INITIAL COMMENTS
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This report is a result of an on-site inspection to this newly licensed facility following the admittance of its first client. The inspection was conducted on June 7, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of this on-site inspection, Anthony Pater Counseling 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) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on the review of the facility policy manual and fire drill documentation, the facility failed to maintain a fire drill log which addressed the number of persons in the facility at the time of the drill, the exit route used, problems encountered or whether the fire alarm or smoke detector was activated.
The findings included:
A plan of correction follow up inspection was conducted on May 7, 2012. The fire drill log documentation provided for review included four fire drills -2/20/12, 3/20/12, 4/20/12 and 5/21/12. None of the fire drills included documentation of the number of persons in the facility at the time of the drill, the exit route used, problems encountered or whether the fire alarm or smoke detector was activated.
The findings were reviewed with the Project Director and were not disputed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 the review of client records, the facility failed to document a psychosocial evaluation in three of four client records and the psychosocial evaluation was incomplete in the fourth client record.
The findings include:
A Plan of Correction follow up inspection was conducted on June 7, 2012. Four client records were reviewed. There facility failed to include documentation of a psychosocial evaluation in three of four client records. One psychosocial evaluation was incomplete.
Client record # 1- The client was admitted on 3/20/12 and was last treated on 5/31/12. There was no documentation of psychosocial evaluation from a clinician at the facility as of May 7, 2012.
Client record # 2- The client was admitted on 2/20/12 and was last treated on 5/25/12. The psychosocial evaluation did not include the client's needs/problems; assets /strengths, support systems and the counselor's clinical impressions.
Client record # 3- The client was admitted on 2/23/12 and was last treated on 5/11/12. There was no documentation of psychosocial evaluation from a clinician at the facility as of May 7, 2012.
Client record # 4- The client was admitted on 2/20/12 and was last treated on 4/24/12. There was no documentation of psychosocial evaluation from a clinician at the facility as of May 7, 2012.
The findings were reviewed with the Project Director and were not disputed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to include documentation of support services on the client's treatment plan in four of four client records.
The findings include:
Four client records were reviewed during a plan of correction follow up inspection conducted on June 7, 2012. The facility failed to include documentation of support services on the treatment plans in four of four client records.
Client record # 1- The client was admitted on 3/20/12 and was last treated on 5/31/12. There was no documentation of support services on the treatment plan.
Client record # 2- The client was admitted on 2/20/12 and was last treated on 5/25/12. There was no documentation of support services on the treatment plan.
Client record # 3- The client was admitted on 2/23/12 and was last treated on 5/11/12. There was no documentation of support services on the treatment plan.
Client record # 4- The client was admitted on 2/20/12 and was last treated on 4/24/12. There was no documentation of support services on the treatment plan.
The findings were reviewed with the Project Director and were not disputed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 the review of client records, the facility failed to document an aftercare plan in one of one client record.
The findings included:
A Plan of Correction follow up inspection was conducted on June 6, 2012. Four client records were reviewed. One client had been successfully discharged and was required to have documentation of an after care plan. Written facility policy indicated that the aftercare plan was to be formulated by the client and the counselor and the client would then review the plan.
Record # 3- The client was admitted on 2/23/12 and discharged on 5/11/12. Documentation in the record stated that the client was a successful discharge. There was no documentation of an after care plan in the client record.
The findings were reviewed with the Project Director and were not disputed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |