INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 17, 2019 through December 18, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, Monroe County Counseling Services 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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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
The facility failed to provide documentation of an individual training plan for the current training year reviewed for employee #1, who was hired as the project director/facility director/counselor on February 1, 2017.These findings were reviewed with facility staff during the licensing process
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Plan of Correction
The Project Director completed an individual training plan on December 19th, 2019 for the current and upcoming year for employee #1. The plan includes an alert mechanism to ensure training is tracked in a timely manner. This plan was incorporated into employee #1's Personnel Record. |
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
The facility failed to ensure that employee #1, the project director/facility director/counselor hired on February 1, 2017, received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe, based on a review of the facility's Staffing Requirement Facility Report and the employee's personnel file.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project Director set up a Training schedule with appropriate time frames and alerts to ensure that he makes best efforts to obtain the minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training for employee #1. To this end, The Project Director contacted the SCA, and will work with the Behavioral Health Training and Education Network, the DDAP Training system to ensure Training is completed by May 30th, 2020 or sooner depending on the training availability/schedules of the available online or other Program schedules by "ORGANIZATIONS DEEMED TO PROVIDE INDEPENDENT TRAINING. . . REQUIREMENTS OF 28 PA. CODE § 704.11." |
705.24 (1) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(1) Provide bathrooms to accommodate staff, clients and other users of the facility.
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Observations
The facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times, as evidenced by the following:1. The facility was currently renovating the co-ed client bathroom on the second day of the inspection and an out-of-service sign was placed on the bathroom door. The other available bathroom wihtin the facility was in poor shape as the ceilings in both client bathrooms were caving in, which allowed individuals to visibly see the pipework as well as insulation. 2. The director indicated that because of the renovations in both client bathroom's, all clients would use the staff bathroom, located in the group counseling room. However, there was no hot water pressure or soap available in the staff bathroom.3. The client bathrooms had ceiling tiles that were missing and contained multiple holes in it, two holes which enabled outside visual access. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. The Facility landlord made some major repairs regarding one of the three Restrooms at this facility. He has committed to completing all work by January 28th, 2020. The Project Director will track renovation/repair work to ensure that work is satisfactorily completed.
2. In the meantime, clients have been using the restroom in the Client Meeting Room which has always been available to them and meets the 705.24 standards. The hot water pressure was immediately corrected and soap provided on Dec. 19.2019.
3. One of the Facility bathrooms was "closed" until repairs are completed. The other facility restroom is being used by other Tenants at this facility. Nevertheless, the Facility landlord has committed to make the appropriate improvements for all tenants and our clients to use if necessary. As noted above, clients have been using the restroom in the Client Meeting Room which meets the 705.24 standards.
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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
The facility failed to ensure that all heaters were permanently mounted or installed as a space heater was discovered in the group session room. This was discoverd during the physical plant inspection of the facility.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
There has never been any problems with the HVAC system at this facility. The Project Director kept a space heater for efficiency and personal use when he is in the Director's office alone. Briefly, the portable space heater is more efficient than turning on the entire heating system for a large room or the Director's office. Nevertheless, the space heater will no longer be used. It was removed by the Project Director on 12/19/19. |
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
The facility failed to conduct unannounced fire drills as it was reported by the director that clients were informed prior to when all the 2019 fire drills occurred. Additionally, the facility failed to properly document all of the required components in the January through December 2019 fire drill logs. The amount of time it took to evacuate the facility was missing from the January through November 2019 logs. The August 2019 fire drill was missing the date of the drill. Both October 2019 and November 2019 fire drill logs were missing documentation on if there were any problems encountered.Also, the facility failed to conduct fire drills during different times of the day and on different staffing shifts as the director reported that all fire drills would take place on Tuesdays, Thursdays, and Saturdays, generally around the same times of 6:50pm, 11:20ma, and 9:50am.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director updated the Fire Drill project policies and procedures on 12/20/19 consistent with 705.28 (d) (4) to ensure that all elements are covered in future Fire Drills.
