INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 23-24, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Asociacion De Puertorriquenos En Marcha Proyecto Nueva Vida was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
Based on the review of employee records, the facility failed to document assessments of staff training needs in four of five employee records reviewed.
The findings include:
Five employee records were reviewed on January 23, 2012. Training need assessments were required in all employee records reviewed, #1, 2, 4, 5 and 6. Per the facility's policy training need assessments are due by the end of the facility's fiscal year that runs July 1 through June 30 of each year. This was discussed with facility staff on January 24, 2012.
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Plan of Correction
All employee records as they relate to yearly training assessments, with regards to the Proyecto Nueva Vida program have been brought up to date as of February 1, 2012. The Facility Director will conduct monthly reviews of the training assessments to determine if updates are required throughout the fiscal year. The Facility Director will compile the appropriate information regarding the yearly training assessments to ensure that all assessments are completed by June 30th of each fiscal year and remain in compliance. |
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 employee records, the facility failed to ensure that feedback forms are filled out following trainings in two of five employee records reviewed.
The findings include:
Five employee records were reviewed on January 23, 2012. Feedback forms were required in all employee records reviewed, #1, 2, 3, 4 and 5. Per the facility's policy, feedback forms are to be filled out after every training. During the review of employee records, #4 and 5's feedback forms were not documented and could not be review. This was discussed with facility staff on January 24, 2012.
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Plan of Correction
The Facility Director, Quality Assurance and Human Resources are developing a system to ensure that the feedback forms are available to each staff person upon the completion of all on-site and off-site trainings. The forms have been uploaded on our staff intranet for easy staff access. The feedback forms can also be picked up in the Human Resources office or from the Facility Director. During weekly supervision one-on-one sessions with the Facility Director a review of any completed training certificates will be conducted to ensure that the feedback forms are completed before turning the certificate in to Human Resources for filing. The process will be completely implemented by March 1, 2012 and monitored weekly by the Facility Director. This process will also be monitored during monthly Quality Assurance meetings. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of employee records, the facility failed to document individual training plans in two of five employee records reviewed.
The findings include:
Five employee records were reviewed on January 23, 2012. Individual training plans were required in all employee records reviewed, #1, 2, 3, 4 and 5. Per the facilty's policy individual training plans are due by the end of the facility's fiscal year that runs July 1 through June 30 of each year. During the review of employee records #4 and 5 individual training plans were not documented and could not be reviewed. This was discussed with facility staff on January 24, 2012.
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Plan of Correction
The Facility Director, Quality Assurance are developing a system to ensure that the employee individual training plans are completed by the end of each fiscal year. Those that were outstanding, #4 and #5 have been completed and filed in the employee personel file as of February 7, 2012. The corrective action to address the deficiency was effective as of February 7, 2012. All individual employee training plans will be reviewed monthly in the one-on-one supervision session so that continuous information is updated on a more regular basis.The facility director will review employee individual training plans quarterly, Quality Assurance will review the employee training plans semi-annually and Human Resources will confirm annual submissions via interoffice memo to the program directors. |
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 personnel records, staffing requirements facility summary report, the facility failed to ensure that all staff obtained a minimum of 6 hours of training in HIV/AIDS and a least 4 hours related topics within one year of the date of hire for counselors and counselor assistant and within two years of the date of hire date for all other staff.
The findings include:
Five personnel records were reviewed on January 23, 2012. There was no documentation of HIV/AIDS or TB/STD training in one employee record. This employee was required to have HIV/AIDS and TB/STD training within the two years of employment.
Employee #5 was hired February 13, 2001 and was required to have HIV/AIDS & TB/STD training by February 13, 2002. There was no documentation of TB/STD training in the employee's record as of January 23, 2012.
An interview with the facility director and quality assurance director on January 23, 2012 confirmed the findings.
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Plan of Correction
The employee that was hired on February 13, 2001 is scheduled to complete the mandatory traning on March 19, 2012. The Facility Director will monitor the completion of all required trainings in weekly one-on-one supervision sessions. Trainings will also be monitored with Quality Assurance during monthly team meetings. Quality Assurance will work with the Facility Director to develop a yearly training series that provides opportunities for staff to complete required trainings before the end of each fiscal year. The yearly training series plan will be completed by March 1, 2012. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of employee records, the facility failed to provide a sufficient number of staff persons trained in Cardio Pulmonary Resuscitation (CPR) during the project's hours of operation.
