INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 22 - 24 and 29, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Snug Harbor Rehabilitation and Recovery 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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704.1-704.2(a) LICENSURE Staffing Compliance Plan
CHAPTER 704. STAFFING REQUIREMENTS FOR DRUG AND ALCOHOL TREATMENT ACTIVITIES
704.1. Scope.
This chapter applies to staff persons employed by drug and alcohol treatment facilities which are licensed or approved under Chapters 157, 709 and 711 (relating to drug and alcohol services; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility) with the exception of staff persons employed in intake, evaluation and referral facilities as delineated in Chapter 709, Subchapter D (relating to standards for intake, evaluation and referral activities) and Chapter 711, Subchapter C (relating to standards for intake, evaluation and referral activities). Staff persons shall possess the qualifications set forth in this chapter and shall also participate in training as required in this chapter.
704.2. Compliance plan.
(a) The project's governing body shall approve a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
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Observations
(a) Facility failed to provide documentation of the governing body approval of the written compliance plan. The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
The Governing Body has met and approved the compliance plan as of 2/10/2020. An amendment has been added to the January 2019 meeting notes to indicate this error of omission.
Moving forward all Governing Body minutes are maintained in a "Governing Body Manual".
Meetings are conducted as needed but at a minimum of quarterly.
Governing Body assumes responsibility for these records. |
704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Facility failed to provide a complete plan documenting the qualifications and training of staff. Despite revisions, the Staffing Requirement Facility Summary Report form presented between January 22 -24, 2020, does not include the required information, complete information, and consistent information between what is documented in the personnel record and what is documented on this form. The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
The compliance plan has been updated to include the specific qualifications for each position. At this time, our year runs from October to October for training purposes. We have prepared a calendar (per position) with educational requirements, date completed and educational topic for all personnel. This calendar is monitored monthly and maintained by Program Manager.
In addition, we have a spreadsheet which records all items needed for personnel file listing resume, license, orientation check list, college degree and or transcripts, detailed work history listing required experience as well as items required by our agency.
This information is gathered during the orientation process and is managed by our Team Coordinator as she discusses employee handbook during orientation.
Facility will present a complete plan, including all required information for qualifications and training to DDAP licensing during all future on-site visits. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
The facility failed to ensure each counselor met the qualifications for the position for two of four counselor personnel records reviewed on January 23 - 24, 2020. Employee # 3 was hired for the position of counselor on December 18, 2019. Documentation of the education or experiential qualifications was not provided.Employee #10 was hired for the position of Intake, but also provides counseling. Documentation of the education or experiential qualifications was not provided.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
A check list and spreadsheet has been prepared recording all items that should be contained in the employee file. This spreadsheet record is updated regularly to ensure copies of current license are available.
The Team Coordinator manages this task. In addition there is a prepared itemized list of all pertinent copies of resumes with detailed work history, transcripts (when indicated) certification, license, orientation checklist etc. for each person.
This will help to ensure all documents are readily available within the employee file for review for both current and new emloyees. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
The facility failed to document supervision notes for two counselor assistants, # 5, and #6. Information was reviewed on January 23 -24, 2020. Employee #5 was hired on October 12, 2019, and should be under the (5) supervision period. Supervision notes were not documented for October 2019, November 2019, December 2019 and January 2020.Employee #6 was hired on December 2, 2019, and should be under the (5) supervision period. Supervision notes were not documented for December 2019 and January 2020.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
Supervisory notes are now filed neatly in a binder for review. Education will be provided to both program manager and counseling assistants of the weekly supervisory meeting,the importance of documenting these sessions and the importance of holding them weekly was stressed.
The appropriate supervision will be provided to both current and future employees who are counseling assistants.
Program Manager is responsible for this supervision,documentation and filing of each session.
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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
The facility failed to document policies and procedures for the overall plan to address the needs, and the annual evaluation of the overall training plan in the policies and procedures of the staff development program. The facility failed to include who is responsible, when it will be completed and how it will be documented in the procedures for the assessment, and mechanism for feedback. Administrative information was reviewed on January 22 - 24, 2020.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
Policy and procedure manual will be updated to address each point of education and qualifications required for every position
Program Manager will monitor educational needs on monthly basis to ensure educational requirements for the year have been completed. Each topic will have a sign off sheet with dates and names once complete.
