INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 8 through 10, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, POWER was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on January 15, 2009.
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Plan of Correction
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709.26(e)(2) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(2) The employe's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
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Observations
Based on a review of the policy and procedure manual, the facility failed to provide complete documentation of employee rights.
The findings include:
The policy and procedure manual was reviewed on December 8-9, 2008. The facility did not document the employee ' s right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from his or her records.
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Plan of Correction
While both the Employee Manual and the Program Policy & Procedure Manual describe employee rights and reswponsibilities, the policies were revised to more specifically address (2) "employee's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information" from her/his personnel file.
The Employee Manual and Program Policy & Procedure Manual were revised on 1/15/09 by the Executive Director. The HR Director will address the revision with Managers at a meeting on 1/8/09 and the revised pages will be distributed to all staff by 1/15/09. All staff will also be required to sign off on a new Manual Receipt form that will be filed in their personnel record. |
709.30(3) LICENSURE Client Rights
709.30. Client rights.
(3) A client has the right to inspect his own records. The project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.
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Observations
Based upon a review of the policy and procedure manual the facility failed to develop a written policy on client rights and demonstrate efforts toward informing clients that the the reasons for removing sections of the records shall be documented and kept on file.
Findings:
The policy and procedure manual did not include a written policy to include that the the reasons for removing sections of the records shall be documented and kept on file and that the client would be informed of this right.
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Plan of Correction
While the General Program Policy & Procedure Manual included a written policy that addressed the reasons for removing sections of the records shall be documented and kept on file and that the client would be informed of this right; it was inadvertently deleted from the Partial NewDayProgram Policies & Procedures Manual. This oversight will be corrected by January 31, 2009; by the Associate & Clinical Director ; the staff will be given this addition to the Policies and Procedure Manual and all current clients will be advised of this right during morning group. This information will be added to the Client Rights form by the Associate & Clinical Director and given out at Intake Appointments. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a physical plant inspection and fire drill log review, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
A physical plant inspection and fire drill log review was conducted on December 10, 2008. The facility did not utilize alternate exit routes from the suite or the building during fire drills.
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Plan of Correction
As follow up to the exit interview on 12/16/08, which was attended by the Executive Director, the Associate & Clinical Director was reminded that the Partial Program must utilize alternate exit routes from the suite or the building during fire drills. The Associate & Clinical Director sent a written memo to the Partial staff advising of the above. The Associate & Clinical Director will randomly review the fire drill log at least quartely as a way to monitor compliance. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in one of four client records.
The findings include:
Five client records were reviewed on December 10, 2008. Psychosocial evaluations were required in four records. The facility did not document a psychosocial evaluation in client record # 9.
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Plan of Correction
As follow up to the exit interview on 12/16/08 which was attended by the Executive Director, the Associate & Clinical Director was reminded that all Bio-psychosocials evaluation/narrative are regired to be documented and placed in the client record. A written memo was given to the Counselor/Therapists at the Partial Program advising of the above.The Associate & Clinical Director will randomly review client records at least twice a year as a way to monitor compliance and assure quality. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document type and frequency of treatment and rehabilitation services in three of four records. The facility did not document type and frequency of treatment and rehabilitation services in client records # 2, 8 and 9.
The findings include:
Five client records were reviewed on December 10, 2008. Four records were required to have individual treatment and rehabilitation plans developed to include the type and frequency of treatment and rehabilitation services.
The facility did not document the type and frequency of services to be provided on the individual treatment and rehabilitation plan in client records # 2, 8 and 9.
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Plan of Correction
As follow up to the exit interview 12/16/08, which was attended by the Executive Director, the Associate & Clinical Director reminded the treatemnt staff by written memo that Individual Treatment Plans are to document the type and frequency of treatment and rehabilitation services in all client records. The Associate & Clinical Director will randomly review client records at least twice each year as a way to monitor compliance and assure quality. |
709.83(a)(11) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up in one of one client records.
The findings include:
Five client records were reviewed on December 10, 2008. Follow up documentation was required in one record. The facility did not document a follow up in client record # 8.
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Plan of Correction
As follow up to the exit interview 12/16/08, which was attended by the Executive Director, the Associate & Clinical Director sent a written memo to all Therapists/Counselors that Follow Up Information is to be included in the client record. The Associate & Clinical Director will randomly review client records at least twice aeach year as a way to monitor compliance and assure quality. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations in one of three client records.
The findings include:
Five client records were reviewed on December 10, 2008. Case consultations were required in three client records. The facility did not document case consultations in client record # 7.
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Plan of Correction
As follow up to the exit interview 12/16/08, which was attended by the Executive Director, the Associate & Clinical Director sent a written memo to the treatment staff that Case Consultations must be documented and placed in the client record.
The Associate & Clinical Director will randomly review client records at least twice each year as a way to monitor compliance and assure quality. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document aftercare plans in one of one client records.
The findings include:
Five client records were reviewed on December 10, 2008. Aftercare plans were required in one client record. The facility did not document an aftercare plan in client record # 3.
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Plan of Correction
As follow up to the exit interview 12/16/08, which was attended by the Executive Director, the Associate & Clinical Director sent a written memo as a reminder that Aftercare Plans must be initated early in the client's treatment episode and every attempt is made to have this plan completed at the time of discharged. The Associate & Clinical Director will randomly review client records at least twice a year as a way to monitor compliance. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up in one of one client records.
The findings include:
Five client records were reviewed on December 10, 2008. Follow up documentation was required in one record. The facility did not document a follow up in client record # 4.
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Plan of Correction
As follow up to the exit interview 12/16/08, which was attended by the Executive Director, the Associate & Clinical Director sent a written memo to the Therapist/Counselors that Follow Up Information is to be included in the client record. The Associate & Clinical Director will randomly review client records at least twice each year as a way to monitor compliance and assure quality. |