INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 19-20, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Jefferson Outreach Drug and Alcohol Program Central 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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711.92(c)(3) LICENSURE Support Service
711.92. Treatment and rehabilitation services.
(c) 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.
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Observations
Based on the review of client records, the facility failed to document treatment plans to include proposed type of supportive services.
The findings include:
The facility's policy titled "Proposed type of supportive services" states:
Each treatment plan should contain a statement of the type of supportive services provided or arranged for the patient, based upon the patients' unique set of needs as well as an indication of the steps to be taken by the patient and/or program to obtain those services.
On January 19-20, 2012 eighteen client records requiring treatment plans were reviewed. Seven out of eighteen treatment plans lacked documentation of a proposed type of support service, specifically client records # 3, 7, 10, 13, 14, 15, and 19.
Client # 3 was admitted on March 29, 2011. The treatment plan documented on May 7, 2011 did not contain a statement of the type of supportive services provided or arranged for the patient.
Client # 7 was admitted on September 26, 2011. The treatment plan documented on November 1, 2011 did not contain a statement of the type of supportive services provided or arranged for the patient.
Client # 10 was admitted on July 13, 2011. The treatment plan documented on August 13, 2011 did not contain a statement of the type of supportive services provided or arranged for the patient.
Client # 13 was admitted on March 14, 2011 and discharged on August 22, 2011. The treatment plan documented on April 6, 2011 did not contain a statement of the type of supportive services provided or arranged for the patient.
Client # 14 was admitted on January 13, 2011 and discharged on September 1, 2011. The treatment plan documented on April 7, 2011 did not contain a statement of the type of supportive services provided or arranged for the patient.
Client # 15 was admitted on August 4, 2011 and discharged on November 4, 2011. The treatment plan documented on September 4, 2011 did not contain a statement of the type of supportive services provided or arranged for the patient.
Client # 19 was admitted on January 21, 2011 and discharged on October 6, 2011. The treatment plan documented on February 21, 2011 did not contain a statement of the type of supportive services provided or arranged for the patient.
On January 20, 2011 a conversation was held with the clinical staff, which confirmed the treatment plans were missing support services.
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Plan of Correction
Training conducted by the Division of Substance Abuse Program's Coordinator of Treatment on February 17, 2012 reviewed the findings from the DOH licensing visit. During this session, procedures for securing needed supportive services were reviewed. Ongoing administrative review of treatment plans, conducted by supervisory staff for a period of four months, should allow staff sufficient time to modify their treatment planning activities so that they include a discussion of supportive services (where appropriate). |
711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in accordance with the facility's policies and procedures.
The findings include:
The facility's policy in reference to aftercare plans states:
"The patient and the counselor work out the aftercare plan during the last treatment sessions. An aftercare plan is not required for AMA clients or those being referred to another agency for further treatment."
On January 20, 2012 eleven discharged client records were reviewed. An aftercare plan was required in one of those records. One out of one client record lacked documentation of an aftercare plan, specifically client record # 13.
Client # 13 was admitted on March 14, 2011. A progress note dated June 13, 2011 documented that the counselor was planning to discharge the client on June 13, 2011. The client had not been discharged until August 22, 2011 and no aftercare plan had been developed.
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Plan of Correction
Program policy on the completion of aftercare plans was reviewed with staff by the Coordinator of Treatment on 2/17/12. The charts of all planned (i.e., non-AMA) discharges will be reviewed for a period of four months by supervisory staff to ensure that the review of policy has satisfactorily remediated the deficiency. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill record log, the facility failed to conduct an unannounced fire drill at least once a month.
The findings include:
The fire drill log was reviewed on January 19, 2012. The log was reviewed from the time period covering December 2010 to January 2011. There was no documentation that a fire drill had been conducted in September 2011.
On January 20, 2012 a conversation with the Program Coordinator confirmed the missing fire drill.
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Plan of Correction
It is the responsibility of the Program Coordinator of the Narcotic Addict Rehabilitation Program to onduct unannounced monthly fire drills. As part of the administrative process, for a period of six consecutive months the Director of the Division of Substance Abuse Programs will review the log to ensure compliance. It is expected that this additional level of administrative oversight will remediate the identified deficiency. |