INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 1 - 2, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Consortium 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(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 personnel records and the facility's facility summary report, the facility failed to provide documentation of individual training plans in eleven of nineteen personnel/ training records reviewed.
The findings include:
Six personnel/training records were reviewed on April 1 - 2, 2013 and the facility summary report was reviewed on April 1-3, 2013. Individual training plans were required for all personnel reviewed. Eleven of the nineteen were reviewed from the facility summary report, #7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 and 19. The facility did not document individual training plans for the January 1 - December 31, 2013 training year in eleven records. Training plans, per facility policy were required to be completed no later than December 31.
Employee #9 was hired in April 15, 2007. An individual training plan was not completed for the 2013 training year.
Employee #10 was hired August 14, 2009. An individual training plan was not completed for the 2013 training year.
Employee #11 was hired September 1, 2009. An individual training plan was not completed for the 2013 training year.
Employee #12 was hired August 14, 2009. An individual training plan was not completed for the 2013 training year.
Employee #13 was hired August 14, 2009. An individual training plan was not completed for the 2013 training year.
Employee #14 was hired August 14, 2009. An individual training plan was not completed for the 2013 training year.
Employee #15 was hired March 5, 2012. An individual training plan was not completed for the 2013 training year.
Employee #16 was hired August 14, 2009. An individual training plan was not completed for the 2013 training year.
Employee #17 was hired December 8, 2008. An individual training plan was not completed for the 2013 training year.
Employee #18 was hired May 28, 1996. An individual training plan was not completed for the 2013 training year.
Employee #19 was hired July 28, 1983. An individual training plan was not completed for the 2013 training year.
An interview with the facility director on April 3, 2013 confirmed the findings.
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Plan of Correction
Responsible:
The Supervisor/Manger is responsible for developing, annually with input from the employee, the individual training plan for each employee. The individual training plans are to be completed for the new training year, by January 31st of each year.
Monitoring:
The Human Resource Director will monitor the personnel records of all employees to ensure an individual training is completed and filed in the personnel record by January 31st of each year.
Time Frame:
The individual training plans for personnel #7,8,9,10,11,12,13,14,15,16 and 17 will be completed by 5/15/13.
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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 personnel/training records and the facility summary report, the facility failed to provide documentation of a minimum of 6 hours of HIV/AIDS and/or at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training in eleven of nineteen personnel records.
The findings include:
Six personnel records were reviewed on April 1, 2013 and the facility's staffing summary report was reviewed on April 1-3, 2013. The facility was required to provide documentation that fifteen personnel had HIV/AIDS and/or tuberculosis, sexually transmitted diseases and other health related topics training. Employee records # 7, 8, 9, 10, 11, 12, 13, 14, 16, 17 and 18 did not include documentation of the completion of the required training.
Employee # 7 was hired on October 4, 2010. HIV/AIDS and TB/STD training was due to be completed by October 4, 2012. There was no documentation that the employee had completed the HIV/AIDS & TB/STD training as of April 3, 2013.
Employee # 8 was hired on March 3, 1997. HIV/AIDS and TB/STD training was due to be completed by March 3, 1999. There was no documentation that the employee had completed the TB/STD training as of April 3, 2013.
Employee # 9 was hired on April 15, 2007. HIV/AIDS and TB/STD training was due to be completed by April 15, 2009. There was no documentation that the employee had completed the HIV/AIDS & TB/STD training as of April 3, 2013.
Employee # 10 was hired on August 14, 2009. HIV/AIDS and TB/STD training was due to be completed by August 14, 2011. There was no documentation that the employee had completed the HIV/AIDS & TB/STD training as of April 3, 2013.
Employee # 11 was hired on September 1, 2009. HIV/AIDS and TB/STD training was due to be completed by September 1, 2011. There was no documentation that the employee had completed the HIV/AIDS & TB/STD training as of April 3, 2013.
Employee # 12 was hired on August 14, 2009. HIV/AIDS and TB/STD training was due to be completed by August 14, 2011. There was no documentation that the employee had completed the HIV/AIDS & TB/STD training as of April 3, 2013.
Employee # 13 was hired on August 14, 2009. HIV/AIDS and TB/STD training was due to be completed by August 14, 2011. There was no documentation that the employee had completed the HIV/AIDS & TB/STD training as of April 3, 2013.
