physical that lacked documentation regarding the client ' s general appearance.
Client records were reviewed with the facility and project directors during the exit interview and the findings were not disputed.
|
Plan of Correction
We communicated with the phyician(s), regarding the requirement for more detailed documentation of the physician's assessment of the client's general appearance during all physical examination. The physician(s) were also provided a copy of the standard and agreed to provide this documentation for all future physical examinations. The physician(s)also agreed to review all physical examinations of clients that were completed at another facility within the preceding 12 months of the client's entry to our program to determine if a new physical examination is necessary. If the physical examination is adequate, the physician(s)will validate the physical examination form with an approved signature. If inadequate, a new physical examination will be performed. Facility Director will review each physical examination upon completion to ensure the standard is upheld. If standard is not upheld, Facility Director will consult with the physician for corrective measures. |