INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 8, 2013 through April 10, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cove Forge Behavioral Health System at Williamsburg 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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704.9(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.
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Observations
Based on a review of personnel records, the facility failed to document the required period of close supervision for a counselor assistant in one of eight records reviewed.
The findings include:
Eight personnel records for counselor assistants requiring documentation of close supervision were reviewed on April 2-3, 2013 during the administrative review. The facility failed to document the required period of close supervision for a counselor assistant in one of eight records reviewed, specifically record # 10.
Employee # 10 was hired as a counselor assistant on 5/29/12. This employee has a MA in Criminology and a BS in Criminal Justice. The MA in Criminology is not a qualifying degree, however, the BS in Criminal Justice is a qualifying degree. The facility is required to document supervision for a period of six months for a Bachelors level counselor assistant. The facility documented supervision for this employee for a four month period, covering 5/29/12-9/29/12.
The Facility Director confirmed the findings.
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Plan of Correction
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.
Plan of Correction:
Employee #10 will be closely supervised by the Assistant Program Director for an additional two month period.
Upon completion of the two month period employee # 10 will be placed back on quarterly supervision until reaching Counselor status.
Supervisions will be monitored by the Quality Improvement Department.
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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 the physical plant inspection, the facility failed ensure that the hot water temperature did not exceed 120 findings include:
The physical plant inspection was conducted on April 9, 2013. At approximately 1:55 PM, the water temperature was tested in the Acceptance House bathroom and it read 134 At approximately 2:30 PM, the water temperature was tested in the back bathroom of Challenge house and it read 135
The maintenance technician confirmed the temperatures exceeded the required 120
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Plan of Correction
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.
Plan of Correction:
The hot water heater was adjusted to 120F in Acceptance and Challenge.
Running water temperatures will be checked in all client bathrooms on a weekly basis to ensure that the hot water temperature does not exceed 120F.
Responsible Person: Maintenance Supervisor
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document that staff were instructed in the use of the fire extinguisher upon staff employment in one of eight personnel records.
The findings include:
Eight records requiring documentation of fire extinguisher training were reviewed April 2-3, 2013 during the administrative review. The facility failed to instruct employee #5 in the use of the fire extinguisher upon employment.
Employee # 5 was hired as a counselor assistant on November 19, 2012. The facility did not document the completion of fire extinguisher training until December 5, 2012.
The Facility Director confirmed the findings.
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Plan of Correction
705.10 (c) (4) LICENSURE
Fire safety.:
705.10. Fire safety. (c) Fire extinguisher. The residential facility shall: (4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
Plan of Correction:
Every Thursday at 8am and 3pm fire safety/emergency preparedness training is held in the Administration Conference room by the Maintenance Supervisor and Asst. Nursing Coordinator.
Fire safety /emergency preparedness training information is included in the new hire packet; giving the employees the date, time and location of the training and the time frame they must complete the training by(within 7 days of hire). This is done by the Human Resources Department.
Weekly reports are sent out by the HR Department to the managers with the names of their new hires and the date they need to attend the fire safety/emergency preparedness training.
Every Wednesday afternoon a task reminder will be sent out, to the management team, as a reminder of the training.
This will be ongoing. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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, the facility failed to ensure that all personnel were trained to perform assigned tasks during emergencies in one of eight records reviewed.
The findings include:
Eight personnel records requiring documentation of emergency training were reviewed April 2-3, 2013 during the administrative review. The facility failed to document the completion of emergency training within one week of employment in one of eight records reviewed, specifically employee record # 5.
Employee # 5 was hired as a counselor assistant on November 19, 2012. Emergency training was due to be completed no later than November 26, 2012. The facility did not document the completion of emergency training until December 5, 2012.
The Facility Director confirmed the findings.
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Plan of Correction
705.10 (d) (3) LICENSURE
Fire safety.:
705.10. Fire safety. (d) Fire drills. The residential facility shall: (3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
Plan of Correction:
Every Thursday at 8am and 3pm fire safety/emergency preparedness training is held in the Administration Conference room by the Maintenance Supervisor and Asst. Nursing Coordinator.
Fire safety /emergency preparedness training information is included in the new hire packet; giving the employees the date, time and location of the training and the time frame they must complete the training by(within 7 days of hire). This is done by the Human Resources Department.