Employee # 14 was hired on August 14, 2009. HIV/AIDS and TB/STD training was due to be completed by August 14, 2011. There was no documentation that the employee had completed the HIV/AIDS & TB/STD training as of April 3, 2013.
Employee # 16 was hired on August 14, 2009. HIV/AIDS and TB/STD training was due to be completed by August 14, 2011. There was no documentation that the employee had completed the HIV/AIDS & TB/STD training as of April 3, 2013.
Employee # 17 was hired on December 8, 2008. HIV/AIDS and TB/STD training was due to be completed by December 8, 2010. There was no documentation that the employee had completed the HIV/AIDS & TB/STD training as of April 3, 2013.
Employee # 18 was hired on May 28, 1996. HIV/AIDS and TB/STD training was due to be completed by May 28, 1998. There was no documentation that the employee had completed the HIV/AIDS & TB/STD training as of April 3, 2013.
Employee # 19 was hired on July 28, 1983. HIV/AIDS and TB/STD training was due to be completed by July 28, 1985. There was no documentation that the employee had completed the HIV/AIDS & TB/STD training as of April 3, 2013.
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Plan of Correction
Responsible:
The Supervisor/Manger is responsible for ensuring that staff and volunteers receive a minimum of 6 hours HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum.
Monitoring:
The Human Resource Director, in collaboariation with the Director of Training, will ensure that personnel have completed the required 6 hours HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum.
Time Frame:
The training hours will be completed for the required personnel 7,8,9,10,11,12,13,14,16,17, 18 and 19 by July 31, 2013.
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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on the inspection of the physical plant of the facility, the facility failed to ensure the grounds were clean, safe and in good repair.
The findings include:
The physical plant inspection was conducted on April 3, 2013 between 10:30 AM and 12:30 PM with the head of security.
The following areas of non-compliance were noted:
1) The carpet in group counseling room # 121 was observed to have carpet areas that were buckled and ripped upholstery on a chair.
2) The first floor women's bathroom had missing floor tiles and the men's bathroom was out of order.
3) In the large waiting room area, there was a cabinet with a sink that contained broken and splintered wood.
4) The first floor women's bathroom had both stalls covered with graffiti.
5) The medical records room had carpeting that was ripped and buckling.
6) In Suite 140, the business office area, there were two outlets exposed and extended from the wall.
7) In the enclosed reception office area, there was dirty carpeting and ripped chair upholstery.
8) From the doorway into medication hallway, a large section of tile was torn up. A rug was identified as covering this area, presenting a potential tripping hazard.
9) In room #148, a phone wire was observed dangling from wall and there was an exposed electrical outlet.
10) In room # 152, the tile and rug was ripped at the doorway, presenting a tripping hazard.
11) In room # 154, the staff lounge, a wire was found pulled up from middle of floor and exposed; a staff refrigerator was very dirty, covered with spilled food and beverage; and the closet wall had large areas of peeling paint
12) In room #157 torn carpet was observed, presenting a tripping hazard.
13) In room # 158, carpeting was stained and torn; a window was held open with a cup due to the window weights being broken.
14) Security room contained exposed outlets, wires hanging from wall and the carpet was stained and ripped.
15) Th exit door from the dosing area was broken and wood, cardboard and tape replaced glass; this is a safety/security concern.
16) In room # 201, there was a hole in the flooring in the doorway.
17) In room # 202, there was ripped carpeting a phone lines piled behind the counseling chairs
18) In room # 237, the plaster was falling from the wall around the windows.
19) In suite area #234, floor tile was broken
20) In room # 249, ripped carpeting was found and identified as a tripping hazard..
21) In suite area 240, there was a pile of office furnishings that presented a potential hazard if it fell over as well as carpet buckling in different areas.
22) In rooms # 242 and 243, the carpeting was torn in the doorways, presenting a tripping hazard.
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Plan of Correction
Responsible: The Maintenance and Facilities Department is responsible for the completion of repairs to keep the grounds of the facility clean, safe and sanitary and in good repair at all times for the safety and well being of persons in treatment, employees and visitors.
Monitoring: The Program Director will conduct a monthly walk through of the program grounds to ensure all areas are in compliance. All findings will be reported to the Maintenance and Facilities Department within 72 hours.
Time Frame:
1) The carpet in group counseling room # 121 will be repaired/replaced by 6/30/13. Ripped chair has been removed.
2) The first floor women's bathroom will have all missing floor tiles repaired by 6/30/13, and the men's bathroom, which has been out of order, will be repaired by 6/30/13.
3)The cabinet with a sink that contained broken and splintered wood in the large waiting room area, will be removed by 6/30/13.
4) The graffiti found in the first floor women's bathroom will be removed and painted over by 6/30/13.
5) The medical records room had carpeting that was ripped and buckling. This will be repaired by 6/30/13.
6) In suite 140, the business office area, there were two outlets exposed and extended from the wall. These outlets have been covered as of 4/30/13.
7)In the enclosed reception office area, dirty carpeting and ripped chair upholstery, will be repaired/replaced by 6/30/13.
8) From the doorway into medication hallway, a large section of tile was torn up. A rug was identified as covering this area, presenting a potential tripping hazard. All tiles that are broken, will be repaired/replaced by 6/30/13.
9) In room #148, a phone wire was observed dangling from wall and there was an exposed electrical outlet. The phone wire will be secured appropriately, and the electrical oulets will be covered by 5/15/13.
10) In room # 152, the tile and rug was ripped at the doorway, presenting a tripping hazard. The tile and rug will replaced/repaired by 6/30/13.
11) In room # 154, the staff lounge, exposed wire will be covered by 5/15/13. Refigerator has been cleaned out as of 4/30/13. Closet wall will be repaired and repainted by 6/30/13.
12)Torn carpet in room #157 will be repaired by 6/30/13.
13)Carpeting in room #158 will be repaired/replaced by 6/30/13. Also, the window will be repaired by 5/30/13.
14)Exposed outlets in the security room will be oovered by 5/30/13. Wires hanging from the wall will be secured by 5/15/13. Carpet will be replaced/repaired by 6/30/13.
15) The broken exit door from the dosing area will be replaced by 5/30/13. Proposal has been submitted.
16) In room # 201, there was a hole in the flooring in the doorway. Repairs are in progress. Expected completion 6/15/13.
17) In room # 202, there was ripped carpeting and phone lines piled behind the counseling chairs. Repairs in progress. Expected completion date 6/30/13.
18) In room # 237, the plaster was falling from the wall around the windows. Repairs are in progress, expected completion date 6/30/13.
19) In suite area #234, floor tile was broken. Tiles will be repaired/removed by 6/30/13.
20) In room # 249, ripped carpeting will be replaced/repaired by 6/30/13.
21) In suite area 240, there was a pile of office furnishings that presented a potential hazard, as well as carpet buckling in different areas. Office furnishings have already been removed. Carpet will be repaired/replaced by 6/30/13.
22) In rooms # 242 and 243, the carpeting will be replaced/repaired by 6/30/13.
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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on an inspection of the facility's physical plant, the facility failed to ensure the bathrooms all had hot water or the water temperature was no hotter than 120 degrees Fahrenheit.
The findings include:
1) The sink in the unisex employee restroom located in the employee's lounge had a hot water temperature reading of 138 Fahrenheit. The kitchen sink in the same lounge also had hot water exceeding the 120 degrees.
2) The first floor men's and women's bathrooms near the large waiting area were found to have no hot water at the time of the inspection.
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Plan of Correction
Responsible: The Facilities and Maintenance Department is responsible for ensuring that facility bathrooms have hot and cold water and the hot water shall not exceed 120F.
Monitoring: The Facilities and Maintenance Department will monitor all restrooms on a weekly basis and test the hot water to show a reading not to exceed 120F.
Time Frame:
1. The sink in the unisex employee restroom located in the employee lounge shall have hot water not to exceed 120F no later than June 30, 2013. The kitchen sink in the employee lounge shall have hot water not to exceed 120F no later than June 30, 2013 as well.
2. The bathroom located in the large group room had no hot water. The bathroom will have hot water by May 31, 2013.
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705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on the inspection of the physical plant of the facility, the facility failed to ensure that all the bathrooms within the facility were functional.
The findings include:
The physical plant inspection was conducted on April 3, 2013 between 10:30 AM and 12:30 PM with the head of security.
On the first floor, the men's bathroom was found to be out of order.
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Plan of Correction
Responsible: The Maintenance and Facilities Director is responsible to maintain each bathroom in a functional, clean and sanitary manner.
Monitoring: The Program Director will conduct a monthly walk through of the program grounds to ensure all areas are in compliance.
All findings will be reported to the Maintenance and Facilities Department within 72 hours. The maintenance and facilities department will make all repairs reported.
Time Frame:
On the first floor, the men's bathroom will be repaired by July 31, 2013.
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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on the inspection of the physical plant of the facility, the facility failed to ensure all the exits from the facility were unobstructed.
The findings include:
The physical plant inspection was conducted on April 3, 2013 between 10:30 AM and 12:30 PM with the head of security.
On the first floor, the exits leading to the sides of the building were obstructed in that the push bars on the doors were observed to be difficult to push open. The head of security had to force them to open.
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Plan of Correction
Responsible: The Facilities and Maintenance Dept is repsonsible for ensuring that all exits of the facility are unobstucted.
Monitoring: The Program Director will do a monthly review of all all exits to ensure that all exits are clear and free of obstruction.
The Program Director will report to the Facilities and Maintencance Dept, any exis that are found to be obstructed, within 72 hours of identification.
The Facilities Dept, will make all repairs as reported.
The 1st floor side exit will be repaired by 5/30/13. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on the inspection of the physical plant of the facility, the facility failed to ensure the fire extinguishers were inspected and approved annually.
The findings include:
The physical plant inspection was conducted on April 3, 2013 between 10:30 AM and 12:30 PM with the head of security.
The fire extinguishers located throughout the facility were last inspected in February 2012. They should have been re-inspected by the end of February 2013.
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Plan of Correction
Responsible: The Facilities and Maintenance Dept, is responsible for ensuring that the fire extinguishers are inspected and approved annually.
Monitoring: The Program Director will conduct a monthly review of all fire extginguishers to ensure compliance. All fire extinguishers that are close to annual update and approval will be reported to Facilities and Maintenance Dept.
Timeframe: All fire extinguishers throughout the building will be updated and approved by 5/30/13. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher 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 instruct staff in the use of the fire extinguisher upon staff employment in two of six personnel records, as required by regulation.
The findings include:
Six personnel records were reviewed on April 1, 2013. Five employees were hired since the last inspection. Per regulation, the residential facility shall instruct all staff in the use of the fire extinguishers upon staff employment. The facility failed to document that fire extinguisher training was completed upon employment in employee records # 1 and 4.
Employee # 1 was hired on February 19, 2013. Fire extinguisher training was required to be completed upon hire. The facility did not document the completion of fire extinguisher training until February 28, 2013.
Employee #4 was hired on January 28, 2013. Fire extinguisher training was required to be completed upon hire. The facility failed to document that employee #4 received the required fire extinguisher training.
An interview with the facility director on April 1, 2013 confirmed the findings.
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Plan of Correction
Responsible:
The Training and Licensing Director in conjunction with the Human Resource Director will be responsible to ensure new hires are instructed in the use of the fire extinguisher upon staff employment and documentation of the training is filed in personnel records.
The training will be provided by the Training and Licensing Director. New hires will sign?off on having participated in the fire extinguisher training and the sign-off sheet will be filed in their personnel record.
Time Frame: Employees #1 and #4will have documentation of fire extinguisher training in their personnel records, by 5/30/13.
Monitoring: The Human Resource Director will monitor personnel records for the documentation of instruction in the use of the fire extinguisher and filing of the sign-off sheet for receiving fire extinguisher training along with employee on-site orientation.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 train staff to perform assigned tasks during emergencies upon staff employment in three of six personnel record, as required by regulation.
The findings include:
Six personnel records were reviewed on April 1, 2013. Five employees were hired since the last inspection. Per regulation, the residential facility shall train staff to perform assigned tasks during emergencies upon staff employment. The facility failed to document that this training was completed upon employment in employee records # 1, 4 and 6.
Employee # 1 was hired on February 19, 2013. Emergency training was due to be completed upon hire. The facility did not document the completion of the emergency training until February 28, 2013.
Employee #4 was hired on January 28, 2013. Emergency training was due to be completed upon hire. The facility failed to document that employee #4 received the required emergency training.
