INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 22, 2011 through August 24, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Self Help Movement, 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:
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the personnel records and the facility's Staffing Requirements Facility Summary Report form, the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of STD/TB training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff in four of six personnel records reviewed.
The findings include:
On August 23, 2011, thirteen personnel records the facility's Staffing Requirements Facility Summary Report form were reviewed to verify that employees had HIV/AIDS and STD/TB training were reviewed for documentation of HIV/AIDS training and documentation of STD/TB training. The facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS training and/or STD/TB training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff in 7 of 13 records reviewed, specifically, records # 1, 8, 9, 7, 11, 12, and 13.
Employee # 1, the project director, was initially hired on June 15, 2009 and was hired for his current position on January 1, 2010. Employee #1 would have been due to complete the training by June 15, 2011; however, personnel record # 1 did not include documentation of HIV/AIDS training as of August 23, 2011.
Employee # 7 was initially hired on October 12, 2009 and was promoted to his current position a counselor on December 1, 2009. Employee #7 would have been due to complete the training by December 1, 2010; however, based on the facility's Staffing Requirements Facility Summary Report form completed on August 22, 2011, employee 7 has not completed STD/TB training and did not complete HIV/AIDS training until December 13, 2010.
Employee # 8 is a counselor assistant and was hired on April 13, 2009. Employee #8 would have been due to complete the training by April 13, 2010; however, employee # 8 did not complete HIV/AIDS training until December August 4, 2010.
Employee # 9 was initially hired on June 1, 2008 and was promoted to his current position as a counselor on April 29, 2009. Employee #9 would have been due to complete the training by April 29, 2010; however, personnel record # 9 did not include documentation of STD/TB training as of August 23, 2011.
Employee # 11 is a residential assistant and was hired on December 8, 2008. Employee #11 would have been due to complete the training by December 8, 2010; however, based on the facility's Staffing Requirements Facility Summary Report form completed on August 22, 2011, employee # 11 has not completed HIV/AIDS training.
Employee # 12 is a case manager and was hired on June 1, 2009. Employee #12 would have been due to complete the training by June 1, 2011; however, based on the facility's Staffing Requirements Facility Summary Report form completed on August 22, 2011, employee # 12 has not completed HIV/AIDS training.
Employee # 13 is a residential assistant and was hired on July 1, 2009. Employee #13 would have been due to complete the training by July 1, 2011; however, based on the facility's Staffing Requirements Facility Summary Report form completed on August 22, 2011, employee # 13 has not completed HIV/AIDS and STD/TB training.
During ongoing dialogues with the Director of Administration conducted on August 22, 2011 from approximately 1:00 P.M. to 3:30 P.M. and on August 23, 2011 from approximately 9:30 A.M. to 3:00 P.M., the Director of Administration confirmed the findings.
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Plan of Correction
All staff members who have not received the 6 hours of HIV/AIDS training and 4 hours of STD/TB training have been scheduled to attend the trainings on September 28, 2011 for HIV/AIDS and November 30, 2011 for STD/TB. The Compliance Officer will be responsible for making sure that those staff members scheduled for the trainings attend the trainings on the given dates and that the documentation of the completed trainings are placed in the personnel records of the staff members attending the training.
The Compliance Officer and the Director of Administration will meet on a quarterly basis to review all training requirements for all staff members to make sure that HIV/AIDS training is done with the first year of employment for counselors and counselor assistants and within two years of employment for all other staff. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on observations on August 24, 2011, the facility failed to ensure that the hot water temperature did not exceed 120 F.
The findings include:
On August 24, 2011 a physical plant inspection was conducted and nine bathrooms were checked to verify that each had hot and cold water under pressure, and that the hot water did not exceed 120 F.
Temperatures for sinks in eight out of nine bathrooms tested exceeded 120 F.
The bathroom sinks in the male residential bathroom on the first floor had a temperature reading of 141 F at approximately 12:34 P.M.
The bathroom sinks in the male public bathroom on the first floor had a temperature reading of 143 F at approximately 12:24 P.M.