The Fire Drill log was updated by the project Director on 12/20/19 and now includes all of the components under 705.28(d) (4).
Effective immediately, the Project Director will ensure that Fire Drills will be conducted on different days without prior notification to clients and other facility staff.
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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
The facility failed to document that the project director had prepared, annually updated and signed the facility's written manual, which delineates the project policies and procedures. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director signed the Agency's policies and procedures Manual on 12/22/19. The Project Director will continue to carefully review its written Manual vis a vis DDAP regulations, DDAP Alerts, etc. to ensure that its Manual is consistent with all current regulations and standards and incorporate any changes into said Manual. |
709.24 (a) (2) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(2) Identification of the treatment models and practices utilized by the project.
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Observations
The facility failed to document which treatment models and practices that were going to be utilized by facility staff. This is to be documented as part of the written plan for treatment and rehabilitation management in the facility's policy and procedure manual.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The MCCS Policy & Procedures Manual was immediately revised to specifically indicate that Cognitive Behavioral Therapy (CBT) is the primary treatment model used by the agency. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
The facility failed to document the time frames in which specific treatment and rehabilitation services are to be completed and by whom. This is to be documented as part of the written plan for treatment and rehabilitation management in the facility ' s policy and procedure manual.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The MCCS Policy & Procedures Manual was immediately revised by the Project Director to clearly indicate specific treatment and rehabilitation services by Levels of Care and type (individual or group), clients and responsible coordinating staff. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
The facility failed to provide documentation of an annual financial audit of the activities associated with the project's drug and alcohol abuse services for the project's prior fiscal year.These findings were discussed with facility staff during the licensing process.
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Plan of Correction
To correct this deficiency, the Project Director will submit paperwork for financial exception consistent with DDAP Licensure Licensing Alert 01-11. This exception will be completed after Project Director meets with current agency auditor on January 29th,2020. All current financial statements and the exception paperwork submitted to DDAP Licensure will be available for DDAP personnel at their next site visit. |
709.28 (a) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
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Observations
The facility failed to document, as part of the policy and procedure manual, a written confidentiality policy and procedure that discusses and complies with 4 PA Code 255.5.These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The MCCS Policy & Procedures Manual was immediately revised by the Project Director that addresses and complies with 4 PA Code 255.5. Additionally, a new Release of Information was executed that excludes all references that exceed PA Code 255.5 limits. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
The facility failed to document and address, as part of the policy and procedure manual, specific procedures on how the project plans to address the security and release of paper and electronic client records. The procedure should include who is responsible for the maintenance of the client records.These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project Director immediately updated the Agency's Policies and Procedures Manual to clearly specific procedures on how the project plans to address the security and release of paper and electronic client records. The revised procedure includes specific staff responsible for the maintenance of the client records. |
709.28 (a) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(2) Identification of project staff having access to records, and the methods by which staff gain access.