Weekly reports are sent out by the HR Department to the managers with the names of their new hires and the date they need to attend the fire safety/emergency preparedness training.
Every Wednesday afternoon a task reminder will be sent out, to the management team, as a reminder of the training. This will be ongoing.
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709.83(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document discharge summaries according to facility policy in two of two records reviewed.
The findings include:
Facility policy states that discharge summaries will be completed within seven days of discharge.
Two client records requiring documentation of a discharge summary were reviewed on April 9, 2013. The facility failed to document discharge summaries within seven days of discharge in two of two records reviewed, specifically records # 16 and 17.
Client # 16 was admitted into treatment on 12/7/12 and was discharged on 1/3/13. The facility did not document a discharge summary for this client until 3/15/13.
Client # 17 was admitted into treatment on 12/21/12 and was discharged on 1/1/13. The facility did not document a discharge summary for this client until 3/22/13.
The Facility Director confirmed the findings.
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Plan of Correction
Plan of Correction:
709.83(a)(10) 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: (10) Discharge summary.
The Program Director and Assistant Program Director will hire 1 ? 2 counselor/counselor assistants. These hires will be responsible for assisting counselors by conducting groups when needed, completing discharge summaries , filing, and entering data in the computer. This will allow all discharge summaries to be completed in the timeline.
Medical Records staff will meet with the counselors and review the process and importance of the discharge summaries being completed in a timely manner.
The Program Director and Assistant Program Director will review random charts on a monthly basis for 3 months. If at the end of 3 months it is found all charts are in compliance, random chart reviews will be conducted on a quarterly basis.
Responsible Persons: Program Director and Assistant Program Director.
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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 the client's progress as it relates to the goals identified on the individual treatment plan in three of six records reviewed. Additionally, the facility failed to document a treatment plan update in one of six records reviewed.
The findings include:
Six client records requiring documentation of a treatment plan update were reviewed on April 8-9, 2013. The facility failed to document the client's progress as it relates to the goals identified on the individual treatment plan in three of six records reviewed, specifically client records # 2, 6, and 7. Additionally, the facility failed to document a treatment plan update in one of six records reviewed, specifically client record # 3.
Client # 2 was admitted into treatment on 3/15/13 and was still an active client at the time of the inspection. A treatment plan update was completed on 3/30/13. The update did not include the progress on the identified goals of the treatment plan, specifically goals # 3, 4, and 5.
Client # 3 was admitted into treatment on 2/22/13 and was still an active client at the time of the inspection. The comprehensive treatment plan was completed on 2/27/13. A treatment plan update would have been due to be completed by 3/29/13. This client file did not include documentation of a treatment plan update at the time of inspection.
Client # 6 was admitted into treatment on 3/6/13 and was still an active client at the time of the inspection. A treatment plan update was completed on 3/19/13. The update did not include the progress on the identified goals of the treatment plan, specifically goal # 3.
Client # 7 was admitted into treatment on 2/7/13 and was discharged on 3/7/13. A treatment plan update was completed on 2/22/13. The update did not include the progress on the identified goals of the treatment plan, specifically goal # 2.
The Facility Director confirmed the findings.
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Plan of Correction
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.
The Program Director and Assistant Program Director discussed the findings of the audit.
The counselors were reminded that the Treatment Plan Update needs to be completed in a timely manner.
They were also reminded that the clients progress must be documented in each of the goals.
Monthly chart reviews will be conducted for a 3 month period to ensure compliance. If at the end of the 3 months, it is found all charts are in compliance, random chart reviews will be conducted on a quarterly basis.
Client #2
Monthly chart reviews will be conducted by the Program Director and Assistant Program Director for a 3 month period to ensure that the clients progress is documented in the identified goals of the treatment plan. If at the end of the 3 months, it is found that all charts are in compliance, random chart reviews will be conducted on a quarterly basis.
Client #3
Monthly chart reviews will be conducted by the Program Director and the Assistant Program Director for a 3 month period to ensure that the Treatment Plan Update is completed in a timely manner. If at the endof the 3 months, it is found that all charts are in compliance, random chart reviews will be conducted on a quarterly basis.