The bathroom sinks in the female public bathroom on the first floor had a temperature reading of 140 F at approximately 12:25 P.M.
The bathroom sinks in the male residential bathroom on the second floor in the north side wing had a water reading of 141 F at approximately 12:35 P.M.
The bathroom sinks in the male residential bathroom on the second floor in the south side wing had a water reading of 140 F at approximately 12:40 P.M.
The bathroom sinks in the male residential bathroom on the second floor in the west side wing had a water reading of 140 F at approximately 12:43 P.M.
The bathroom sinks in the transitional living bathroom on the third floor in the b wing had a water reading of 130 F at approximately 12:41 P.M.
The bathroom sinks in the transitional living bathroom on the third floor in the c wing had a water reading of 140 F at approximately 12:45 P.M.
During an ongoing dialogue with the maintenance supervisor conducted on August 24, 2011 from approximately 12:35 P.M. to 12:47 P.M., the maintenance supervisor confirmed the findings.
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Plan of Correction
The Director of Building and Maintenance had a zone valve motor replaced which is responsible for the hot water mix. This brought the temperature of the water down to 120 degrees F. or below. On 9/12/11 the Director of Building and Maintenance re-tested the water temperatures in the bathroom sinks in the male residential bathroom on the first floor, the bathroom sinks in the male public bathroom on the first floor, the bathroom sinks in the female public bathroom on the first floor, the bathroom sinks in the male residential bathroom on the second floor in the north side wing,the bathroom sinks in the male residential bathroom on the second floor in the southside wing, the bathroom sinks in the male residential bathroom on the second floor in the west side wing, the bathroom sinks in the transitional living bathroom on the third floor in the b wing south side wing, the bathroom sinks in the transitional living bathroom on the third floor in the c wing and found them to be under 120 degree F.
On September 13, 2011, the Director of Building and Maintenance created a weekly temperature log to ensure that water temperatures are maintained below 120 degrees F. The Director of Building and Maintenance then met with his staff on September 13, 2011 to ensure that the logs are completed and the temperatures are maintained below 120 degrees F. The Director of Building and Maintenance will check the log on a bi-weekly to ensure compliance.
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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to ensure that hot food was served at or above 140 F.
The findings include:
A physical plant inspection was conducted on August 24, 2011. During the inspection, the Licensing Specialist asked to see a food serving temperature log. A food serving temperature log was not presented for review; therefore, there was no way to determine if hot food at the facility had been served at or above 140 F.
An interview with the Food Service Director conducted on August 24, 2011 at approximately 1:00 P.M. confirmed that the facility does not have a food serving temperature log. Also, during the same interview, the Food Service Director explained that at times he cooks food for residents at the facility but does not record the temperatures of the hot food served at the facility.
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Plan of Correction
On August 25, 2011, the Director of Food Services created a food serving temperature log to ensure that hot food is served at or above 140 F. The Director of Food Services met with his staff on August 25, 2011 to ensure that the standards for hot food are met and logged in the log book. The Director of Food Services will inspect the logs on a weekly basis to ensure that hot food is served at or above 140 degrees F. |
709.24(a) 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:
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Observations
Based on an review of the facility's policy and procedures manual, and interviews with the Director of Administration and the Compliance Officer, the facility failed to adopt a written plan for the coordination of client treatment and rehabilitation services which included policy and procedure for completing psychosocial evaluations.
The findings include:
On August 24, 2011, the facility's policy and procedures manual was reviewed for a written plan for the coordination of client treatment and rehabilitation services. The facility failed to include a policy and procedure for the completion of psychosocial evaluations.
During an ongoing dialogue with the Director of Administration and the Compliance Officer on August 24, 2011, the Director of Administration and the Compliance Officer confirmed that the facility does not have a policy on psychosocial evaluations, but stated that the facility's standard practice, is to allow the counselors to complete the psychosocial evaluation within three days from the date of completion of the histories.
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Plan of Correction
Self Help's policy for psychosocial evaluations was revised by the Clinical Director, Director of Compliance and Quality Improvement Director on 9/30/11. This new policy requires completion of the psychosocial evaluation and integrated summary within 72 hours of client's admission. The board met on 10/06/11 and approved new policy. Director of Administration will ensure placement of the revised policy in our policy and procedure manual.
Director of Treatment, Quality Improvement Director and Compliance Officer provided training for all counselors on 9/30/11. To ensure that the policy and procedures are followed for this document Director of Treatment, Quality Improvement Director, and Compliance Officer will facilitate future staff trainings regarding this policy. Quality Improvement Director and Compliance Officer will utilize chart audits to ensure the implementation and compliance with revised psychosocial evaluations policy requirements.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. 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 a psychosocial evaluation according to the their standard practice for completing psychosocial evaluation in five of seven records reviewed.
Also, based on a review of client records and an interview with the Director of Administration, the facility failed to document a psychosocial evaluation that included an assessment of the client's support systems and/or coping mechanisms in five of seven records reviewed.
The findings include:
On August 24, 2011, seven records requiring documentation of a psychosocial evaluation were reviewed. The facility did not document a psychosocial according to their standard practice in client records # 2, 4, 5, 6, and 7. Also, the facility did not document a psychosocial evaluation that included an assessment of the client's support systems and/or coping mechanisms in client records # 2, 4, 5, 6, and 7.
The facility does not have a policy on psychosocial evaluations. However, during an ongoing dialogue with the Director of Administration and the Compliance Officer on August 24, 2011, the Director of Administration and the Compliance Officer stated that the facility's standard practice is to allow the counselors to complete the psychosocial evaluation within three days from the date of completion of the histories.
Client # 2 was admitted on July 6, 2011. The medical history, drug or alcohol history, and personal history was completed on July 8, 2011; however, the psychosocial evaluation was not completed until July 12, 2011. Also, the psychosocial evaluation did not include an evaluation of the client ' s coping mechanisms.
Client # 4 was admitted on July 18, 2011. The medical history, drug or alcohol history, and personal history was completed on July 21, 2011; however, the psychosocial evaluation was not completed until July 27, 2011. Also, the psychosocial evaluation did not include an evaluation of the client ' s support systems.
Client # 5 was admitted on July 18, 2011. The medical history, drug or alcohol history, and personal history was completed on July 21, 2011; however, the psychosocial evaluation was not completed until July 25, 2011. Also, the psychosocial evaluation did not include an evaluation of the client ' s support systems and coping mechanisms.
Client # 6 was admitted on July 19, 2011. The medical history, drug or alcohol history, and personal history was completed on July 22, 2011; however, the psychosocial evaluation was not completed until July 26, 2011. Also, the psychosocial evaluation did not include an evaluation of the client ' s support systems and coping mechanisms.
Client # 7 was admitted on July 19, 2011. The medical history, drug or alcohol history, and personal history was completed on July 21, 2011; however, the psychosocial evaluation was not completed until July 25, 2011. Also, the psychosocial evaluation did not include an evaluation of the client's support systems and coping mechanisms.
During an ongoing dialogue with the Director of Administration conducted on August 24, 2011 from approximately 1:30 P.M. to 3:30 P.M., it was confirmed that the facility did not document a psychosocial according to their standard practice in client records # 2, 4, 5, 6, and 7. Also, during the same ongoing dialogue with the Director of Administration, it was confirmed that the facility did not document a psychosocial evaluation that included an assessment of the client ' s support systems and/or coping mechanisms in client records # 2, 4, 5, 6, and 7.
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Plan of Correction
Self Help's policy for psychosocial evaluations was revised by the Director of Compliance and Quality Improvement on 9/30/11 to include the assessment/integrated summary to be done within 72 hours of client's admission. The board met on 10/06/11 and approved new policy. Director of Administration will ensure placement of the revised policy in our policy and procedure manual.
Director of Treatment, Quality Improvement Director, and Compliance Officer provided training on 9/30/11 regarding revised psychosocial policy. Lead Counselor, Director of Inpatient/Assistant Director of Inpatient, and Director of Half Way House will be responsible to ensure psychosocial evaluations are completed on time in accordance with our policies and procedures on psychosocial evaluations.