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Observations
The facility failed to address and identify the project staff that would have access to client records and how that staff would have access to the records, as part of the facility's policy and procedure manual.These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project Director immediately revised the Agency Policies and Procedures Manual to clearly specify what project staff would have access to client records and how that staff would have access to the client records. |
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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to ensure that all informed and voluntary consent to release information forms were kept within the guidelines of 4 PA code 255.5 in five of seven records reviewed. Client #1 was admitted on October 29, 2019 and was active at the time of the inspection. There was a consent to release information form to the probation office and court house, signed and dated on October 29, 2019, that allowed for the release of the D/A assessment, which exceeded 255.5.Client #2 was admitted on October 26, 2019 and was active at the time of the inspection. There was a consent to release information form to the probation office and court house, signed and dated on October 26, 2019, that allowed for the release of the full D/A assessment, which exceeded 255.5.Client #3 was admitted on October 17, 2019 and was active at the time of the inspection. There was a consent to release information form to the probation office and court house, signed and dated on October 17, 2019, that allowed for the release of the D/A assessment, which exceeded 255.5.Client #6 was admitted on April 12, 2019 and was discharged on May 12, 2019. There was a consent to release information form to the probation office and court house, signed and dated on April 12, 2019, that allowed for the release of the D/A assessment, which exceeded 255.5.Client #7 was admitted on January 19, 2019 and was discharged on March 19, 2019. There was a consent to release information form to the probation office and court house, signed and dated on January 19, 2019, that allowed for the release of the treatment discharge status, which exceeded 255.5.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director can attest to the fact that the agency has never released a full D/A assessment. That is not the intent of this Consent Release. The Project Director immediately revised the language on the said Consent to Release information Form to read: "The Court and/or Probation will be notified that Client completed a full D/A Assessment" in order to satisfy the Monroe County Court who mandates that DUI clients complete a full D/A assessment before sentencing. An annotation was made to the Consent to Release for Client #1.
See above response regarding "full D/A assessment. An annotation was made to the Consent to Release for Client #2.
See above response regarding "full D/A assessment. An annotation was made to the Consent to Release for Client #3.
See above response regarding "full D/A assessment. An annotation was made to the Consent to Release for Client #6
The Consent to Release was outdated and an annotation was made to Client 7 record. The Project Director immediately made annotation to Client #7 record.
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709.28 (c) (5) 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 must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
The facility failed to document a valid witness signature/date in one of seven client records reviewed. Client #3 was admitted on October 17, 2019 and was active at the time of the inspection. There was a consent to release information form to the probation office and court house, signed and dated on October 17, 2019 by the client; however, the form was not signed and dated by a witness.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project Director corrected this oversight immediately by adding his signature as witness to Consent. |
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 record.
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Observations
The facility failed to provide documentation that a copy of a consent to release information form was offered to the client in four of seven client records reviewed. Client #1 was admitted on October 29, 2019 and was active at the time of the inspection. The consent to release information form was to the probation office and court house, signed and dated on October 29, 2019.Client #2 was admitted on October 26, 2019 and was active at the time of the inspection. The consent to release information form was to the probation office and court house, signed and dated on October 26, 2019.Client #4 was admitted on April 18, 2019 and was discharged on June 18, 2019. The consent to release information form was to the probation office and court house, signed and dated on April 18, 2019.Client #7 was admitted on January 19, 2019 and was discharged on March 19, 2019. The consent to release information form was to the probation office and court house, signed and dated on January 19, 2019.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All clients are offered copies of all consent to release information. This oversight was corrected by obtaining the signature of the Client #1 and Client #2 on 12/20.
As noted above, all clients are offered copies of their Consent to Release information form. The Project Director made annotations to this effect to Client Record # 4 and Client #7. The Project Director will immediately take steps to avoid this kind of paperwork error in the future. |
709.29 (a) LICENSURE Retention of client records
§ 709.29. Retention of client records.
(a) Client records, regardless of format, shall be readily accessible for a minimum of 4 years following the discharge of a client.