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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
The facility failed to document an assessment of staff training needs. Administrative information was reviewed on January 22 - 24, 2020.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
Snug Harbor is developing an assessment tool to be completed for each employee's educational needs.
Policies of Staff development have been revised to include the exact language found in the regulation as well as specific revisions made to the training program.
This will be managed by the Program Administrator and monitored monthly. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
The facility failed to document an overall plan for addressing staff training needs Administrative information was reviewed on January 22 - 24, 2020.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
An overall facility wide educational calendar will be developed to address facility educational needs based on information from employees and State requirements.
The Program Manager is responsible for the documentation and managing of the educational program and plan is reviewed monthly. |
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 document an individual training plan for nine of nine staff reviewed on January 23 - 24, 2020.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
Individual training/educational calendars have been prepared for each employee.
In addition and Master copy has been developed per position.
The individual training plans for all staff will be completed in each training year. The record of this training shall be placed in the employee file and signed off on as educational programs have been completed.
Our training year is October to October
The Program Manager will monitor this training need in September in advance of the end of the training year. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
The facility failed to provide documentation of CPR certification and First Aid training for residential treatment coverage. During the review on January 23 -24, 2020, CPR certification and First Aid training documentation was not provided for residential treatment staff.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
Copies of CPR cards are kept in our employee file. We will offer on an as needed basis, non employee conducted trainings for employees in need of CPR recertification. We have scheduled training for March 5th, 2020 at 2:30pm for our newest employees who may not have their current cards.
We have nursing staff available on campus 24/7.
First Aid training is offered routinely as well.
At least one person per shift will be trained and available in residential buildings.
Our RN on staff will monitor CPR training schedules.
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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
(5) The facility failed to provide verification of temperatures for the refrigerator and the freezer located in the residential treatment building during the physical plant inspection conducted on January 29, 2020.(6) The facility failed to store all food items off the floor in the residential treatment building during the physical plant inspection conducted on January 29, 2020.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
A log sheet has been placed in a binder. This log sheet displays:
date and time
temperature
Refrigerator
Freezer
Initials of individual monitoring temperatures.
Cold food stored at 40F degrees or below...and hot food at 140F degrees
Frozen items at 0F degrees
No bottles or containers of food will be stored on the floor. Staff have been educated on proper storage.
This will be monitored daily and the initials of the individual performing the procedure listed each day.
Nursing staff will monitor detox facility and House Monitor will record residential units daily.
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705.9 (4) (i) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of residents and staff to a safe location.
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Observations
The facility failed to document written procedures which include (i)(ii)(iii). Administrative information was reviewed on January 22 - 24, 2020.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
Procedures are now documented in both Safety Committee and Emergency Preparedness Manuals and staff is oriented to these procedures upon hiring.
Any unforeseen event requiring exit from a building is rehearsed. The Security Guard Manager is responsible for this activity.
Log sheet is maintained and Our Security Manager is in charge of this drill and documentation of the activity.
Staff has been educated on this process.
Policies will be updated to reflect this meeting place and to address (I) through (iii)of regulation
Program Manager is responsible for the documentation collection of this procedure and ensure POC correction is held monthly and placed in manual for review.
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705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
The facility failed to ensure exits from the facility were unobstructed. During the physical plant inspection conducted on January 29, 2020, three of four exits in the detox building were key locked and not accessible.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
Stairways, hallways and exits are un-obstructive and free for passing.
The doors changed out from electronic release and or key to push bar exits.
Program Manager and director will monitor this activity and random physical plant inspections will occur daily with use to ensure compliance.
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705.10 (b) (6) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(6) Maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
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Observations
During the physical plant inspection conducted on January 29, 2020, the facility failed to ensure a person with a hearing impairment would be alerted in the event of a fire. The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
The parts have been ordered to repair the short in the strobe lights for hearing impaired individuals to protect them from danger in the event of fire. The repair is expected to be completed on or before 4/15/2020.
Regular inspections are performed by Fire Line on an annual basis.
The Maintenance Department will be responsible for the completion of this repair and ongoing monitoring during weekly checks of facility.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Facility failed to document staff were trained in the use of fire extinguisher upon staff employment. Missing for nine of nine staff reviewed on January 23 - 24, 2020.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
The orientation Checklist has been updated to include fire safety instruction and unforeseen incidents evacuation procedures. Current staff and all new employees will be trained on this.
The orientation checklist documenting this training is maintained in the employee file and overseen by team coordinator.
Safety Committee Chair Person is responsible for this exercise. Program Manager monitors its completion. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
(1) Facility failed to conduct monthly fire drills. The facility was approved to begin providing services in May 2019, and the first client was admitted in September 2019. At the time of the inspection on January 22, 2020, no fire drills have been documented. (3) Facility failed to document staff were trained to perform assigned tasks in the event of an emergency. Missing for nine of nine staff reviewed on January 23 - 24, 2020.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
Unannounced fire drills conducted one time each month during daylight hours and one time every six months (twice a year) during sleeping hours will be documented and documentation will be housed in a fire drill safety binder.
The responsibility for conducting these drills will be the Security Manager and the Safety Committee Chairperson. This will be monitored on a quarterly basis to ensure completion monthly. |
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 provide a project policy and procedure manual that included complete and consistent policies and procedures. Administrative information was reviewed on January 22 - 24, 2020.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
Our current Policy and Procedure Manual has been revised to reflect exact wording from State regulations as well as wording specific to our facility.
A signature page has been developed for sign off by project/facility manager for the 2020 year and annually thereafter.
All revisions have been signed off on.
Program Manager and Executive Director will assume responsibility for the policy manual. |
709.24 (a) 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:
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Observations
The facility failed to provide the governing body adoption of the written plan for the coordination of client services. Administrative information was reviewed on January 22 - 24, 2020.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
The policy pertaining to the client treatment and rehabilitation services of our facility has been revised to include a statement of approval by the Governing Body.
In addition, a signature of acceptance by the Governing Body of this policy has been placed in the Governing Body Minute Manual.
The Executive Director assumes responsibility for this item. |
709.24 (a) (4) 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:
(4) Written procedures for referral outlining cooperation with other service providers including, but not limited to, provisions for access to emergency services.
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Observations
The facility failed to provide written procedures for outgoing referrals. Administrative information was reviewed on January 22 - 24, 2020.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
The treatment/rehabilitation policy has been updated specific to the regulation wording.
Outside service needs are identified upon admission and throughout rehabilitation based on needs identified.
Should a client request transfer or require a transfer due to the need of higher level of care; this is physician ordered request and signed off by the client.
The client choice of facilities will considered and attempted transfer made, however, in the event of urgent need facilities with available beds will be contacted.
Proper documentation will be sent regarding medication dosage and progress toward goals with treatment plan summary,
Program Manager will identify the need based on input from the team. these specific needs are discussed at weekly team meetings. The Counselor assigned to the client and Case Management will monitor this referral.
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709.26 (a) LICENSURE Personnel Management
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
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Observations
The facility failed to provide the governing body adoption of the project personnel policies and procedures. Administrative information was reviewed on January 22 - 24, 2020.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
Governing Body will approve and sign off on the revisions to this policy and procedure manual notification of this sign off will be maintained in the Governing Body Minutes Manual
Director and Program Manager will ensure this procedure is monitored at least quarterly.
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709.26 (b) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(2) Written verification of qualifying professional credentials.
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Observations
The facility failed to maintain personnel records that include the written verification of qualifying credentials in six of nine personnel records reviewed on January 23 - 24, 2020. Personnel records # 2, 4, 5, 6, 7, and 8 did not include credentials. The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
A check list has been placed on the inside of each employee file to indicate all items to be contained within their file.
The employee files 2,4,5,6,7,8 have been updated to include the verifications and credentials that were not I the file upon survey.
New staff members have been instructed on how to complete and maintain employee files.
Included in the file is verification of the qualifying professional's credentials.
Team Coordinator will be responsible for this task. |
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.
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Observations
The facility failed to obtain an informed and voluntary consent from the client prior to disclosure of information in four of five clients records reviewed on January 24, 2020.Client records # 1, 2 and 3 did not document consents for the pharmacy that provides the buprenorphine, but information was disclosed. Client Record #4 - did not document a consent for the insurance company, but a progress note dated on 11-27-2019 documents a phone call regarding authorization.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
A Release of information has been developed for the Pharmacy and for the Insurance(funding)agency specifying information to be released and start and end dates for the ROI.
Intake Counselor is responsible for completion of all consents.
Ultimate monitoring will be by the Program Manager upon chart review weekly.
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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 include the specific information to be disclosed on release of information forms in three of five client records reviewed on January 24, 2020.Client record #1 included a release of information form for a funding source signed on January 20, 2020. The release form did not identify the specific information to be disclosed; " other " any info needed by insurance company " . A fax form to the funder indicated medication/MAR and treatment plans were disclosed which exceed the parameters of 255.5.Client record #3 - Release of information for Probation signed on December 30, 2019, does not indicate specific information to be disclosed.Client record #5 - Release of information signed for another person on December 30, 2019, does not indicate specific information to be disclosed. The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
The Release of Information forms have been revised to include the specific information being released. The "other" box has been eliminated.
Director is responsible for this corrective action form update.
Intake is responsible for the completion of ROI's upon admission.
The program manager will monitor this process during chart audits which will occur weekly.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
The facility failed to include the purpose of disclosure on release of information forms in five of five client records reviewed on January 24, 2020.Client record #1 - The purpose of disclosure was not identified on the funding release dated January 20, 2020.Client record #2- The purpose of disclosure was not identified on three release forms dated on October 4, 2019 and October 7, 2019.Client record #3 - The purpose of disclosure was not identified on the Probation office release dated December 30, 2019.Client record #4 - The purpose of disclosure was not identified on a release dated November 15, 2019.Client record #5- The purpose of disclosure was not identified on two release forms dated on December 30, 2019.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
The consent for release of information forms have been revised to include the purpose of the information released. The staff has been educated.
Intake Staff will be responsible for the management of the Release of Information content, accuracy, and signatures as they receive the request.
Program Manager will audit this procedure during chart audits which occur weekly. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
The facility failed to include the expiration on the release of information forms in three of five client records reviewed on January 24, 2020.Client record #1 - The expiration was not identified on the funding release dated January 20, 2020.Client record #3 - The expiration was not identified on the probation release dated December 30, 2019 or the pharmacy release dated January 2, 2020.Client record #4 - The expiration was not identified on a release form dated on November 15, 2019.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
The staff has been educated again on the process of completing the release of information. There must be a start and end date.
The end date will state clearly upon discharge or other. ROIs have been preprinted with "upon discharge" / or other for end date.
Program Manager will monitor this during regular chart audits which are performed weekly.
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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 document a copy of the consents were offered to the client in two of five client records reviewed on January 24, 2020. Client records #2 and #3 included releases that are blank for an offered copy.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
The consent forms have been revised so that all include boxes at the bottom of the forms that state
I have received a copy
I have refused a copy
then the client signs.
This is performed in Intake and monitored by the Intake Counselor and Program Manger daily and with weekly chart audits for ongoing compliance.
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709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
The facility failed to document a client rights policy and procedure than includes all required areas. Procedure for (3), (4), (5), and (6) are missing. The documentation of written acknowledgement is also missing all required areas. Administrative information was reviewed on January 22 - 24, 2020. The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
The client rights have been revised to correctly include 3,4,5 and 6 of this regulation. Right to inspect record, right to an appeal, right to request correction, and right to submit rebuttal and that sections of chart may be removed if it is determined to be a concern for well being of client, these points have been added to the Client Right and client handbooks have been corrected to reflect this.
Team Coordinator will monitor printing to ensure this error of omission is not repeated. This will be monitored prior to every printing at least every quarter for continued compliance.
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to document a client rights policy and procedure than includes (1) Civil rights. The documentation of written acknowledgement was also missing (1) Civil rights. Client records were reviewed on January 24, 2020. The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
Civil Rights of each individual will be addressed in the policy and procedure for Client Rights. The acknowledgement of receipt of /client rights /civil rights notification will also be corrected.
This will state clearly that no one will be deprived of their civil rights.
Director and Program Manager will see this addition is clearly stated and that it is not missing on future printings to comply with this regulation..
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
The facility failed to document a client rights policy and procedure than includes (2) is missing creed, marital status, and sexual orientation. The documentation of written acknowledgement was also missing (2) is missing creed, marital status, and sexual orientation. Client records were reviewed on January 24, 2020. The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
The non-discrimination error of omission has been corrected in all printings to include creed, marital status and sexual orientation. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
The facility failed to document a verbal order (VO) is authenticated in writing by the physician within the required time frame in three of five client records reviewed on January 24, 2020.Client record #2 had VO dated October 4, 2019 that did not include a date on the physician's signature, therefore not able to determine if the VO was signed within 24 hours. This was a detoxification treatment client.Client record #3 had VO dated December 30, 2019 that did not include a date on the physician's signature, therefore not able to determine if the VO was signed within 24 hours. This was a detoxification treatment client.Client record #4 had VO dated November 15, 2019 and November 28, 2019 that did not include a date on the physician's signature, therefore not able to determine if the VO was signed within three business days. This was a residential treatment client.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
Physicians and staff have been re-educated on this regulation and a tickler system has been implemented as a reminder tool to check dates times and signature of physician orders/ verbal orders.
The Nursing supervisor will review all verbal orders to ensure appropriate signatures within time frame.
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709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
The facility failed to document an inspection of storage areas that includes (ii)(iii)(iv) for the detoxification storage area and the residential treatment storage area. This information was reviewed on January 29, 2020. The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
Inspection of storage areas procedures have been revised to include the following specific... Inspections are to be completed quarterly.
Staff has been educated again on the procedure.
RN and Program manager review all quarterly medication area inspections to ensure they are completed. |
709.32 (c) (5) LICENSURE Medication control
§ 709.32. Medication control.
(5) Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
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Observations
The facility failed to document a medication policy and procedure than includes theft, loss and misuse of drugs. Administrative information was reviewed on January 22 - 24, 2020.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
The policy for theft, loss and misuse of drugs has been revised to include how drugs are secured and counted and discrepancies addressed in a more clear manner.
The Charge Nurse and Medical Director will ensure this policy is adhered to and documentation is timely, legible and accurate.
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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 an unusual incident policy and procedure that addresses storm, flood or other occurrence that closes the facility for more than one day. Administrative information was reviewed on January 22 - 24, 2020. The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
The unusual event policy will be revised to reflect more clearly the plans in place for significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
The Executive Director and Program Manager will monitor this policy and procedure. |
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 an unusual incident policy and procedure that addresses an event at the facility requiring the presence of police, fire and ambulance personnel. Administrative information was reviewed on January 22 - 24, 2020.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
The policy on unusual incidents will be revised to more clearly define "events at the facility requiring the presence of the police, fire or ambulance personnel."
Staff will be retrained on this policy and Charge RN and Program Manager will ensure it is adhered to. |
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 an unusual incident policy and procedure that addresses who is responsible to implement the corrective action plan. Administrative information was reviewed on January 22 - 24, 2020. The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
The Unusual Incident policy will be revised to include " implementation of a timely and appropriate corrective action plan, when indicated."
This will enable identification and causes to be avoided so the event will not be repeated.
Staff will be re-educated on procedure to be followed in the event of an unusual incident.
This correction will be implemented by the Director and Program manager and the Program Manager will monitor this procedure moving forward. |
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 an unusual incident policy and procedure that addresses who is responsible to monitor the corrective action plan. Administrative information was reviewed on January 22 - 24, 2020.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
Policy on unusual Incident will be revised to more clearly define the "ongoing monitoring of the corrective action plan.
