INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the April 11 2011 licensure renewal inspection. The follow-up inspection was conducted on October 25, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Guidance For Growing, LLC 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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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill records, the facility failed to provide documentation that the facility's alarm was in working order.
The findings include:
Fire drill records were reviewed on October 25, 2011. The facility was granted an approval on September 7, 2010 to the Physical Plant Standards for Nonresidential Facilities, Chapter 705.28 (d) (7), relative to activating a fire alarm or smoke detector during a fire drill. As a result of the approval, the facility was required to provide documentation that their fire alarm is in working order. Documentation that the facility's fire alarm was tested and in working order was not presented for review.
An interview with the project director conducted on October 25, 2011 confirmed the findings.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the April 11, 2011 licensing inspection.
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Plan of Correction
The clinical supervisor will be responsible for addressing the fire alarm is in working order.
The clinical supervisor will ask permission from the building owner to 'trip' the alarm at a time when the building is empty. Concurrently, the clinical supervisor will continue to ask for proof that the fire alarm is in working order.
The clinical supervisor will continue to ask the building owner via phone call and email for either of the above solutions.
The proof of working fire alarm request was implemented at the time of the survey and the request to 'trip' the alarm was implemented 12/1/2011. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document the date of completion of the clients' medical history in accordance with the facility's policy and procedures..five of five records reviewed.
The findings include:
Per the facility's policy medical histories will be completed on all clients within the 2nd week of the client initial assessment
On October 25, 2011, five client records requiring documentation of a medical history were reviewed. Five out of five records reviewed, #1-5, lacked the dates of completion to determine if they were completed within 2 weeks of the clients initial assessments
Client #1 was admitted on June 15, 2011 and discharged on August 18, 2011. The medical history was documented in record reviewed, but could not determine the date of completion due to the form not having the date documented.
Client #2 was admitted on June 29, 2011 and discharged on September 1, 2011. The medical history was documented in the record reviewed, but the date of completion was not documented.
Client #3 was admitted on July 14, 2011 and discharged on August 4, 2011. The medical history was not documented at the time of the clients discharge date.
Client #4 was admitted on July 4, 2011 and discharged on September 26, 2011. The medical history was documented in the record reviewed, but the date of completion was not documented.
Client #5 was admitted on September 1, 2011. The medical history was documented in the record reviewed, but the date of completion was not documented.
An interview with them project director on October 25, 2011 confirmed the findings.
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Plan of Correction
The lack of a completion date of medical histories will be corrected by the clinical supervisor.
The clinical supervisor will add a "date" line to the medical history background form, where previously there was no place to enter a date.
The therapist completing the intake will check to insure each form is dated upon completion by the client.
The corrective action plan was implemented on 11/22/2011. |
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 accordance with facility policy and procedures.
The findings include:
Per the facility policy follow-ups will be completed within 30 days of the client discharge date if not being referred.
On October 25, 2011, three client records requiring documentation of a follow-up were reviewed. Three of three records reviewed lacked documentation of a follow-up.
Client #1 was admitted on June 15, 2011 and discharged on August 18, 2011. Follow-up was to be documented by September 18, 2011. No follow-up was documented in record reviewed.
Client #2 was admitted on June 29, 2011 and discharged on September 1, 2011. Follow-up was to be documented by October 1, 2011. No follow-up was documented in record reviewed.
Client #3 was admitted on July 14, 2011 and discharged on August 4, 2011. Follow-up was to be documented by September 4, 2011. No follow-up was documented in record reviewed.
An interview with the project director on October 25, 2011 confirmed the findings.
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Plan of Correction
The follow-up plan of correction for clients being called within 30 days of discharge will be corrected by the clinical supervisor.
An electronic prompt system was created by the clinical supervisor on the agencies calender to notify the therapist when successfully discharged clients need their 30-day follow-up call.
Upon discharge, therapists will be responsible for putting into an eletronic calender the date upon which a follow up call will be placed. The clinical supervisor will monitor the call backs as the prompts appear.
This corrective action was put into place on 11/22/2011. |