The findings include:
The employee records were reviewed on January 23, 2012. It was determined that the facility did not have sufficient CPR coverage during the project's hours of operation, Monday - Friday 8:30 am to 5 pm. On January 23, 2012 and January 24, 2012 interviews were conducted with the Quality Assurance Director. During the interview, the Quality Assurance Director advised that the Mental Health workers, who works in the same building, had current CPR certification. However, he failed to provide documentation of the CPR certifications by the end of the inspection on January 24, 2012.
A discussion with the facility on January 24, 2012 confirmed the findings.
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Plan of Correction
The Facility Director and Quality Assurance Coordinator are working with the CPR/First Aid instructor to verify the validity of the CPR/First Aid training previously completed. The Substance Abuse Counselor has completed CPR/First Aid training on January 26, 2012. The Substance Abuse Counselor was issued his CPR/First Aid certificate on January 26, 2012. Any outstanding CPR/First Aid trainings will be addressed in the development of the APM yearly training series that is being developed by the Facility Director and Quality Assurance Coordinator. The APM yearly training series will be finalized and implemented by March 1, 2012. We anticipate that all CPR/First Aid trainings will be appropriately completed by June 30, 2012 |
705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on a licensing inspection observation, the facility failed to have noncombustible covered containers that prevent the penetration of insect and rodents.
The findings include:
At the time of the licensing specialist's arrival to the facility on January 23, 2012, it was observed that the dumpster was not covered. Also, the dumpster was observed to be full with additional trash bags located alongside of the dumpster. On January 24, 2012 again it was observed that the dumpster was not covered. Also, the dumpster was observed to have accumulated more bags from the pervious day. A discussion was conducted with the directors on January 24, 2012, informing them of the licensing specialists observations on January 23 and 24, 2012.
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Plan of Correction
The dumpster's cover has been secured as of February 1, 2012. To ensure that this problem does not persist, the Facility Director is working with the Facilities Manager to purchase another dumpster. In this way we have an extra resource to address any overflow of trash between scheduled trash pick up days. The finalization of the plan of correction is anticipated for April 2, 2012. Continuous montoring of this deficiency will be conducted by the Faciity Director and the Facilities Manager on a weekly basis. The Facilities Manager will monitor the dumpster on a daily basis to ensure that trash is properly secured. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill record, the facility failed to document two monthly fire drills.
The findings include:
The fire drill record was reviewed on January 23, 2012. The record was reviewed from June 2011 through January 2012. Two of those seven months did not document that a fire drill was conducted. June 2011 and July 2011 were the two months that did not document fire drills. This was confirmed with facility staff on January 24, 2012.
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Plan of Correction
APM will ensure that fire drills are conducted every month. The fire drill process that is put in place is that fire drills are documented on the fire drill log form and are filed as they occur monthly. The fire drill log form includes the date, time, location and what exit was used during the drill. Each person who participated in the fire drill signs off on the fire drill log. If the fire drill participant is a consumer, only first name and initial are documented. Fire Drills are conducted on a monthly basis. They are unannounced and various exits are used at each drill. At the completion of each fire drill the Facility Director collects the fire drill log and the Quality Assurance Coordinator ensures that the log is filed in a timely fashion.
The Quality Assurance Director and the Facility Director will ensure that fire drills continue to be conducted on a monthly basis and that when the fire drills are conducted they are random, unannounced and that at each fire drill a different exit is used. Our next fire drill will be held on February 21, 2012 as an announced drill. Staff have no knowledge that the drill will occur. The Facility Director and the Quality Assurance Coordinator will montior, document and file the fire drill log form for this event. The Facility Director and Quality Assurance Coordinator will monitor this process monthly and continuously. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on the review of the policy and procedure manual, the facility failed to make available to the public an annual report.
