INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 24, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Holcomb Associates, 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:
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Plan of Correction
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection the facility failed to prohibit facility heaters that are not permanently or installed.
The findings include:
A physical plant inspection was conducted on March 25, 2015 at approximately 3:30 pm. A space heater was observed in a counseling office, specifically counseling office #2.
The findings were reviewed with staff during the licensing process.
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Plan of Correction
The facility has reviewed the Holcomb policy which prohibits all heaters which are not permanent or installed with all facility staff. This review occurred on 3/26/15. The space heater found on March 25, 2015 was removed from the facility on March 25, 2015. Space heaters will not be permitted on the premises. Facility Director will conduct random checks each month to monitor this action item and ensure this deficiency does not recur. |
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 a review of administrative documentation, the project failed to make the annual report available to the public.
The findings include:
Based on a review of administrative documentation, the project failed to provide verification that an annual report has been made available to the public.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project Director obtain copy of notice which announced Annual Report was available. Project Director to obtain copy within 30 days. Moving forward, Chief Compliance Officer will complete the Project's Annual Report and make available to public via submitting post to newspaper or announcing via Holcomb website. Project Director will ensure that proof of publication of the announcement of the Annual Report will be obtained via securing copy of the announcement. Facility Director has set up "tickler system" so that Facility Director receives a reminder each year to prompt the procedure of posting and obtaining copy of the announcement. This new tickler system will prevent the deficiency from recurring. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in two of two client records.
The findings include:
Seven client records were reviewed on March 24, 2015. Four of the client records reviewed were that of discharged clients. Two of the discharged clients were involuntarily terminated from treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client record #5 and #7.
Client #5 was admitted into treatment on 6/20/14 and was involuntarily terminated from the facility on 2/2/15. There was no documentation of written notification provided to the client as of the date of the licensing inspection.
Client #7 was admitted into treatment on 7/14/14 and was involuntarily terminated from the facility on 12/31/14. There was no documentation of written notification provided to the client as of the date of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has revised its discharge procedures and has added a discharge notification letter to the discharge process. Effective immediately, all clients who are being discharged involuntarily will be notified via the discharge letter. The discharge letter will include date of discharge and facility contact information so the client can re-engage in treatment when ready. All staff were notified of this change in during a staff meeting which took place on 03/26/2015. New procedure was reviewed with all staff and all staff acknowledged understanding. Clinical Supervisors are now monitoring all involuntary termination discharges to ensure a copy of the letter is included in the discharge packet as proof it was sent. Should Clinical Supervisors see the letter was not created or sent, they will review with individual staff person during clinical supervision and ensure letter is sent. If problem persists and specific staff are not sending the letter, and Corrective Action will ensure with the staff person. Facility Director will monitor overall completion of this procedure via random chart reviews. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in two of seven client records reviewed.
The findings include:
Seven client records were reviewed on March 24, 2015. The facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in records, #1 and 2.
Client #1 was admitted into treatment on 11/12/14 and was still active at the time of the licensing inspection. Client #1's treatment plan dated 12/12/14 stated that the client was to receive an individual counseling session once a week. Client #1's last counseling session occurred on 2/4/15. Client #1's next individual counseling session was scheduled for 3/5/15.
Client #2 was admitted into treatment on 9/17/14 and was still active at the time of the licensing inspection. Client #2's treatment plan dated 11/10/14 stated that the client was to receive individual counseling sessions once week. Additionally, the client's treatment plan updates dated 11/17/14, 1/7/15, and 3/6/15 state the client was to receive individual counseling sessions once a week. Client #2 received individual counseling sessions on the following dates: 3/18/15, 3/11/15, 2/11/15, 2/4/15, 1/28/15, 12/30/14, 12/26/14, 11/10/14, 11/5/14, 10/29/14, 10/22/14, 10/15/14, 10/10/14, 10/1/14, 9/29/14, and 9/25/14. Client #2 did not have scheduled individual counseling sessions between 11/10/14 and 12/26/14.
The findings were reviewed with staff during the licensing process.
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Plan of Correction
This particular deficiency occurred due to a brief lapse in treatment for the client. All staff attended a group supervision/staff meeting on 3/26/15 and the requirement to have the treatment plan recommended frequency match actual frequency of scheduled session was reviewed. All staff acknowledged understanding. Facility Director and Clinical Supervisors have revised the scheduling procedure and will now schedule out all future therapy sessions as per the treatment plan so that schedule frequency matches treatment plan. Should a client need to cease services for a short period, the change in frequency along with the date will be documented on the treatment plan and then scheduled accordingly. Change in procedure will be monitored during weekly clinical supervision by Clinical Supervisors. Charts will be reviewed to ensure sessions are being scheduled as per the treatment plan. Should staff struggle in this area, more intensive individual supervision will occur and result in Corrective Action should the staff not follow new procedure. Facility Director will monitor overall abidance by conducting random chart reviews. |