Director of Inpatient will supervise counselors of record for client's records #2, 4, 5, 6 and 7 while amending psychosocial evaluations to include an assessment of the client's support systems and/ or coping mechanisms
Training was provided regarding an assessment that includes the client's support systems and coping mechanisms. Quality Improvement Director and Compliance Officer will facilitate future staff trainings regarding this policy to ensure implementation and compliance. Quality Improvement Director and Compliance Officer will utilize chart audits to ensure compliance with revised psychosocial evaluations policy requirements.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records,
the facility failed to document a treatment and rehabilitation plan update in one of two records reviewed.
The findings include:
On August 24, 2011, two client records were reviewed for documentation of a treatment and rehabilitation plan update. The facility did not document a treatment and rehabilitation plan update in client record # 1.
The facility's policy titled: "Treatment and Rehabilitation Services," states:
"Treatment Plan Update
The Comprehensive Treatment Plan (CTP) is updated every thirty days."
Client # 1 was admitted June 23, 2011. The preliminary treatment and rehabilitation plan was completed on June 23, 2011 and the individual treatment and rehabilitation plan was completed on July 22, 2011. However, client record # 1 did not include documentation a treatment and rehabilitation plan update as of August 24, 2011.
During an ongoing dialogue with the Director of Administration conducted on August 24, 2011 from approximately 1:30 P.M. to 3:30 P.M.,the Director of Administration confirmed the findings.
This is a repeat citation. The facility was cited on August 18, 2010 for treatment and rehabilitation plan updates.
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Plan of Correction
Treatment plan update for client #1 was completed by counselor of record. Compliance Officer placed treatment plan update for client record #1 in chart on 8/29/11. Director of Inpatient Director of Half Way House and Lead Counselor will be responsible to ensure all existing and new clients will have treatment plans updates documented on time in accordance with our policies and procedures.
Director of Treatment, Lead Counselor and Quality Improvement Director will monitor and ensure that treatment plan updates are documented on time and placed in the client record in a timely manner.
A Chart audits will be done on a weekly basis by the compliance officer to make sure all documents are placed in client's charts. An assistant to the compliance officer was hired on September 30. 2011 to make sure all documents are placed in client's charts in a timely manner. Chart audits will be done on a weekly basis by the compliance officer to make sure all documents are placed in client's charts.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in one of six records reviewed.
The findings include:
On August 24, 2011, six records were reviewed to verify that counseling services are provided according to the individual treatment and rehabilitation plan. The facility did not provide counseling services according to the individual treatment and rehabilitation plan in one of six records reviewed, specifically, client records # 4.
Client # 4 was admitted July 18, 2011. The individual treatment and rehabilitation plan was completed on July 31, 2011 and indicated that the client will receive individual sessions one time a week. However, client record # 4 did not include documentation of individual progress notes as of August 24, 2011.
During ongoing dialogue with the Director of Administration conducted on August 24, 2011 from approximately 1:30 P.M., to 3:30 P.M., it was confirmed that the facility did not provide counseling services according to the individual treatment and rehabilitation plan in client record # 4.
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Plan of Correction
Compliance Officer placed the Individual progress notes in client record #4 on 8/29/11. Counselor of record for client #4 started providing Individual counseling services on 7/20/11. Individual sessions were performed on weekly basis by counselor of record.
Director of Treatment, Lead Counselor and Quality Improvement Director will utilize supervision, chart audits and trainings to ensure that counseling services are provided according to the individual treatment plan.
The compliance officer will be doing weekly chart audits to make sure these documents are being completed and placed in the client's charts.
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709.53(a)(5) LICENSURE Progress Notes
709.53. 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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to document individual progress notes.
The findings include:
On August 24, 2011, seven records were reviewed for documentation of progress notes in five of seven client records reviewed, specifically, records # 2 and 4.
The findings include:
Client # 2 was admitted July 6, 2011. Client record # 2 included documentation of group notes from July 2011 to August 2011. However, client record # 2 did not include documentation of individual progress notes as of August 24, 2011.
Client # 4 was admitted July 18, 2011. Client record # 4 included documentation of group notes from July 2011 to August 2011. However, client record # 4 did not include documentation of individual progress notes as of August 24, 2011.