The Findings Include:
The policy and procedure manual was reviewed on January 23, 2012. The 20010/2011 annual report was to be made to the public by the end of the facility's fiscal year June 30, 2011. During the inspection, the only report that was presented for review was the 2009/2010 annual report which would have been reviewed during the prior inspection. An interview was conducted with the director on January 24, 2012 and she informed me that the 2010/2011 annual report had not been completed.
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Plan of Correction
The Project Director, Vice President of Finance, The Facility Director and The Communications Manager are working together to complete the annual report and make it available to the public for the 2010-2011 fiscal year. The anticipated completion date of the pending Annual Report is April 11th, 2012. During the month of Febraury, 2012, a timeline for the coordination of the audit and the annual report will be developed by the Project Director, Vice President of Finance and Facility Director to ensure the timely completion of this project. The timeline will be monitored by the Project Director along with the Facility Director. The timelines will focus on quarterly preparation for the financial audit with all members of the fiscal team. The Communications Manager will meet with Senior Management staff weekly to gather the information needed for the Annual Report. The Project Director will monitor the development of the Annual Report in weekly one-on-one supervision with the Communications Director.These timelines are effective as of February 1, 2012. |
709.26(d)(4) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(4) Salary information.
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Observations
Based on a review of personnel records, the facility failed to document salary information in two of five personnel records, as required by regulation.
The findings include:
Five personnel record were reviewed on January 23, 2012. Per regulation, personnel records should include salary information. Personnel records #4 and 5 did not include documentation of salary information.
Employee #4 was hired on November 1, 2010. There was no documentation of salary information in personnel record #4.
Employee #5 was hired on February 13, 2001. There was no documentation of salary information in personnel record #5.
A discussion with facility staff on January 24, 2012 confirmed the findings.
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Plan of Correction
As of February 1, 2012, salary information has been documented in all personnel files. The Facilty Director, Project Director and Human Resources developed a plan of correction to address the need to have salary information documented in each personnel record. The Facility Director will monitor, monthly, any changes in salary for all staff and ensure that all changes are appropriately documented in each personnel file. This process began on January 25, 2012 and will continue as a regular agency practice. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records, the facility failed to document annual performance evaluations as required by agency policy and regulation in five of five personnel records.
The findings include:
Five personnel records were reviewed on January 23, 2012. All personnel records were required to include documentation of annual performance evaluations or a three month performance evaluation for newly employeed staff. Per agency policy, performance evaluations are conducted at three months and annually after thereafter. There were no annual performance evaluations documented in personnel records #1, 2, 4 and 5. There was no three month performance evaluation documented in personnel record #3.
Employee #1 was hired on July 1, 1997 and the current annual performance evaluation was to be documented by July 1, 2011. Employee record #1 did not have documentation of the annual performance evaluation as of January 23, 2012.
Employee #2 was hired on November 29, 2010 and the current annual performance evaluation was to be documented by November 29, 2011. Employee record #2 did not have documentation of their annual performance evaluation as of January 23, 2012.
Employee #3 was hired on October 11, 2011 and the three month performance evaluation was to be documented by January 11, 2012. Employee record #3 did not have documentation of their annual performance evaluation as of January 23, 2012.
Employee #4 was hired on November 1, 2010 and the current annual performance evaluation was to be documented by November 1, 2011. Employee record #4 did not have documentation of their annual performance evaluation as of January 23, 2012.
Employee #5 was hired on February 13, 2001 and the current annual performance evaluation was to be documented by February 13, 2011. Employee record #5 did not have documentation of their annual performance evaluation as of January 23, 2012.
An interview was conducted with the Facility Director and Quality Assurance Director on January 23-24, 2012.
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Plan of Correction
As of February 1, 2012 all annual performance evaluations have been completed, submitted and brought up to date for each staff member. This includes the 3 month performance evaluation and the yearly performance evaluations. The Facility Director will monitor performance as it relates to the completion of the annual performance evaluation during weekly one-on-one sessions. Quality Assurance will monitor on-going completion of the annual performance evaluation on a quarterly basis. |
709.28 (c)(1) 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 shall be in writing and shall include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent from the client that included the name of the person, agency or organization to whom disclosure is made in eleven of sixteen client records reviewed.
