INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on September 28-29, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated on-site inspection, Cove Forge Behavioral Health System at Williamsburg 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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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to keep the facility in good repair at all times as evidenced by the following, 1. The bathroom outside of room 10 in Acceptance building had a cracked bathtub/shower. 2. The light covers in room 3 and 6 in Acceptance building were broken. 3. Room 8 and 11 in Acceptance building had paint chipping off the walls that plywood/drywall was visible. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
1. The bathtub/shower has been ordered and we are waiting for it to come in. It will be installed as soon as it arrives. Completion date 12/15/20 in case there are delays with shipment.
2. The light covers were repaired on October 2, 2020.
3. Rooms 8 and 11 in Acceptance will be painted by 12/15/20.
Managers who conduct weekly leadership rounds will be made aware of the aforementioned findings. The CEO will educate them on the importance of looking for chipped paint, cracks and broken light covers during their rounding week.
Leadership round reports will be handed in to the operations director on a weekly basis and reviewed by him. Items that need repaired will be handed in to the director of maintenance. |
705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
Based on a physical plant inspection, the facility failed to ensure that each porch a well secured railing as evidenced by the following, 1. The banister outside of Challenge building had board rot that exposed rusty rails and was no longer secure. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The banister was replaced on October 9, 2020.
Managers who conduct weekly leadership rounds will be made aware of the aforementioned finding. The CEO will educate them on the importance of looking for faulty or non-secure banisters/railings during their rounding week.
Leadership round reports will be handed in to the operations director on a weekly basis and reviewed by him. Items that need repaired will be handed in to the director of maintenance. |
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
Based on a review of 21 client records, the facility failed to keep all releases for all 21 records for the Single County Authority (SCA) within the limits of 255.5. These releases all included the release of case consults, biopsychosocial, continuing care plan and nursing assessment. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Health Information Manage will re-educate all departments who obtain SCA consents (admissions, intake, clinical) on the limits of 255.5 and what can be released to the SCA.
The Health Information Manager will created a "cheat sheet"/educational tool as a reference for staff to utilize when in question.
The Health Information Manager/designee will review 10 charts for the next 4 months to ensure SCA consents are being completed correctly. |
709.32 (c) (2) 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:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
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Observations
Based on a physical plant inspection of the medication rooms, the facility failed to ensure the secure storage of controlled substances in accordance with state and federal regulations and program requirements as evidence by the following, 1. The medication cart in detox A contains a broken Narc box that can be opened without a key. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The medication cart has been fixed and the narcotic box now locks and a key must be used to open it.
Moving forward, the charge nurse will be responsible for informing the DON/ADON immediately if the lock should break again or if there are deficiencies with the cart.
The DON/ADON will be responsible for fixing the cart or requesting a new cart within 48 hours of finding out the cart is deficient in any way. |
709.82(c) LICENSURE Treatment and rehabilitation services
709.82. 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 clients received services according to the individual training plan.Client #8 was admitted on July 31, 2020 and was still active at the time of the inspection. The comprehensive treatment plan, August 5, 2020, indicated seven group sessions per week and two individual session per week. The record of service and progress notes indicated that the client had received three group session the week of August 30, 2020, four groups the week of September 6, 2020 and only individual session a week for the entire month of August 2020.Client #9 was admitted on August 3, 2020 and was still active at the time of the inspection. The comprehensive treatment plan, August 5, 2020, indicated five group sessions per week and two individual session per week. The record of service and progress notes indicated that the client received two groups the week of August 23, 2020 and only one individual session the week of August 3, 2020 and August 16th, 2020. Client #10 was admitted on August 20, 2020 and was still active at the time of the inspection. The comprehensive treatment plan, August 27, 2020, indicated five group sessions per week and two individual session per week. The record of service and progress notes indicated that the client received two group session the week of September 6, 2020 and no individual sessions the week of August 30, 2020. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The PHP clinical supervisor will re-educate the PHP counselors on the importance of making sure individuals attend 5 group sessions weekly and have 2 individual sessions weekly. If an individual does not attend group and/or an individual session, a note will be written indicating that the individual did not attend.
The PHP supervisor/designee will audit 10 charts per month for the next 4 months to ensure this regulation is being met.
Chart audits will be handed in to the CEO. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up information in two of the three applicable records.Client #5 was admitted on July 17, 2020 and discharged on July 20, 2020. Client #7 was admitted on March 31, 2020 and discharged on April 3, 2020 These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The case management supervisor will re-educate the case management staff on the importance of making sure follow up appointments and/or discharge information is documented on all individuals who are discharged from the facility.
The case management supervisor/designee will audit 10 charts per month for the next 4 months to ensure completion of discharge summaries.
Chart audits will be handed in to the CEO. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. 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 clients received services according to the individual training plan.Client #15 was admitted on September 5, 2020 and was still active at the time of the inspection. The comprehensive treatment plan, dated 9/13, 2020, indicated five group sessions per week and one individual session per week. The record of service and progress notes indicated the client had received three group sessions the week of September 6,2020, and four group sessions the week of September 11, 2020.Client #16 was admitted on September 3, 2020 and was still active at the time of the inspection. The comprehensive treatment plan, September 10, 2020, indicated five group sessions per week and one individual session per week. The record of service and progress notes indicated the client received one group the week of September 6, 2020 and four groups the week of September 13, 2020. Client #17 was admitted on September 2, 2020 and was still active at the time of the inspection. The comprehensive treatment plan, September 12, 2020, indicated five group sessions per week and one individual session per week. The record of service and progress notes indicated the client received four group sessions the week of September 13, 2020. Client #19 was admitted on August 22, 2020 and was discharged on September 20, 2020. The comprehensive treatment plan, August 24, 2020, indicated five group sessions per week and one individual session per week. The record of service and progress notes indicated the client received two groups the week of August 30, 2020, four groups the week of September 6, 2020 and four groups the week of September 13, 2020. Client #20 was admitted on May 3, 2020 and was discharged on May 28, 2020. The comprehensive treatment plan, May 7, 2020, indicated five group sessions per week and one individual session per week. The record of service and progress notes indicated the client received two groups the week of May 3, 2020, three group sessions the week of May 10, 2020 and no individual session the week of May 17, 2020. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The rehab clinical supervisors will re-educate the rehab counselors on the importance of making sure individuals attend 5 group sessions weekly and have 1 individual session weekly. If an individual does not attend group, a note will be written indicating that the individual did not attend.
The rehab supervisors will each audit 10 charts per month for the next 4 months to ensure this regulation is being met.
Chart audits will be handed in to the CEO. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to complete and document a discharge summary for all discharged clients. Client record #19 was admitted on August 22, 2020 and discharged on September 20, 2020. Client Record #21 wad admitted on August 13, 2020 and was discharged on August 19, 2020. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The clinical supervisors will re-educate the counseling staff on the importance of making sure discharge summaries are completed on all individuals within the designated time frame.
The rehab supervisors/designee will each audit 10 charts per month for the next 4 months to ensure completion of discharge summaries.
Chart audits will be handed in to the CEO. |