During an ongoing dialogue with the Director of Administration conducted on August 24, 2011 from approximately 1:30 P.M. to 3:30 P.M., it was confirmed that client records # 2 and 4 did not include documentation of individual progress notes.
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Plan of Correction
Counselor of record for client #2 began providing Individual counseling services on 7/9/11, and facilitated individual sessions weekly while client was in treatment. Counselor of record completed the individual progress notes for client #2. Compliance Officer placed those individual progress notes in client record on 8/29/11.
Counselor of record for client #4 began providing Individual counseling services for client #4 on 7/20/11. Counselor of Record for client #4 completed all required Individual Progress Notes. Individual sessions were performed on weekly basis by counselor of record. . Compliance Officer placed those individual progress notes in client record on 8/29/11.
Director of Treatment, Lead Counselor and Quality Improvement Director will utilize supervision, chart audits and trainings to ensure that counseling services are provided according to the individual treatment plan. Director of Inpatient and Director of Half Way House will be responsible for making sure individual progress notes for all existing clients and new clients will be documented for all individual counseling sessions in a timely manner. Director of Quality Improvement will meet with Compliance Officer and report to Directors of Half Way House and Inpatient regarding completion of individual sessions and placement in charts in timely manner.
The compliance officer will be doing weekly chart audits to make sure these documents are being completed and placed in the client's charts. Compliance officer will meet with Directors and Quality Improvement Director to ensure compliance.
Director of Treatment, Lead Counselor and Quality Improvement Director will utilize supervision, chart audits and trainings to ensure that counseling services are provided according to the individual treatment plan.
The compliance officer will be doing weekly chart audits to make sure these documents are being completed and placed in the client's charts.
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709.53(a)(9) LICENSURE Aftercare plans
709.53. 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in accordance with their policies and procedures.
The findings include:
On August 24, 2011, four client records were reviewed for documentation of aftercare plans. The facility failed did not document an aftercare plan according to their policies and procedures in three of four client records reviewed, specifically, records # 8, 10, and 11.
The facility's policy titled: "Client Records", states:
"AFTERCARE
The Aftercare Plan serves as the client's personal plan for the future and includes goals with timeframes and potential resources to assist in meeting those goals. This plan may include establishing support systems such as AA/NA meetings; or identifying areas which may still be problematic or in need of further attention such as job planning and obtaining employment. Furthermore, this plan shall include the identification of a contact person at the SHM for purpose of re-evaluating the Aftercare Plan if the client so determines to be in need of such. It will also list the termination date of the plan and serve to notify the client that re-admission to the program is determined via an individual evaluation for re-admission."
Client # 8 was admitted April 15, 2011 and was discharged May 19, 2011. The aftercare plan was completed on May 18, 2011, but did not include goals with times frames, support services, and a contact person.
Client # 10 was admitted January 28, 2011 and was discharged May 3, 2011. The aftercare plan was completed on May 3, 2011, but did not include goals with times frames, support services, and a contact person.
Client # 11 was admitted May 10, 2010 and was discharged May 31, 2011. The aftercare plan was completed on May 31, 2011, but did not include goals with times frames, support services, and a contact person.
During an ongoing dialogue with the Director of Administration conducted on August 24, 2011 from approximately 1:30 P.M. to 3:30 P.M., it was confirmed that the facility did not document an aftercare plan according to their policies and procedures in client records # 8, 10, and 11.
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Plan of Correction
Compliance Officer will place amended aftercare plans that will be in accordance with our facility policies and procedures for client records # 8, 10, 11 by 10/24/11.
Director of Treatment, Lead Counselor and Quality Improvement Director will utilize supervision, chart audits and trainings to ensure implementation and documentation of all aftercare plans are in accordance with policies and procedures.
The Compliance Officer will be doing weekly chart audits to make sure these documents are being completed and placed in the client's charts.
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709.54(d)(1) LICENSURE Outreach Identifying Persons
709.54. Project management services.
(d) The project shall develop a written plan providing for outreach services which includes, but is not limited to:
(1) Identifying persons in need of project services.