Employee # 6 was hired on February 4, 2013. Emergency training was due to be completed upon hire. The facility did not document the completion of the emergency training until February 28, 2013.
An interview with the facility director on April 1, 2013 confirmed the findings.
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Plan of Correction
Responsible:
The Training and Licensing Director in conjunction with Human Resource Director will be responsible to ensure staff on all shifts is trained to perform assigned tasks during emergencies.
The Training and Licensing Director will provide Disaster training to all new hires to be completed within 7 days of hire.
Time Frame: Employees #1 #4, and #6 will recieve training to perform assigned tasks during emergencies by the Licensing and Training Direcor by 5/30/13.
Monitoring: The Human Resource Director will monitor personnel records of new hires for the documentation of staff on all shifts are trained to perform assigned tasks during emergencies.
The Training and Licensing Director in conjunction with Human Resource Director will ensure the that existing employees that do not have the emergency training will be trained by May 30, 2013.
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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 administrative documentation and discussion with facility director, the facility failed to make available to the public an annual report within six months of the end of the facility's fiscal year June 30, 2012.
The findings include:
The facility presented documentation on April 1, 2013, that the public was notified of the annual report availability. The annual report was completed on January 8, 2013. It was required to have been posted by December 31, 2012. An interview with the facility director on April 3, 2013 confirmed the findings.
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Plan of Correction
Responsible: The Facility Director is responsible for ensuring that the annual report is made available to the publice within 6 months of the end of the fiscal year, June 30th.
Monitoring: The Facility Director will begin the process of making the annual report public by Dec 1st each year.
Time Frame: The annual report was made available to the public on January 8, 2013. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative documentation, the project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
The facility's administrative records were reviewed for documentation of an annual audit of financial activities associated with the project's drug/alcohol abuse services on April 1, 2013. The facility's fiscal year runs from July 1 to June 30. The facility failed to provide document an independent financial audit for the July 1, 2011 through June 31, 2012 fiscal year.
An interview with facility director on April 1, 2013 confirmed the findings.
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Plan of Correction
Responsible: The Chief Financial Officer (CFO) will be responsible to facilitate the financial statement audit process. An independent certified public accounting firm will be engaged by the project to complete the financial statement audit for the fiscal year end; June 30th.
Monitoring: The CFO will coordinate and monitor the process of obtaining the services of an independent certified public accounting firm to perform the financial statement audit for each fiscal year end.
Time Frame: The facility will obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol services no later than (6) months from the end of each fiscal year.
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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 provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in five of sixteen client records.
The findings include:
Sixteen client records were reviewed on April 2-3, 2013. Five of the sixteen client records were reviewed for psychosocial evaluations, #2, 5, 6, 7 and 8. Per the facility's policy, psychosocial evaluations will be completed within 30 days of the clients admission date.
The psychosocial evaluations in client records #6 and 8 did not include a composite picture of the client.
The psychosocial evaluations in client records #5, 6 and 8 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records #5, 6 and 8 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluations in client records #5, 6 and 8 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records #5, 6 and 8 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluations in client records # 6 and 8 did not include an evaluation of the client's attitude toward treatment and how they would impact treatment.
The psychosocial evaluations in client records #5, 6 and 8 did not include an evaluation of the counselor conclusions/impressions of the client.
Also, client records #2 and 7 did not have documentation of their psychosocial evaluation.
Client #2 was admitted on December 6, 2012. The psychosocial evaluation was due by January 6, 2013. As of the date of the licensing inspection there was no psychosocial evaluation in client record #2.
Client #7 was admitted on November 20, 2012. The psychosocial evaluation was due by December 20, 2012. As of the date of the licensing inspection there was no psychosocial evaluation in client record #7.
An interview with the facility director on April 3, 2013 confirmed the findings.
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Plan of Correction
Responsible Party: The Counselor of Record is responsible for completing a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client within 30 days of the admission date of each client.
Timeframe:
Records #2, 5, 6, 7 and 8 will have a completed Psycho Social Evaluation with all identified deficiencies corrected by 5/30/13.
The Clinical Supervisor is responsible for the review of all submitted bio psycho social evaluations to ensure completeness, and submission within 30 days of the client's admission date.