The findings include:
Sixteen client records were reviewed on January 23 - 24, 2012. Eleven client records were required to have informed and voluntary consent forms which included the name of the person, agency or organization to whom disclosure is made. The name of the person, agency or organization to whom disclosure is made was not documented in the informed and voluntary consent forms in client records, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11. An interview with the Facility Director and Quality Assurance Director on January 23-24, 2012 confirmed the findings.
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Plan of Correction
On January 27, 2012 the Quality Assurance Coordinator reviewed the structure of the informed and voluntary consent forms to ensure that the format is accurate in its collection of information. Upon completion of the form review, modifications were made to the form. The Facility Director completed an in-service training that provided instruction on the completion of the informed and voluntary consent forms as they have been modified. The inservice training was completed on February 3, 2012. We will begin phasing out the old froms as of February 3, 2012. It is anticipated that all of the old forms will be replaced with the newly revised froms by March 2, 2012. Weekly monitoring will be conducted by the Facility Director in one-on-one supervision sessions. The Quality Assurance Coordinator will conduct monthly chart audits to assess the quality of documentation in this area. |
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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent from the client that included specific information disclosed in eleven of sixteen client records reviewed.
The findings include:
Sixteen client records were reviewed on January 23 - 24, 2012. Eleven client records were required to have informed and voluntary consent forms which included specific information disclosed. The specific information disclosed was not documented in the informed and voluntary consent forms in client records, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11. An interview with the Facility Director and Quality Assurance Director on January 23-24, 2012 confirmed the findings.
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Plan of Correction
On January 27, 2012 the Quality Assurance Coordinator reviewed the structure of the informed and voluntary consent forms to ensure that the format is accurate in its collection of information. Upon completion of the form review, modifications were made to the form. The Facility Director completed an in-service training that provided instruction on the completion of the informed and voluntary consent forms as they have been modified. The inservice training was completed on February 3, 2012. We will begin phasing out the old forms with the newly revised forms on February 3, 2012. We anticipate that all of the new forms will be completed by our clients by March 2, 2012. Weekly monitoring will be conducted by the Facility Director in one-on-one supervision sessions. The Quality Assurance Coordinator will conduct monthly chart audits to assess the quality of documentation in this area. |
709.28(c)(3) 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 shall be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent from the client that included the purpose of disclosure in eleven of sixteen client records reviewed.
The findings include:
Sixteen client records were reviewed on January 23 - 24, 2012. Eleven client records were required to have informed and voluntary consent forms which included the purpose of disclosure. The purpose of disclosure was not documented in the informed and voluntary consent forms in client records, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11. An interview with the Facility Director and Quality Assurance Director on January 24, 2012 confirmed the findings.
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Plan of Correction
On January 27, 2012 the Quality Assurance Coordinator reviewed the structure of the informed and voluntary consent forms to ensure that the format is accurate in its collection of information. Upon completion of the form review, modifications were made to the form. The Facility Director completed an in-service training that provided instruction on the completion of the informed and voluntary consent forms as they have been modified. The inservice training was completed on February 3, 2012. We will begin phasing out the old forms as of February 3, 2012. We anticipate that all of the old forms will be replaced with the newly revised forms by March 2, 2012. Weekly monitoring will be conducted by the Facility Director in one-on-one supervision sessions. The Quality Assurance Coordinator will conduct monthly chart audits to assess the quality of documentation in this area. |
709.28(c)(6) 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 shall be in writing and include, but not be limited to:
(6) Expiration date of the consent.
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent from the client that included the name of the expiration date of the consent in eleven of sixteen client records reviewed.
The findings include:
Sixteen client records were reviewed on January 23 - 24, 2012. Eleven client records were required to have informed and voluntary consent forms which included the expiration date of the consent. The expiration date of the consent was not documented in the informed and voluntary consent forms in client records, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11. An interview with the Facility Director and Quality Assurance Director on January 23-24, 2012 confirmed the findings.
