INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 17-19, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Parkside Recovery 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 December 23, 2008.
|
Plan of Correction
|
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
|
Observations
Based on a review of personnel records, the facility failed to ensure that clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services completed a core curriculum in clinical supervision provided by the Department or approved by the Department.
Findings:
Twenty-one personnel records were reviewed on November 17-19, 2008. Two staff were required to complete the core curriculum in clinical supervision. The facility did not document the core curriculum in clinical supervision in personnel records # 11 and 12.
|
Plan of Correction
All clinical Supervisors who have not functioned as a Clinical supervisor for two years will complete the Core Curriculum in clinical supervision. The Program Director will see that supervisors receive the training scheduled for April 20- 24, 2009. |
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.
|
Observations
Based on an inspection of the facility ' s physical plant, the facility failed to maintain hot water below 120 degrees.
Findings:
A physical plant inspection was conducted on November 19, 2008. The facility was required to maintain hot water below 120 degrees. The hot water in the staff bathroom was 136 degrees.
|
Plan of Correction
The Program Facilities manager will contact NHS facilities and put in a work order to have them come and adjust all bathroom hot water temperatures to 120 degrees. This will be done immediately. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a review of the facility ' s fire drill log, the facility failed to document alternate exit routes to be used during fire drills.
Findings:
The facility ' s fire drill log was reviewed on November 17-19, 2008. The facility was required to document alternate exit routes to be used during fire drills. The facility documented all exits were used during each fire drill.
|
Plan of Correction
The fire drills will be done using alternate routes and the fire drill log book will document the drills correctly. The Security Supervisor will be responsible for seeing that this is done. The Safety and Risk chairman will check the log and ensure the drills are being done correctly as well as documented correctly on the log. |
709.28(c) 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:
|
Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent for the disclosure of client information in ten of sixteen client records.
Findings:
Twenty-five client records were reviewed on November 17-19, 2008. Informed and voluntary consent from the client for the disclosure of information was required in 16 client records.
The facility did not document the client ' s right to verbally revoke voluntary consent for the release of information in client records # 1, 2, 3, 4, 5, 7, 9, 10, 11 and 24. The facility documented that the client must revoke the consent for the disclosure of information in writing.
|
Plan of Correction
The consent forms have been revised to show the client has the right to verbally revoke voluntary consent of release of information. Intake staff will begin to use these forms immediately. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
|
Observations
Based on a review of client records, the facility failed to document drug and alcohol histories in five of fifteen client records.
Findings:
Twenty-five client records were reviewed on November 17-19, 2008. Drug and alcohol histories were required in fifteen client records. The facility did not document drug and alcohol histories in client records # 2, 6, 8, 9 and 13.
|
Plan of Correction
Intake specialist and counselors will be trained on how to correctly document the drug and alcohol questions asked on the histories. This training will be done by the Program Director. The Clinical Supervisor during supervision will review the histories as part of the chart audit process and provide on going review to staff that needs it. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
Based on a review of client records, the facility failed to document personal histories in five of fifteen client records.
Findings:
Twenty-five client records were reviewed on November 17-19, 2008. Personal histories were required in fifteen client records. The facility did not document the client's personal histories in client records # 2, 6, 8, 9 and 13.
|
Plan of Correction
The Intake Supervisor will re-train the Intake Specialist on how to complete histories which include personal information on the client. The files noted in the findings will be used as a point of reference for the training. The Intake supervisor who audits all intake charts will be responsible for ensuring the histories are completed during admission . |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to document psychosocial evaluations in five of fifteen client records.
Findings:
Twenty-five client records were reviewed on November 17-19, 2008. Psychosocial evaluations were required in fifteen client records. The facility did not document psychosocial evaluations in client records # 2, 6, 8, 9 and 13.
|
Plan of Correction
Training will be conducted with all counselors to teach and review with them how to complete an evaluation after they have completed the psychosocial history. This training will be done by the Program Director. The Clinical Supervisor will provide on going support in supervision for counselors who need further assistance. |
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.
|
Observations
Based on a review of client records, the facility failed to document treatment and rehabilitation plans to include proposed type of supportive services in eight of twelve client records.
Findings
Twenty-five client records were reviewed on November 17-19, 2008. Treatment and rehabilitation plans with proposed type of supportive services were required in twelve client records. The facility did not document treatment and rehabilitation plans with proposed type of supportive services in client records # 1, 3, 6, 7, 9, 10, 14 and 15.
|
Plan of Correction
Training will be done to teach and discuss with all counselors how and when a treatment and rehabilitative plan should be done, what the plan should include and how to document the information. The Program Director will conduct this training. Clinical Supervisors are responsible for ensuring rehabilitative plans are completed and documented in the medical record of the clients. A review of support services available to clients and referral agencies we partner with will also be discussed. |
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.
|
Observations
Based on a review of client records, the facility failed to document case consultation notes at least quarterly in four of eight client records.
Findings:
Twenty-five client records were reviewed on November 17-19, 2008. Case consultation notes were required in eight client records. The facility did not document case consultation notes at least quarterly in client records # 7, 11, 12 and 13.
|
Plan of Correction
Clinical Supervisors has received training on the use of their Chart and Audit Grid. This Grid alerts both the counselor and the supervisor when the case consultation is due. Case consultations will be documents per regulation on a quarterly basis for the first year from admission of the client. The Assistant Program Director will monitor the grid during the clinical supervisor's supervision session to ensure the case consults are being done. |
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.
|
Observations
Based on a review of client records, the facility failed to document a complete aftercare plan in two of two client records.
Findings:
Twenty-five client records were reviewed on November 17-19, 2008. Aftercare plans were required in two client records. The facility did not document an aftercare plan in client records # 17 and 25.
|
Plan of Correction
Training on what constitutes a complete record on a client which includes when an aftercare plan should be done will be done. This training will be done by the Program Director. Clinical Supervisors will be responsible for ensuring the after care is in the medical records of those clients who should have one in their record. |
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.
|
Observations
Based on a review of client records, the facility failed to document follow-up information in four of eight client records.
Findings:
Twenty-five client records were reviewed on November 17-19, 2008. Follow-up information was required in eight client records. The facility did not document follow-up information in client records # 21, 22, 23 and 25.
|
Plan of Correction
Follow up will be done on each client within 30 days of the client leaving treatment. The Clinical Supervisor is responsible for seeing that a letter is mailed. A copy of the letter with the date will be put in the file. The Clinical Supervisor is responsible for ensuring this is done when they audit a closed chart. A review of this process will take place in the next clinical supervisor's supervision meeting. |