Monitoring: The Clinical Supervisor will review all new admission records to ensure that bio psycho social evaluations are completed fully and on time. This will be reviewed in bi-weekly supervision. |
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 the review of client records, the facility failed to documented treatment plans within the required time frame per the facility's policy in three of sixteen client records reviewed.
The findings include:
Sixteen client records were reviewed on April 2-3, 2013. Six of the sixteen were required to have documentation of a comprehensive treatment plan, #2, 5, 6, 7, 8 and 10. The facility's policy, states that the comprehensive treatment plan will be completed within 30 days of the client's admission date.
Client #2 was admitted on December 6, 2012. The comprehensive treatment plan was to be completed by January 6, 2013. Client #2's comprehensive treatment plan was completed on February 13, 2013.
Client #6 was admitted on November 30, 2012. The comprehensive treatment plan was to be completed by December 30, 2012. Client #6's comprehensive treatment plan was completed on January 17, 2013.
Client #7 was admitted on November 20, 2012. The comprehensive treatment plan was to be completed by December 20, 2012. Client #7's comprehensive treatment plan was not documented as of the date of the licensing inspection, April 1-2, 2013.
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Plan of Correction
Responsible Party: The Counselor of record is responsible for completing the Comprehensive treatment plan within 30 days of admission.
The Clinical Supervisor is responsible for reviewing status of completed treatment plans by the counselor.
Timeframe: Patient record #7 will be reviewed for the comprehensive tx plan. All outstanding treatment plans will be submitted by 5/15/2013.
Staff will be trained by 6/30/113 on the timeframes for the completion of Comprehensive treatment plans.
Monitoring: The Clinical Supervisor will review status of treatment plan submission bi weekly in the supervision process.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the review of client records, the facility failed to documented treatment plan updates within the required time frame per the facility's policy in three of sixteen client records reviewed.
The findings include:
Sixteen client records were reviewed on April 2-3, 2013. Six of the sixteen were required to have documentation of a treatment plan update, #1, 3, 4, 6 and 8. The facility's policy, states that the treatment plan updates will be updated every 60 days after the documentation of the clients comprehensive treatment plan.
Client #1 was admitted on February 3, 2012. The comprehensive treatment plan was documented on February 14, 2012. The last treatment plan update documented in client #1's record was dated December 12, 2012. The next treatment plan update was to be completed by February 12, 2013. As of the date of the licensing inspection there was no treatment plan update available for review after December, 2012.
Client #3 was admitted on March 23, 2012. The comprehensive treatment plan was documented on April 8, 2012. The last treatment plan update documented in client #3's record was dated January 30, 2013. The next treatment plan update was to be completed by March 30, 2013. As of the date of the licensing inspection there was no treatment plan update available for review after January 2013.
Client #4 was admitted on June 26, 2012. The comprehensive treatment plan was documented on June 26, 2012. The last treatment plan update documented in client #4's record was dated February 1, 2013. The next treatment plan update was to be completed by April 1, 2013. As of the date of the licensing inspection there was no treatment plan update available for review after February 2012.
An interview with the facility director on April 3, 2013 confirmed the findings.
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Plan of Correction
Responsible Party: The Counselor of record is responsible for completing all updated treatment plans every 60 days,following the comprehensive treatment plan.
The Clinical Supervisor is responsible for reviewing the status of completed treatment plans by the counselor.
Timeframe: Patient records #1, #3, and #4 will be reviewed for updated treatment and/or comprehensive treatment plans. All outstanding treatment plans will be submitted by 6/15/2013.
Staff will be trained by 6/30/13 on the timeframes for the completion of comprehensive and updated treatment plans.
Monitoring: The Clinical Supervisor will review status of treatment plan submission bi weekly in the supervision process.
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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 a case consultation in seven of sixteen client records.
The findings include:
Sixteen client records were reviewed on April 2-3, 2013. Eight of the sixteen were required to have documented a case consultation, # 1, 2, 3, 4, 6, 7, 8 and 9. Per the Standards case consultations are to be documented every 90 days then annually thereafter. During the review of the client records seven did not have documentation of case consultations, #1, 2, 3, 4, 6, 7 and 8.
