INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 19- 22, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Insights, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on March 21, 2008.
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Plan of Correction
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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 the review of personnel and training records during the licensing inspection of February 19-22, 2008, the facility failed to document that all staff were trained in fire extinguisher use. Documentation was missing or incomplete in Employee records # 8 and 10.
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Plan of Correction
The policy will be revised to be more specific in terms of who is responsible to conduct the fire extinguisher instruction and review procedures and evacuation routes for an actual fire emergency. The person conducting these fire safety orientations will be the Assistant director at Lemoyne site and the facility Office Manager at the York facility. The policy will be revised by March 15th, 2008 by the Executive Director. This procedure revision will also require that whoever provides the instruction is responsible to make sure the document verifying this activity is signed and entered into their personnel file. The Executive Director will review this new policy with the facility Office Manager (York) and the Assistant Director (Lemoyne) by March 15th, 2008. |
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 the review of personnel and training records during the licensing inspection of February 19-22, 2008, the facility failed to document that all staff were trained to perform assigned tasks during emergencies. Personnel record # 10 was missing the required documentation.
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Plan of Correction
The policy will be revised to be more specific in terms of who is responsible to conduct the fire extinguisher instruction and review procedures and evacuation routes for an actual fire emergency. The person conducting these fire safety orientations will be the Assistant Director at Lemoyne site and the facility Office Manager at the York facility. The policy will be revised by March 15th, 2008 by the Executive Director. This procedure revision will also require that whoever provides the instruction is responsible to make sure the document verifying this activity is signed and entered into their personnel file. The Executive Director will review this new policy with the facility Office Manager (York) and the Assistant Director (Lemoyne) by March 15th, 2008. |
709.81(b)(5) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based on the review of client records during the licensing inspection of February 19-22, 2008, the facility failed to meet the requirements of its own policy regarding physical exams. The policy indicated that a physical examination had to be obtained prior to admission when no physical examination had been completed within the past year. There was no documentation of physical examinations found in client records # 4, 5, 6 and 9 ( 4 of 4 client records).
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Plan of Correction
The Executive director will thoroughly review the entire policy regarding this standard to assure that all the language infers a recommendation, not a requirement, for admission to both the outpatient and partial hospitalization programs. The Executive Director will distribute copies and review this revised policy at the regularly scheduled staff meetings: York, March 12th, 2008 and Lemoyne, March 19th, 2008 |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records during the onsite inspection of February 19-22, 2008, the facility failed to consistently document type and frequency of services on the treatment plan. Information on type and frequency was missing or incomplete in two of four client records reviewed (# 5, 9).
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Plan of Correction
The clinical supervisor will review with the counseling staff, at the staff meeting on April 16th, 2008 how to properly develop an individual treatment plan for all clients admitted for drug and alcohol counseling. This will include, but not be limited to, the level of treatment, the frequency of all individual sessions, and the frequency of all group sessions, if applicable to that client. The clinical supervisor or Executive Director will sign off on all initial and updated individual treatment plans to monitor for compliance. Those treatment plans that do not make note to the level of care and frequency of sessions will be returned to the counselor to rectify the deficiency. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on the review of client records during the licensing inspection of February 19-22, 2008, the facility failed to document treatment plan updates in one of one applicable client records reviewed ( #9).
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Plan of Correction
The clinical supervisor will review with the counseling staff, at the staff meeting on April 16, 2008, New Insights policies on the time frames for the development of the initial individualized treatment plan, and the time frames for updated treatment plans for clients in outpatient, intensive outpatient and partial hospitalization levels of care. One chart from each of the counseling staff will be randomly audited by the clinical supervisor, every other week during clinical supervision, to monitor for compliance. |
709.83(a)(5) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(5) Medication records.
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Observations
Based on the review of client records during the onsite inspection of February 19-22, 2008, the facility failed to consistently document complete medication histories. The medication information was incomplete in client record # 6 ( 1 of 2 applicable client records).
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Plan of Correction
The clinical supervisor will review with the counseling staff and the front office staff, at the staff meeting on April 30th, 2008, New Insights policy to have all clients who are presenting for their initial evaluation, to complete a medical history form. Each counselor is to review the completed medical history at the initial session and attempt to obtain from the client any missing data. This would include, but not be limited to all medication doses. If the client is unaware of any medication names or doses, the counselor will request that the client bring that information to their next session. One chart from each of the counseling staff will be randomly audited by the clinical supervisor, every other week during clinical supervision. to monitor for compliance. |
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 a review of client records during the onsite inspection of February 19-22, 2008, the facility failed to adhere to limitations imposed at 4 Pa. Code subsection 255.5(b). Information in client records # 4 and 5 was not clearly stated, or exceeded the limitations imposed by the regulation in the releases made to funding entities.
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Plan of Correction
The clinical supervisor will review with the clinical staff at the staff meeting on April 30, 2008 what specific information can be released by signed consent in accordance with Code subsection 255.5. In addition, those charts that were in violation with Code subsection 255.5 will be reviewed at the staff meeting, and more specific and appropriate wording for the purpose of release will be reviewed. The clinical supervisor will randomly review one of each clinician's charts every 2 weeks during clinical supervision, to monitor for compliance. |
709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based on the review of client records during the onsite inspection of February 19-22, 2008, the facility failed to meet the requirements of its own policy regarding physical exams. The policy indicated that a physical examination had to be obtained prior to admission if a physical examination was not completed within the past year. No documentation of physical examinations was found in client records # 1, 2, 3, 7 and 8 ( 5 of 5 records).
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Plan of Correction
The Executive Director will thoroughly review the entire policy regarding this standard, to assure that all the language infers a recommendation, not a requirement, for admission to both the outpatient and partial hospitalizaiton programs. The Executive Director will distribute copies and review this revised policy at the regularly scheduled staff meetings: York, March 12th, 2008 and Lemoyne, March 19th, 2008. |
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 during the onsite inspection of February 19-22, 2008, the facility failed to consistently document treatment plan updates within appropriate timeframes. Treatment plan updates were late or missing in two of four applicable client records (# 3 and 7).
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Plan of Correction
The clinical supervisor will review with the counseling staff, at the staff meeting on April 16th, 2008, New Insights policies on the time frames for the development of the initial individualized treatment plan, and the time frames for updated treatment plans for clients in outpatient, intensive outpatient, and partial hospitalization levels of care. One chart from each of the counseling staff will be randomly audited by the clinical supervisor, every other week during clinical supervision, to monitor for compliance. |
709.93(a)(7) 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:
(7) Client-related correspondence.
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Observations
Based on the review of client records during the onsite inspection of February 19-22, 2008, the facility failed to consistently document client related correspondence in client records # 1, 2, 3 and 7.
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Plan of Correction
The clinical supervisor will review with the counseling staff, at the staff meeting on April 30th, 2008, that all correspondence with collateral contacts (family members, probation officers, employers, attorneys, etc) must not only have the appropriate consent signed by the client, and the information being released is in accordance with Code subsection 255.5, but must also be documented in the progress note section of each chart. One chart from each of the counseling staff will be randomly audited by the clinical supervisor, every other week during clinical supervision, to monitor for compliance. |