A performance improvement plan would be identified and ways in which to avoid repetition of the event and continual monitoring of the PIP in place.
Staff will be re-educated on the corrective action portion of the policy.
The Program Manager and Executive Director will monitor the corrective action plan. |
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 an unusual incident policy and procedure that addresses the reporting mechanism. Administrative information was reviewed on January 22 - 24, 2020.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
The unusual incident policy and procedure will be revised to more thoroughly express procedure for "reporting of unusual incidents to an entity in compliance with State and Federal confidentiality laws".
Identifying and reporting
1. physical or sexual assault by staff or client
2. death or serious injury due to trauma, suicide, medication error or unusual circumstances
3. Significant disruption of services due to disaster such as fire, storm, flood or other occurrence that results in closure of a facility for more than 1 day.
4. Event at facility requiring presence of police, fire, or ambulance personnel
5. Outbreak of contagious disease requiring CDC notification.
Program Manager will monitor this procedure. |
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
The facility failed to document follow-up information in two of two applicable detoxification activity client records reviewed on January 24, 2020. Client records #2 and #3 did not include documentation of follow-up. The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
Staff has been re-educated on the importance of clear and concise documentation of client follow-up procedures.
The discharge follow-up form has been discussed in detail with employees.
This process is monitored by Program Manager and supervisors quarterly. |
709.64(a)(1) LICENSURE Purchasing food/equipment
709.64. Project management services.
(a) The inpatient nonhospital project shall have written policies and procedures for its dietetic services which shall include, but not be limited to the following:
(1) Purchasing of food and equipment.
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Observations
The facility failed to document written policies and procedures for dietetic services in the detoxification activity, (a)(1)-(6). Administrative information was reviewed on January 22 - 24, 2020.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
We will develop a policy documenting this change in procedure detailing but not limited to the following:
1. purchase of food and equipment
2. receiving, storage and preserving food
3. proper preparation of food
4. safety and sanitation
5. Personal hygiene of those handling food
6. special dietary needs
Program Manager along with residential house staff will monitor this process daily.
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709.64(b) LICENSURE Promoting treatment
709.64. Project management services.
(b) The project shall develop a written plan that delineates specific service planning and counseling approaches used to promote client interest in participating in necessary treatment, following the detoxification process.
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Observations
The facility failed to document a plan for specific service planning and counseling to promote client interest in treatment following the detoxification process. Administrative information was reviewed on January 22 - 24, 2020.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
A plan shall be written that delineates specific service planning and counseling approaches used to promote client interest in participating in necessary treatment, following detoxification process.
The counseling team will be re-educated on the need for the specific written plan for each client to encourage the necessary treatment. Clear, concise, legible and timely documentation within the client record is required.
The program manager will be responsible for this management. |
709.64(d) LICENSURE Aftercare policy
709.64. Project management services.
(d) The project shall develop a written client aftercare policy.
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Observations
The facility failed to document an aftercare policy for the detoxification activity. Administrative information was reviewed on January 22 - 24, 2020.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
The aftercare policy will be revised to state more clearly the follow-up including outreach services identified for each individual client. The documentation in support of this policy will be concise, legible, detailed and clear and maintained in the client record.
The staff will again be educated on this procedure.
The Program Manager will monitor this process.
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715.6(b)(1-9) LICENSURE Physician Staffing
(b) A narcotic treatment program may employ narcotic treatment physicians to assist the medical director. A narcotic treatment physician 's responsibilities include:
(1) Performing a medical history and physical exam.
(2) Determining diagnosis and determining narcotic dependence.
(3) Reviewing treatment plans.
(4) Determining dosage and all changes in doses.
(5) Ordering take-home privileges.
(6) Discussing cases with the treatment team.
(7) Issuing verbal orders pertaining to patient care.
(8) Assessing coexisting medical and psychiatric disorders.
(9) Treating or making appropriate referrals for treatment of these disorders.