Client #1 was admitted on February 3, 2012. The case consultation was to be documented by May 3, 2012, August 3, 2012, November 3, 2012 and February 3, 2012. As of the date of the licensing inspection April 1-2, 2013 there was no documentation of case consultations in record #1.
Client #2 was admitted on December 6, 2012. The case consultation was to be documented by March 6, 2013. As of the date of the licensing inspection April 1-2, 2013 there was no documentation of a case consultation in record #1.
Client #3 was admitted on March 23, 2012. The first case consultation was to be documented by June 23, 2012. The following months were not documented, September 22, 2012, December 22, 2012 and March 22, 2012 as of the date of the licensing inspection April 1-2, 2013 record #3.
Client #4 was admitted on June 26, 2012. The case consultation was to be documented by September 26, 2012, December 26, 2012 and March 26, 2013. As of the date of the licensing inspection April 1-2, 2013 there was no documentation of case consultations in record #4.
Client #6 was admitted on November 30, 2012. The case consultation was to be documented by February 30, 2012. As of the date of the licensing inspection April 1-2, 2013 there was no documentation of a case consultation in record #6.
Client #7 was admitted on November 20, 2012. The case consultation was to be documented by February 20, 2013. As of the date of the licensing inspection April 1-2, 2013 there was no documentation of case a consultation in record #7.
Client #8 was admitted on November 28, 2012. The case consultation was to be documented by February 28, 2013. As of the date of the licensing inspection April 1-2, 2013 there was no documentation of case a consultation in record #8.
An interview with the facility director on April 3, 2013 confirmed the findings.
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Plan of Correction
Responsible:
Clinical Counseling staff is responsible for ensuring the completion of a case consultation for each quarter within the patient's first year of treatment and annually thereafer.
Timeframe:
The Counselors of record who did not document a case consultation for patient Records #1, 2, 3, 4, 6, 7 and 8 will complete one by 5/30/13.
Clincial Staff will be trained by 6/30/13 on the timelines and content of the documnentation of a case consultation.
Monitoring:
The Clinical Supervisor will review status of the completion of case consulations with their resepctive counselors during the supervision process at least once per month.
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709.93(a)(9) 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:
(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 one of one client records.
The findings include:
Sixteen client records were reviewed on April 2-3, 2013. Per the facility policy, the counselor and client will complete an aftercare prior to discharge for successful completer's. An aftercare plan was required in one client record. The facility did not document an aftercare plan in client record # 12.
Client # 12 was admitted on May 30, 2012 and discharged on February 4, 2013. There was no documentation of an aftercare plan.
An interview with the facility director in April 3, 2013 confirmed the findings.
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Plan of Correction
Responsible Party: The Counselor of Record is responsible for ensuring that all persons, who we are aware, will be dishcarging from the treatment program, have a completed after care plan.
Timeframe: Patient Record #12 will be reviewed for after care plan, by 5/15/13.
Staff will be trained on the completion of an afer care plad by 6/30/13.
Monitoring: Clinical Supervisors will review all discharges to ensure the completion of an after care plan for those who we are aware, are transitioning from our treatment program.
After care plans will be reviewed in the clinical supervision process at least once per month.
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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 client record review, the facility failed to document a follow up attempt in three of seven discharge client records.
The findings include:
Sixteen client records were reviewed on April 2-3, 2013. Seven of the sixteen where required showing documentation of a follow-up attempt, 10, 11, 12, 13, 14, 15 and 16. The facility policy states that follow up will be attempted within seven days for referrals and within 30 days of the clients discharge date.
Client #11 was admitted on November 29, 2012 and discharged on January 24, 2013. There was no follow-up attempt documented in client record #11.
Client #12 was admitted on May 30, 2012 and discharged on February 4, 2013. There was no follow-up attempt documented in client record #12.
Client #13 was admitted on February 1, 2011 and discharged on February 6, 2013. There was no follow-up attempt documented in client record #13.
An interview with the facility director on April 3, 2013 confirmed the findings.
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Plan of Correction
The Counselor of record is responsible for ensuring that follow up is documented for each patient that is discharged from the treatment program by the 30th day of last service.
Timeframe:
Patient records 11, 12 and 13 will have outreach and follow up documented in the record by 5/15/13.
Monitoring: The Clinical Supervisor will review the status of all discharged patients and consequent follow up documentation with the counselor of record during supervision at least once per month.
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