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Observations
The facility failed to document and address, as part of the policy and procedure manual, how long the facility would retain client records after the discharge of a client.These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Agency Policies and Procedures Manual was carefully reviewed and revised by the Project Director on January 19. The updated Manual clearly outlines how long the facility will retain client records after the discharge of a client. The manual will be available on next site visit or upon request. |
709.32 (c) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
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Observations
The facility failed to document, address, and implement policies and procedures regarding the facility ' s medication use by clients, which is to include the administration, storage, and dispensing of all medications.These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Agency Policies and Procedures Manual was carefully reviewed and revised by the Project Director on January 19. The updated Manual clearly outlines the Agency's policy and procedures regarding the facility's medication use by clients. The Manual will be available on next site visit or upon request. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
The facility failed to document in their policy and procedure manual, an unusual incident policy and procedure on how the facility would respond to a physical assault or sexual assault by a staff member or a client.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Agency Policies and Procedures Manual was carefully reviewed and revised by the Project Director on January 19. The updated Manual clearly outlines how the facility would respond to a physical assault by a staff member or client.The Manual will be available on next site visit or upon request. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
The facility failed to document in their policy and procedure manual, an unusual incident policy and procedure on how the facility would respond to the selling or use of illicit drugs on the premises of the facility.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Agency Policies and Procedures Manual was carefully reviewed and revised by the Project Director on January 19. The updated Manual clearly outlines how the facility would respond to the selling or use of illicit drugs on the premises of the facility. The Manual will be available on next site visit or upon request. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
The facility failed to document in their policy and procedure manual, an unusual incident policy and procedure on how the facility would respond to a death or serious injury when known by the facility.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Agency Policies and Procedures Manual was carefully reviewed and revised by the Project Director on January 19, 2020. The updated Manual clearly outlines how the facility would respond to a death or serious injury when known by the facility. The Manual will be available on next site visit or upon request. |
709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
The facility failed to document in their policy and procedure manual, an unusual incident policy and procedure on how the facility would respond to a significant disruption of services due to a variety of disasters that would close the facility for more than 1 day.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Agency Policies and Procedures Manual was carefully reviewed and revised by the Project Director on January 19, 2020. The updated Manual clearly outlines how the facility would respond to a significant disruption of services due to a variety of disasters that would close the facility for more than one day.The Manual will be available on next site visit or upon request. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
The facility failed to document in their policy and procedure manual, an unusual incident policy and procedure on how the facility would respond to a theft, burglar, break-in, or similar incident at the facility.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Agency Policies and Procedures Manual was carefully reviewed and revised by the Project Director on January 19. The updated Manual clearly outlines how the facility would respond to a theft, burglar, break-in, or similar incident at the facility.The Manual will be available on next site visit or upon request. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to document in their policy and procedure manual, an unusual incident policy and procedure on how the facility would respond to any event at the facility that would require the presence of police, fire, or ambulance personnel.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Agency Policies and Procedures Manual was carefully reviewed and revised by the Project Director on January 19. The updated Manual clearly outlines how the facility would respond to any event at the facility that would require the presence of police, fire, or ambulance personnel. This kind of incident and its reporting and documentation will be documented by the appropriate staff and fully reported/executed by the Project Director in a timely manner. The Manual will be available on next site visit or upon request. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
The facility failed to document in their policy and procedure manual, an unusual incident policy and procedure on how the facility would respond to the fire or structural damage of the facility.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Agency Policies and Procedures Manual was carefully reviewed and revised by the Project Director on January 19, 2020. The updated Manual clearly outlines how the facility would respond to the fire or structural damage of the facility. The Manual will be available on next site visit or upon request. |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
The facility failed to document in their policy and procedure manual, an unusual incident policy and procedure on how the facility would respond to an outbreak of a contagious disease that would result in notifying the CDC.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Agency Policies and Procedures Manual was carefully reviewed and revised by the Project Director on January 19. The updated Manual clearly outlines how the facility would respond to an outbreak of a contagious disease that would result in notifying the CDC. This kind of incident and its reporting and documentation will be documented by the appropriate staff and fully reported/executed by the Project Director in a timely manner. The Manual will be available on next site visit or upon request. |
709.34 (b) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(1) Documentation of the unusual incident.