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Plan of Correction
On January 27, 2012 the Quality Assurance Coordinator reviewed the structure of the informed and voluntary consent forms to ensure that the format is accurate in its collection of information. Upon completion of the form review, modifications were made to the form. The Facility Director completed an in-service training that provided instruction on the completion of the informed and voluntary consent forms as they have been modified. The inservice training was completed on February 3, 2012. We will begin phasing out the old forms by February 3, 2012. It is anticipated that the old forms will be replaced with the newly revised forms by March 2, 2012. Weekly monitoring will be conducted by the Facility Director in one-on-one supervision sessions. The Quality Assurance Coordinator will conduct monthly chart audits to assess the quality of documentation in this area. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent from the client that showed the client was offered a copy of the consent in eleven of sixteen client records reviewed.
The findings include:
Sixteen client records were reviewed on January 23 - 24, 2012. Eleven client records were required to have informed and voluntary consent forms which showed the client was offered a copy of the consent. The informed and voluntary consent forms did not show that the client was offered a copy in client records, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11. An interview with the Facility Director and Quality Assurance Director on January 23-24, 2012 confirmed the findings.
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Plan of Correction
On January 27, 2012 the Quality Assurance Coordinator reviewed the structure of the informed and voluntary consent forms to ensure that the format is accurate in its collection of information. Upon completion of the form review, modifications were made to the form. The Facility Director completed an in-service training that provided instruction on the completion of the informed and voluntary consent forms as they have been modified. The inservice training was completed on February 3, 2012. We will begin phasing out the old froms by February 3, 2012. We anticipate that the old forms will be replaced with the newly revised forms by March 2, 2012. Weekly monitoring will be conducted by the Facility Director in one-on-one supervision sessions. The Quality Assurance Coordinator will conduct monthly chart audits to assess the quality of documentation in this area. |
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 a psychosocial evaluation in eleven of sixteen client records.
The findings include:
Eleven client records were reviewed on January 23-24, 2012. There was no documentation of psychosocial evaluations in eleven records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11. An interview with facility staff on January 24, 2012 confirmed the findings.
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Plan of Correction
On January 27, 2012 the Quality Assurance Coordinator and Facility Director reviewed the current Biopsychosocial format. Modifications were made to the Biospsychosocial to include a psychosocial evaluation. The revised Biopsychosocial, that includes a psychosocial evaluation, was implemented February 3, 2012. The Facility Director completed in-service instruction with the Substance Abuse Counselor on February 3, 2012 on the completion of the revised form. Quality Assurance will conduct monthly chart audits to assess the quality of documentation. The Facility Director will assess performance in this area in weekly one-on-one supervision sessions. |
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 treatment plans within the facility's allotted time in nine of sixteen client records.
The finding includes:
Sixteen client records were reviewed on January 23-24, 2012. Treatment plans were reviewed in nine client records, #1, 2, 3, 4, 5, 7, 8 and 11. Per the facility's policy, treatment plans will be completed within 30 days of the clients admission date into the drug and alcohol program after the completion of the client ' s biopsychosocial histories and evaluation. A discussion with facility staff on January 23-24, 2012 confirmed the findings.
Client #1 was admitted to the program on October 18, 2011 and their treatment plan was completed on November 15, 2011. Client record #1's treatment plan was completed on November 15, 2011, prior to the completion of the client's psychosocial evaluation which was not documented in record reviewed.
Client #2 was admitted to the program on October 18, 2011 and their treatment plan was to be completed on or before November 18, 2011. Client record #2's treatment plan was completed on December 27, 2011, prior to the completion of the client's psychosocial evaluation which was not documented in record reviewed.
Client #3 was admitted to the program on October 17, 2011 and their treatment plan was completed on November 15, 2011. Client record #3's treatment plan was completed on November 15, 2011, prior to the completion of the client's psychosocial evaluation which was not documented in record reviewed.
Client #4 was admitted to the program on October 26, 2011 and their treatment plan was completed on November 23, 2011. Client record #4's treatment plan was completed on November 23, 2011, prior to the completion of the client's psychosocial evaluation which was not documented in record reviewed.
Client #5 was admitted to the program on October 14, 2011 and their treatment plan was completed on October 25, 2011. Client record #5's treatment plan was completed on October 25, 2011, prior to the completion of the client's psychosocial evaluation which was not documented in record reviewed.