Client # 6
Monthly chart reviews will be conducted by the Program Director and Assistant Program Director for a 3 month period to ensure that the clients progress is documented in the identified goals of the treatment plan. If at the end of the 3 months, it is found that all charts are in compliance, random chart reviews will be conducted on a quarterly basis.
Responsible Persons: Program Director and Assistant Program Director.
For clients # 2, 6 and 7 an addendum will be added to the chart(s) specifying the client's progress as it relates to the treatment plan goals. For client #3, a treatment plan update, in the form of an addendum, will be added." The persons responsible for this will be the Counselors.
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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
Eight client records requiring documentation that services are being provided in accordance with the treatment plan were reviewed on April 8-9, 2013. The facility failed to provide documentation that services are being provided in accordance with the treatment plan in three of eight records, specifically client records # 3, 7, and 12.
The findings include:
Client # 3 was admitted into treatment on 2/22/13 and was still an active client at the time of the inspection. This client was to get individual counseling one time per week. As of the date of the file review, documentation in the client file for individual counseling sessions occurred on 3/14/13 and 3/26/13.
Client # 7 was admitted into treatment on 2/7/13 and was discharged on 3/7/13. This client was to get individual counseling one time per week. As of the date of the file review, documentation in the client file for individual counseling sessions occurred on 3/1/13, 3/4/13, and 3/6/13.
Client # 12 was admitted into treatment on 2/13/13 and was discharged on 3/5/13. This client was to get individual counseling one time per week. As of the date of the file review, documentation in the client file for individual counseling sessions occurred on 2/28/13.
The Facility Director confirmed the findings.
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Plan of Correction
Program Director and the Assistant Program Director will conduct random chart reviews on a monthly basis until July 14, 2013 to ensure counselors are documenting all client activity, whether it be on a progress note for a completed session or on the record of service if the client cancelled or was a no-show. If at that time, the charts reviewed are found to be in compliance, random chart reviews will be conducted on a quarterly basis.
Client #3 ? Program Director and the Assistant Program Director will conduct random bi-weekly chart reviews to ensure that counselors are documenting their individual sessions as required. This will continue until July 14, 2013 . If at that time, the charts reviewed are found to be in compliance, random chart reviews will be conducted on a monthly basis.
Responsible Persons: Program Director and Assistant Program Director.
For clients # 3,7 and 12 an addendum will be added to the chart(s) specifying services that were received in accordance with the treatment plan."
Responsible person for this will be the counselors. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document discharge summaries according to facility policy in six of six records reviewed.
The findings include:
Facility policy states that discharge summaries will be completed within seven days of discharge.
Six client records requiring documentation of a discharge summary were reviewed on April 9, 2013. The facility failed to document discharge summaries within seven days of the client being discharged in six of six records reviewed, specifically records # 7, 8, 9, 10, 11, and 12.
Client # 7 was admitted into treatment on 2/7/13 and was discharged on 3/7/13. The facility did not document a discharge summary for this client until 4/1/13.
Client # 8 was admitted into treatment on 1/8/13 and was discharged on 1/31/13. The facility did not document a discharge summary for this client until 2/26/13.
Client # 9 was admitted into treatment on 2/26/13 and was discharged on 3/14/13. The facility did not document a discharge summary for this client until 4/5/13.
Client # 10 was admitted into treatment on 2/9/13 and was discharged on 2/23/13. The facility did not document a discharge summary for this client until 3/6/13.
Client # 11 was admitted into treatment on 12/18/12 and was discharged on 1/1/13. The facility did not document a discharge summary for this client until 3/13/13.
Client # 12 was admitted into treatment on 2/13/13 and was discharged on 3/5/13. The facility did not document a discharge summary for this client until 4/8/13.
The Facility Director confirmed the findings.
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Plan of Correction
Plan of Correction:
The Program Director and Assistant Program Director will hire 1 ? 2 counselor/counselor assistants. These new hires will be responsible for assisting counselors by conducting groups when needed, completing discharge summaries , filing, and entering data in the computer. This will allow all discharge summaries to be completed in the timeline.
Medical Records Staff will meet with the counselors and review the process and importance of the discharge summaries being completed in a timely manner.
All discharge summaries will be reviewed until July 14, 2013 to ensure compliance. If by that time, it is found all charts are in compliance, random chart reviews will be conducted on a quarterly basis.
Responsible Persons: Program Director and Assistant Program Director.
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