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Observations
The facility failed to document in their policy and procedure manual, an unusual incident policy and procedure on how the facility would document an unusual incident. The procedure should include who is responsible and identifying the timeframes for completion. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Agency Policies and Procedures Manual was carefully reviewed and revised by the Project Director on January 19. The updated Manual clearly outlines how the facility would document an unusual incident. All unusual incidents will be documented by the appropriate staff and fully executed by the Project Director in a timely manner. The Manual will be available on next site visit or upon request. |
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
The facility failed to document in their policy and procedure manual, an unusual incident policy and procedure on how the facility would promptly review and identify the causes responsible for the incident, both directly and indirectly. The procedure should include who is responsible and identifying the timeframes for completion.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Agency Policies and Procedures Manual was carefully reviewed and revised by the Project Director on January 19. The updated Manual clearly outlines how the facility would promptly review and identify the causes responsible for the incident, both directly and indirectly. This kind of incident and its reporting and documentation will be documented by the Project Director within five days of the incident and/or as soon as possible by the Project Director.The Manual will be available on next site visit or upon request. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
The facility failed to document in their policy and procedure manual, an unusual incident policy and procedure on how the facility would implement a timely and appropriate corrective action plan. The procedure should include who is responsible and identifying the timeframes for completion.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Agency Policies and Procedures Manual was carefully reviewed and revised by the Project Director on January 19. The updated Manual clearly outlines how the facility would promptly review and develop an appropriate corrective action plan to avoid or prevent future (similar) incidents. All corrective action plans would involve the appropriate staff and the Project Director. The corrective action plan would be implemented within five days of the incident and/or as soon as possible by the Project Director.The Manual delineating the above will be available on next site visit or upon request. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
The facility failed to document in their policy and procedure manual, an unusual incident policy and procedure on how the facility would be responsible for the continued and ongoing monitoring of the corrective action plan. The procedure should include who is responsible and identifying the timeframes for completion.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Agency Policies and Procedures Manual was carefully reviewed and revised by the Project Director on January 19. The updated Manual clearly outlines that the Project Director would be monitoring all incident corrective action plans on an ongoing basis. All corrective action plans would be implemented within five days of the incident and/or as soon as possible with Project Director supervision.The Manual delineating the above will be available on next site visit or upon request. |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
The facility failed to document in their policy and procedure manual, an unusual incident policy and procedure on the reporting mechanism the facility would utilize to report to any entity in order to ensure compliance with State and Federal confidentiality laws. The procedure should include who is responsible for reporting, the mechanism, and the timeframes for completion.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Agency Policies and Procedures Manual was carefully reviewed and revised by the Project Director on January 19. The updated Manual clearly outlines that the Project Director would be involved in the reporting mechanism the Agency will use in reporting "confidentially documented" incidents to outside entities in order to ensure compliance with State and Federal confidentiality laws. Incident reports will be reported and documented as expeditiously as possible.
The Manual delineating the above will be available on next site visit or upon request. |
709.91(a)(2) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(2) Treatment methodology.
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Observations
The facility failed to develop, within their intake and admission written plan, which type of treatment methods the facility staff would utilize as well as what requirements a client must meet in order for them to complete treatment. This was discovered based on the review of the facility's policy and procedure manual during the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Agency Policies and Procedures Manual was carefully reviewed and revised by the Project Director on January 19. The updated Manual clearly outlines the treatment methods the facility staff would utilize as well as what requirements a client must meet in order for them to complete treatment. The Manual delineating the above will be available on next site visit or upon request. |
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
The facility failed to provide follow-up information, after discharge, in the client's complete record in four of seven client records reviewed.Client #4 was admitted on April 18, 2019 and was discharged on June 18, 2019.Client #5 was admitted on January 26, 2019 and was discharged on March 26, 2019.Client #6 was admitted on April 12, 2019 and was discharged on May 12, 2019.Client #7 was admitted on January 19, 2019 and was discharged on March 19, 2019.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director was able immediately to rectify this situation immediately by implementing its policies and procedures on " Client follow-up," with Client #4, Client #5, Client#6 and Client #7 by mail. The client records were updated to reflect same. Some of the information requested included, but was not limited to the following:
1) Client's progress since discharge
2) Problem areas with which the client may need help and the development of strategies for resolving these problems.
3) Assurance to the client that the program stands ready to render services at any time they may be needed.
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