Client #6 was admitted to the program on November 1, 2011 and their treatment plan was completed on November 22, 2011. Client record #6 treatment plan was completed on November 11, 2011 before the completion of the client's psychosocial evaluation which was not documented in record reviewed.
Client #7 was admitted to the program on October 26, 2011 and their treatment plan was completed on November 8, 2011. Client record #7's treatment plan was completed on November 8, 2011, prior to the completion of the client's psychosocial evaluation which was not documented in record reviewed.
Client #8 was admitted to the program on October 21, 2011 and their treatment plan was to be completed on or before November 21, 2011. Client record #8's treatment plan was completed on November 28, 2011, prior to the completion of the client's psychosocial evaluation which was not documented in record reviewed.
Client #11 was admitted to the program on October 21, 2011 and their treatment plan was to be completed on or before October 21, 2011. Client record #11's treatment plan was not documented in record reviewed.
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Plan of Correction
The Facility Director completed in-service instruction with the Substance Abuse Counselor regarding the completion of treatment plans. The inservice training was completed on February 3, 2012. Direct instruction was given to educate the counselor that the treatment plan must be completed 30 days after the client's admission to the program. The Facility Director will conduct continued evaluation on the timely completion of treatment plans in weekly one-on-one supervision sessions. The Quality Assurance Coordinator will conduct monthly chart audits to assess the quality of this documentation. |
709.93(a)(8) LICENSURE Client records
709.93. 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations in three of sixteen client records.
Findings:
Sixteen client records were reviewed on January 23-24, 2012. Case consultations were required in four client records, #1, 2, 3 and 5. Per the facility's policy and procedure case consultations are to be documented quarterly, every 90 days. An interview with the Quality Assurance Director and Facility Director on January 23-24, 2012 confirmed the findings.
Client #1 was admitted on October 18, 2011 and their case consultation was to be documented by January 18, 2012. As of January 24, 2012, there was no documentation of client #1's case consultation.
Client #2 was admitted on October 18, 2011 and their case consultation was to be documented by January 18, 2012. As of January 24, 2012, there was no documentation of client #2's case consultation.
Client #3 was admitted on October 17, 2011 and their case consultation was to be documented by January 17, 2012. As of January 24, 2012, there was no documentation of client #3's case consultation.
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Plan of Correction
The Facilty Director conducted in-service training with the Substance Abuse Counselor on the completion of case consultations. Direct instruction and education was provided to ensure that case consultations are completed every 90 days. The inservice training was completed on February 3, 2012 and continued monitoring in this area will be conducted in weekly one-on-one supervision sessions with the Facility Director. The Quality Assurance Coordinator will conduct monthly chart audits to ensure the quality of this documentation is congruent with agency and regulatory expectations. |
709.93(a)(10) LICENSURE Client records
709.93. 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 the review of client records, the facility failed to document discharge summaries in eight of eight discharge records client records.
The findings include:
Sixteen client records were reviewed on January 23-24, 2012. Discharge summaries were required in eight client records. Per regulations and the facility's policy, discharge summaries are required to be completed within 7 days of the client's discharge date. Three of the eight discharge summaries was not documented, #14, 15 and 16. The facility did not completely record the reasons for entering into drug and alcohol services in records, 9, 11 and 12. Also, the facility failed to document services offered to the client on the discharge summaries in records, 10, 11 and 12.
Client #14 was admitted on March 16, 2011 and discharged on August 29, 2011. The discharge summary was due on or by September 5, 2011. Client record #14 did not have documentation of the clients discharge summary.
Client #15 was admitted on June 27, 2011 and discharged on August 13, 2011. The discharge summary was due on or by August 20, 2011. Client record #15 did not have documentation of the clients discharge summary.
Client #16 was admitted on March 8, 2011 and discharged on August 29, 2011. The discharge summary was due on or by September 5, 2011. Client record #16 did not have documentation of the clients discharge summary.
An interview with the Facility Director and Quality Assurance Director on January 24, 2012 confirmed the findings.