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Observations
The facility failed to include " (4) determining dosage and all changes in doses " in the physician responsibilities. Administrative information was reviewed on January 22 - 24, 2020. The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
The narcotic treatment policies will be revised to state more clearly the physician duties which include dosing and changes in dosage.
Physicians have been instructed on documentation.
Nursing Supervisor and Medical Director will manage this process.
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
The facility failed to provide documentation of the physician hours. Facility was approved to begin services on May 1, 2019, and the first clients were admitted in September 2019. Physician hours not documented since client activity began. Administrative information was reviewed on January 22 - 24, 2020.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
In order to document physician hours a log book system has been implemented where physician will sign in and out when on campus. This will enable tracking of this requirement.
This will be monitored by nursing staff in detox and by Program Manager quarterly. |
715.9(a)(1) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(1) Verify that the individual has reached 18 years of age.
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Observations
The facility failed to verify the individual reached 18 years of age in three of three patient records reviewed on January 24, 2020. Three patient records were reviewed for buprenorphine treatment. Client records #1, 2, and 3 did not include the age verification.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
The age of 18 years + of the individual will be verified by drivers license or whatever means available including upon funding verification if drivers license is not available.
A photo copy of license will be maintained in the client chart (if available) if not whatever means of verification was used will be documented.
The nursing staff will self monitor this procedure and the Program Manager will monitor it completion quarterly. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
The facility failed to verify the individual ' s identity in three of three patient records reviewed on January 24, 2020. Three patient records were reviewed for buprenorphine treatment. Client records #1, 2, and 3 did not include the individual ' s identity.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
Prior to administration of an agent the client's photo is taken, proof of age (18 or older) is obtained from a form of identification such as a driver's license, the individual's emergency contact information is collected and all information is recorded and kept in the client record.
Nursing staff of detox and Intake Counselors will oversee this process and Program Manager will monitor quarterly. |
715.9(d) LICENSURE Intake
(d) A narcotic treatment program shall explain to each patient treatment options; pharmacology of methadone, LAAM and other agents, including signs and symptoms of overdose and when to seek emergency assistance; detoxification rights; grievance procedures; and clinic charges, including the fee agreement signed by the patient.
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Observations
The facility failed to document the items were explained to each patient in three of three patient records reviewed on January 24, 2020. Three patient records were reviewed for buprenorphine treatment. Client records #1, 2, and 3 did not include documentation.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
In order to provide a better understanding and compliance with this regulation a packet has been prepared for client education when Suboxone ( Buprenorphine) will be used in treatment. In addition a consent to treat using this medication will be explained, signed and witnessed. this document will be recorded in the client record.
The nursing staff will self monitor this procedure with oversight of the Program manager quarterly. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
The facility failed to document the informed patient consent for the use of buprenorphine in three of three patient records reviewed on January 24, 2020. Patient records # 1, 2, 3 did not document a patient consent for the use of buprenorphine.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
A Suboxone consent form has been developed for use with both male and female clients receiving this medication in detoxification. This form will be dated, signed and witnessed and placed in the client record. As with all consent s the client is offered a copy of the form.
1. Risks will be explained using the educational tool that has been prepared.
2. Adverse effect possibility explained
3. Alternative treatment discussed.
4. Possible risks and complications discussed with client
5. Risks to unborn children discussed,
This will be monitored by nursing staff in detox and overseen by the Program manager quarterly. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
(i) The facility failed to document the medication order was written by the physician in one of three patient records reviewed on January 24. 2020. Patient record #1 included a medication order for buprenorphine. The order did not include the date and time, and was not written by the physician.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
We have revised the physician order form to clearly state date and time, medication and dosage, route and freguency, start and end date as well as purpose.
Medication control for narcotic treatment policy shall be revised to make clear orders must be written by physician, timed and dated and signed by physician.
This procedure is monitored by the nursing staff and overseen by the program manager and Medical director quarterly.
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715.17(c)(4)(i-viii) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(4) Method for control and accountability of drugs. A narcotic treatment program shall develop and implement written policies and procedures regarding who is authorized to remove drugs from the storage area and the method for accounting for all stored drugs. An agent or other drug prescribed or administered shall be documented on an individual medication record or sheet in a manner sufficient to maintain an accurate accounting of medication at all times and shall include:
(i) The name of the medication.
