INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 10, 2019 through October 11, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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.
|
Plan of Correction
|
704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
|
Observations
The facility failed to ensure that one Full-time Equivalent (FTE) counselor was provided for every eight clients.The counselor FTE is determined by dividing the total number of hours the counselor devotes to D&A clients by the facility's workweek. Then, in order to obtain the counselor ratio, the total number of clients is divided by the FTE.Based on the Staffing Requirements Facility Summary Report, the total number of hours devoted to D&A clients in the inpatient non-hospital level of care was 520/40 = 13(FTE). The total number of clients was 115/13=8.846, which equals to a client/counselor ratio of 9:1.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Self Help Movement will ensure that one full-time equivalent (FTE) counselor will be provided for every eight clients. The interim clinical director as well as the human resources manager have scheduled interviews for a counselor until the counselor position is filled.
We will also have a counselor returning from maternity leave in approximately 4 weeks. |
705.4 (2) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
|
Observations
The facility failed to maintain counseling areas with furnishings in good repair as both Group Room G and Group Room H had multiple chairs that were weathered and torn.These findings were reviewed with project and facility staff during the licensing process.
|
Plan of Correction
The Director of Building and Maintenance will ensure that the torn and weathered chairs in Group rooms G and H will be removed and new ones purchased.
The Director of Building and Maintenance in conjunction with the counselors will inspect the furnishings on a monthly basis to make sure that they are in good repair. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
|
Observations
The facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times as the last shower stall, located in the A wing bathroom, had a leaking shower head.The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Director of Building and Maintenance will ensure that the maintenance department replaces the shower head and completes an inspection of the bathrooms on a daily basis to ensure that all are functional, clean and sanitary.
|
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
The facility failed to ensure that all heaters in the facility were permanently mounted or installed as there was a space heater discovered in both the library and the counselor office 1-C.The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Director of Building and Maintenance and/or designee completes a safety and sanitation check of the building on a weekly basis. From now on included in this check the Director and/or designee will be checking that all heaters in the facility are either permanently mounted or installed.
No space heaters will be permitted in the building at any time. If a space heater is brought into the facility it will be removed immediately by the Director and/or designee.
Staff will be made aware of this policy in a staff memo that will be placed on the staff bulletin board, next to the time clock and staff mailboxes.
|
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
|
Observations
The facility failed to ensure there was documentation of an annual written individual performance evaluation in one of three applicable employee records reviewed.Employee # 4 was hired as a counselor on July 17, 2013. There was no documentation of an annual written individual performance evaluation completed for the current review year.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The clinical supervisor as well as the human resources manager will ensure that there is documentation of an annual written performance evaluation in the clinical employee records.
The employee records will be reviewed by the human resources manager twice a year to ensure that all appropriate documentation has been placed in each of the employee records. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
|
Observations
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in 4 of 14 client records reviewed. Client # 1 was admitted to the inpatient non-hospital level of care on June 7, 2019 and was still active at the time of the inspection. There was documentation that urine samples were sent to a urinalysis lab at least once a month; however, there was no consent to release information on file prior to the disclosure.Client # 2 was admitted to the inpatient non-hospital level of care on September 10, 2019 and was still active at the time of the inspection. There was documentation that urine samples were sent to a urinalysis lab at least once a month; however, there was no consent to release information on file prior to the disclosure.Client # 3 was admitted to the inpatient non-hospital level of care on June 24, 2019 and was still active at the time of the inspection. There was documentation that urine samples were sent to a urinalysis lab at least once a month; however, there was no consent to release information on file prior to the disclosure. Additionally, there was documentation of a family counseling session held on August 7, 2019; however, there was no consent on file for one of the family members at the session. Lastly, there was documentation of a facsimile sent to another treatment provider on October 2, 2019; however, there was no consent to release information form on file prior to disclosure.Client # 5 was admitted to the inpatient non-hospital level of care on October 29, 2018 and was discharged on March 4, 2019. There was documentation of a facsimile sent to a judge on November 6, 2018; however, there was no consent to release information form on file prior to disclosure.The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The clinical supervisor will meet with the director of intake to ensure that a Release of Information (ROI) form is completed at every intake for a urinalysis lab.
The clinical supervisor will conduct a supervision and training to ensure that the facility obtains an informed and voluntary consent of information form prior to the disclosure of information. This training will specifically cover the following examples:
1. If family counseling occurs
there must be an ROI form for
each family member involved.
2. All staff will be made aware that
before any documentation is faxed,
they must obtain an ROI form (this
includes judges).
The release of information for the active client list will be completed with the client by the counselor and/or director of intake by Monday, November 4, 2019 |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
|
Observations
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in 7 out of 14 client record reviewed. Each consent to the funding source allowed for the release of immunization records, Addiction Severity Index Contents & Scores, psychological records, protective assessments, history and assessment, treatment plans, health records, education records and the continuing care plan. Client # 1 was admitted to the inpatient non-hospital level of care on June 7, 2019 and was active at the time of the inspection.Client # 2 was admitted to the inpatient non-hospital level of care on September 10, 2019 and was active at the time of the inspection.Client # 3 was admitted to the inpatient non-hospital level of care on June 24, 2019 and was active at the time of the inspection.Client # 4 was admitted to the inpatient non-hospital level of care on April 24, 2019 and was discharged on August 27, 2019.Client # 5 was admitted to the inpatient non-hospital level of care on October 29, 2018 and was discharged on March 4, 2019.Client # 6 was admitted to the inpatient non-hospital level of care on March 12, 2019 and was discharged on June 10, 2019.Client # 7 was admitted to the inpatient non-hospital level of care on July 19, 2018 and was discharged on November 19, 2018.The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The clinical supervisor will meet with the Director of Intake to ensure that a separate Release of Information (ROI) form is completed on every intake for Community Behavioral Health as the client's care management organization.
The clinical supervisor will conduct a training with the intake department as well as the clinical staff on identifying information that is to be kept within the limits established by 4 Pa. Code 255.5 (b) for release of information.
The release of information for the active client list will be completed with the client by the counselor and/or director of intake by Monday, November 4, 2019
|
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
The facility failed to notify the Department within 3 business days following the unusual incidents below, which were discovered during the licensing process.The incident dates and incident reasons are:January 22, 2019 - Ambulance presence requestedJuly 9, 2019 - Ambulance presence requestedAugust 20, 2019 - Ambulance presence requestedThese findings were reviewed with project and facility staff during the licensing process.
|
Plan of Correction
The clinical supervisor will conduct supervision and training to ensure that the clinical department of Self Help Movement reports unusual incidents to the Department within 3 business days. This training will specifically cover the example of whenever ambulance presence is requested. |