INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the December 2008 licensure renewal inspection. The follow-up inspection was conducted on June 29, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, POWER - Wilkinsburg 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 July 24, 2009.
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Plan of Correction
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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 review of the fire drill logs, the facility failed to document that alternate exits from the building are being used during fire drills.
The findings include:
Fire drill logs were reviewed on June 29, 2009. The same exit from the building has been used for every monthly fire drill conducted from January through May 2009.
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Plan of Correction
The non-compliance was the result of a staff member not following agency policy and procedure. The staff person has been retrained and will be monitored monthly by the Program Manager. The Associate/Clinical Director will review the Fire Drill Log on a quartely basis. |
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 the review of client records, the facility failed to document a psychosocial evaluation in one of four client records.
The findings include:
Four partial hospitalization client records were reviewed on June 29, 2009. Psychosocial evaluations were required in all four client records. The facility did not document a psychosocial evaluation in client record # 1.
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Plan of Correction
The non-compliance was the result of staff not following agency policy and procedure. The clinical staff will receive a written memo regarding the necessity of providing documentation of a bio-psychosocial evaluation of each client. The Program Manager will conduct chart reviews for compliance on a monthly basis. The Associate/Clinical Director will review a random sample of charts on a
quartely basis. |
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 the type and frequency of service on the treatment and rehabilitation plan in four of four client records.
The findings include:
Four partial hospitalization client records were reviewed on June 29, 2009. Type and frequency of service was required in four client records. The type and frequency of service was not documented in client records # 1, 2, 3 and 4.
Client record # 1 included no type and frequency documentation.
Client records # 2, 3 and 4 stated that the client would attend treatment five days per week, but did not document the type of service that would be provided nor the frequency at which each service would be provided.
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Plan of Correction
The non-compliance was the result of a staff member not following agency policy and procedure. All clinical staff will receive a memo reminding them that the type and frequency of service is reguired documentation in each clients records. The Program Manager will audit the clinical records monthly. The Associate/Clinical Director will randomly review clinical records on a quartely basis. |
709.91(b)(6) LICENSURE Intake and admission
709.91. 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 two of three client records.
The findings include:
Five outpatient client records were reviewed on June 29, 2009. Psychosocial evaluations were required in three client records. The facility failed to document a psychosocial evaluation in client records # 5 and 9.
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Plan of Correction
The non-compliance was the result of staff not following agency policy and procedure. All clinical staff will receive a mem reviewing all of the non-compliance issues. The memo will go out on 07/24/09 by the Associate/Clinical Director. The Program Manager will audit clincal records for completeness on a monthly basis. The Associate/Clinical Director will randomly review clinical records on an quartely basis. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan in two of three records.
The findings include:
Five outpatient client records were reviewed on June 29, 2009. Comprehensive treatment plans were required in three client records. The facility did not document a comprehensive treatment plan in client records # 5 and 9.
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Plan of Correction
The non-compliance was the result of staff not following agency policy and procedure. The clinical staff will received a memo reviewing all non-compliance issues. This memo will be sent out on July 24, 2009 by the Associate/Clinical Director. The Program Manager will audit the clinical records monthly and the Associate/Clinical Director will randomly review the clinical records on a quarterly basis. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(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 provide written documentation of the type and frequency of service, in the individual treatment and rehabilitation plans, in one of one client record.
The findings include:
Five outpatient client records were reviewed on June 29, 2009. The individual treatment and rehabilitation plans were required to document type and frequency of services in one client record. The facility did not document type and frequency of services in client record # 6.
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Plan of Correction
The non-compliance was the result of staff not following agency policy and procedure. The clinical staff will receive a memo addressing all non-compliance issues, especially as it relates to type and frequency of service delivery to all clients. The Program Manager will audit clinical records on a monthly basis. The Associate/Clinical Director will randomly review clinical records on a quarterly basis. |
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 the review of client records, the facility failed to document follow up in three of three client records.
The findings include:
Five outpatient client records were reviewed on June 29, 2009. Follow up was required in three outpatient client records. The facility did not document follow up in client records # 6, 7 and 8.
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Plan of Correction
The non-compliance was the result of staff not following agency policy and procedure. All clinical staff will receive a memo by 7/24/09 as a wrritten reminder of ensuring compliance with the Division of Drug and Alcohol Program Licensure.
The Program Manager will audit the clinical charts on a monthly basis. The Associate/Clinical Director will randomly review charts on a quarterly basis. |