(ii) The date prescribed.
(iii) The dosage.
(iv) The frequency.
(v) The route of administration.
(vi) The date and time administered.
(vii) The name of the person administering the medication.
(viii) The take-home schedule, if applicable.
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Observations
(vi) The facility failed to document the time administered on the Buprenorphine Medication Administration Record in patient record #3 reviewed on January 24, 2020. Patient #3 was given buprenorphine on January 1, 2020, but no time was indicated on the MAR. The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
Nursing staff and physicians have been re-educated on dating and timing of medication administration.
This is monitored by nursing staff, medical director quarterly. |
715.20 LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
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Observations
The facility failed to document a written transfer procedure that includes who is responsible and how it will be documented. Administrative information was reviewed on January 22 - 24, 2020.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
The client transfer policy has been revised to more clearly state the transfer procedure. The documentation of this transfer shall be placed in the client record.
This will be monitored by Case Management, nursing personnel in detox unit and Program Manager will over see completion quarterly. |
715.26(b) LICENSURE Security
(b) Each narcotic treatment program shall provide the Department with a specific plan describing the efforts it will make to avoid disruption of the community by its patients and the actions it will take to assure responsiveness to the community. This plan shall designate a staff member to act as community liaison.
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Observations
The facility failed to designate a staff member to act as community liaison. Administrative information was reviewed on January 22 - 24, 2020.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
A policy has been revised to more clearly state the existence since day one of a marketing and community liaison who works diligently to avoid disruption of the community by our clients and the action it will take to assure responsiveness to the community. This individual has been designated as a community liaison.
This is monitored by the Program Manager and Executive Director quarterly. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The facility failed to document a psychosocial evaluation in two of two client records reviewed on January 24, 2020. Two client records were reviewed for the residential treatment activity. Client records #4 and #5 did not include a psychosocial evaluation. Client record #4 was admitted on November 14, 2019 and discharged on November 29, 2019.Client record #5 was admitted on December 30, 2019 and discharged on January 21, 2020.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
Intake personnel has been re-educated on the psychosocial completion. Counselors should complete this process on day 2 of intake into detoxification and on day 3 of residential if detox was not performed on campus.
Intake counselors will perform this process and Project Manager will oversee this will be monitored quarterly. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
The facility failed to document a complete client record in two client records reviewed for the residential treatment activity on January 24, 2020.(a)(3) - A record of service was not documented in two of two client records, records #4 and #5. (a)(10) - A discharge summary was not documented in one of two client records. Client record #4 did not include a discharge summary. (a)(11) - Follow-up information was not documented in two of two client records, records #4 and #5.The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
The staff has been re-educated on the content to be included in the client record.
Emphasis is placed on services provided to the client, discharge summary and follow-up after discharge which will be part of the client record.
Project manager will oversee and monitor this procedure by weekly charts audits. |
709.54(a)(1) LICENSURE Purchasing food/equipment
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(1) Purchasing of food and equipment.
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Observations
The facility failed to document written policies and procedures for dietetic services in the residential treatment activity, (a)(1)-(6). Administrative information was reviewed on January 22 - 24, 2020. The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
709.54 (a) (1)
The policy for project management services has been revised to state more clearly the dietetic services for the purchasing of food procedures.
Staff has been re-educated on the policy.
Administration and Project Manager will monitor this procedure. |
709.54(b) LICENSURE Aftercare policy
709.54. Project management services.
(b) The project shall develop a written client aftercare policy.
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Observations
The facility failed to document an aftercare policy in the residential treatment activity. Administrative information was reviewed on January 22 - 24, 2020. The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
709.54 (b)
The aftercare policy has been revised to state more clearly the aftercare plan procedures.
Residential clients have a follow-up procedure and discharge plan beginning upon admission. This plan is starts with information gathered upon admission and continues to be developed through-out the residential stay.
The staff has been re-educated on this policy and procedure.
This is monitored by the Program Manager |