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Observations
Based on an interview with the Director of Administration, the facility failed to provide a written plan providing for outreach services which includes identifying persons in need of project services.
The findings include:
On August 22, 2011 and August 23, 2011, the Licensing Specialist asked to see a copy of the facility's written plan providing for outreach services which includes identifying persons in need of project services. The document presented at the time of review as the facility's written plan providing for outreach services was not a written plan providing for outreach services identifying persons in need of project services; however, the document was a letter describing an event when the project director had taken some of the residents from the facility to a local school to speak to students about problems associated with drug and alcohol abuse.
During an ongoing dialogue with the Director of Administration conducted on August 23, 2011 at approximately 9:30 A.M. to 12:00 P.M., it was confirmed that the document presented at the time of review as the facility's written plan providing for outreach services was not a written plan providing for outreach services identifying persons in need of project services.
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Plan of Correction
Self Help Movement did not present to the Licensing Specialist the written plan for outreach services. Self Help does have a written plan for outreach services which includes identifying persons in need of our services. Director of Administration will ensure that the written plan will remain in place at our facility. Director of Administration will present plan to the Licensing Specialist during future inspections.
The Director of Administration will forward a copy of our written plan for outreach services to the Division of Drug and Alcohol Program LIcensure. on 10/31/11. |
709.54(d)(2) LICENSURE Alerting Persons - Outreach
709.54. Project management services.
(d) The project shall develop a written plan providing for outreach services which includes, but is not limited to:
(2) Alerting persons and their families to the availability of project services.
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Observations
Based on an interview with the Director of Administration, the facility failed to provide a written plan providing for outreach services which includes altering persons and their families to the availability of project services.
The findings include:
On August 22, 2011 and August 23, 2011, the Licensing Specialist asked to see a copy of the facility's written plan providing for outreach services which includes altering persons and their families to the availability of project services. The document presented at the time of review as the facility's written plan providing for outreach services was not a written plan altering persons and their families to the availability of project services; however, the document was a letter describing an event when the project director had taken some of the residents from the facility to a local school to speak to students about problems associated with drug and alcohol abuse.
During an ongoing dialogue with the Director of Administration conducted on August 23, 2011 at approximately 9:30 A.M. to 12:00 P.M., it was confirmed that the document presented at the time of review as the facility's written plan providing for outreach services was not a written plan altering persons and their families to the availability of project services.
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Plan of Correction
Self Help Movement does have a written plan for providing outreach services which includes identifying person in need of project services including alerting persons and their familities to the availability of project services; however, the plan was not presented for review at the time of the inspection. A copy of the written plan for outreach services including alerting persons and their families to the availability of project services will be forwarded to the Division of Drug and Alcohol Program Licensure. The Director of Administration will ensure that the facility's written plan for outreach services will remain in place at the facility. |
709.71(b)(3) LICENSURE Basic Personal data
709.71. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Basic personal data.
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Observations
Based on a review of client records, the facility failed to document a basic personal data in accordance with their policies and procedures.
The findings include:
The facility's policy on basic personal data indicates that the basic personal data should be completed at the time of intake.
On August 24, 2011, six client records were reviewed for documentation basic personal data.
The facility failed to document a basic personal data according to their policies and procedures in two of six client records reviewed, specifically, client records # 3 and 5.
Client # 3 was admitted February 4, 2011. However, the basic personal data in client record # 3 was not completed until February 9, 2011.
Client # 5 was admitted February 4, 2011. However, the basic personal data in client record # 5 was not completed until February 9, 2011.
During an ongoing dialogue with the Director of the Transitional Living Facility Program conducted on August 24, 2011 from approximately 3:30 P.M. to 4:00 P.M., the Director of the Transitional Living Facility Program confirmed the findings.
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Plan of Correction
The director of the transitional living facility met with the case manager of the unit on August 25, 2011 to ensure that the basic personal data will be completed within the timeframe that will be in accordance to Self Help Movement's policies and procedures. The director of transitional living will check charts on a bi-weekly basis to ensure that the basic personal data is completed within Self Help Movement's timeframe. |