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Plan of Correction
The Facility Director conducted in-service training in the area of discharge summary completion. The in-service training was completed on February 3, 2012. Direct instruction and education was provided as per regulations and the facility's policy regarding the completion of discharge summaries within 7 days of the client's discharge date as well as documentation of services offered to the client at the time of discharge. Continued monitoring in this area will be conducted by the Facility Director in weekly one-on-one supervision sessions. The Quality Assurance Coordinator will conduct monthly chart audits to ensure the quality of this documentation. |
709.93(a)(11) LICENSURE Client records
709.93. 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in six of eight discharge records.
The findings include:
Sixteen client records were reviewed on January 23-24, 2012. Eight records were required to document follow-up information, #9, 10, 11, 12, 13, 14, 15 and 16. Follow up was not documented in records, #9, 12, 13, 14, 15 and 16. Per the facility's policy, follow-ups will be done within 30 days following discharge date and 7 days if being referred. An interview with the Facility Director and Quality Assurance Director on January 24, 2012 confirmed the finding.
Client #9 was admitted on November 18, 2011 and discharged on December 12, 2011. The follow-up was due by January 12, 2012. As of the date of review there was no documentation of follow-up in client record #9.
Client #12 was admitted on May 9, 2011 and discharged on August 29, 2011. The follow-up was due by September 29, 2011. As of the date of review there was no documentation of follow-up in client record #12.
Client #13 was admitted on June 7, 2011 and discharged on November 22, 2011. The follow-up was due by December 22, 2011. As of the date of review there was no documentation of follow-up in client record #13.
Client #14 was admitted on March 16, 2011 and discharged on August 29, 2011. The follow-up was due by September 29, 2011. As of the date of review there was no documentation of follow-up in client record #14.
Client #15 was admitted on June 27, 2011 and discharged on August 13, 2011. The follow-up was due by September 13, 2011. As of the date of review there was no documentation of follow-up in client record #15.
Client #16 was admitted on March 8, 2011 and discharged on August 29, 2011. The follow-up was due by September 29, 2011. As of to date there was no documentation of follow-up in record #16.
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Plan of Correction
The Facility Director conducted in-service training in the area of follow up procedures. The in-service training was completed on February 3, 2012. Direct instruction and education was provided regarding the follow up procedures, as per regulations and the facility's policy: all client follow ups will be completed within 30 days after discharge and within 7 days if the cleint is being referred. Continued monitoring in this area will be conducted by the Facility Director in weekly one-on-one supervision sessions. The Quality Assurance Coordinator will conduct monthly chart audits to ensure the quality of this documentation is congruent with agency and regulatory expectations. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records and a discussion with the Facility Director, the facility failed to provide a medical physician to comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
The findings include:
Sixteen client records were reviewed on January 23-24, 2012. Eleven of the sixteen client records were required to have a physician review and sign the clients treatment plans. Per the Department of Welfare standards, all treatment plans are to be signed by the physician within 15 days of the completion of the initial treatment plan. The initial treatment plans, comprehensive treatment plans and/or treatment plan updates did not have documentation of the physician signature for records, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11. A discussion with the facility director and Quality Assurance Director on January 24, 2012 confirmed that the initial treatment plans, comprehensive treatment plans and treatment plan updates were not signed by the physician in records reviewed.
Client record #3's initial treatment plan was completed on January 14, 2011; the physician did not sign the treatment plan until March 20, 2011.
Client record #4's initial treatment plan was completed on November 27, 2010; the physician did not sign the treatment plan until December 29, 2010.
Client record #5's initial treatment plan was completed on January 14, 2011; the physician did not sign the treatment plan until February 17, 2011.
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Plan of Correction
As of February 1, 2012 the Facility Director has ensured that all treatment plans, both initial and comprehensive, are signed by the physician. The Facility Director will review all treatment plans [initial treatment plans witnin the first 7 days, and comprehensive treatment plans within all update timeframes] to ensure that they are signed by the physician. The Facility Director met with the physician on February 8, 2012 to review the current treatment plans for the appropriate signatures. The Quality Assurance Coordinator will conduct chart audits on a monthly basis to ensure the quality of this documentation is congruent with agency and regulatory expectations. |