INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 11, 2010 through February 9, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Adappt Outpatient Treatment Services 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 March 6, 2010.
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Plan of Correction
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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 fire drill records and staff interview, the facility failed to conduct an unannounced fire drill at least once a month.
The findings include:
The fire drill records were reviewed on February 11, 2010. There was no documentation of a fire drill for January 2010. In speaking with the counselor, it was noted that a fire drill was not conducted in January 2010 due to staff oversight.
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Plan of Correction
The Outpatient Counselors shall ensure that unannounced fire drills occur and be documented at least once a month. A fire drill did occur in January 2010, however, the counselor did not document it.
The Clinical Supervisor/Facility Director shall monitor fire drill activity and documentation of same on a month to month basis to ensure compliance. |
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 two of seven client records.
The findings include:
Seven client records were reviewed on February 11, 2010. Of those seven records, only three were required to have a completed aftercare plan due to being discharged. Aftercare plans were not documented in client records #4 and 7. The aftercare plan documented in client record #5 did not include criteria for re-entry into the project or a contact person. Time frames on the aftercare plan goals were documented as "ongoing" or "ASAP" and not specific to the identified goals.
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Plan of Correction
The Outpatient Counselor shall ensure that all Aftercare Plans shall include, in additon to the client's future goals with time frames (time frames shall be documented as specific to the identified goal and utilizing a specific/appropriate date), a description of the services that can be provided by the project after discharge, if necessary, the method and frequency of continuting contact to provide client support, a criteria for re-entry into the project (the contact person's name and telephone number), and provision for periodic re-evaluation and termination of the plan.
All of the above shall be reviewed with the client during the development of the aftercare plan and will be documented on the aftercare plan.
The Clinical Supervisor will meet at least weekly with the Counselor to ensure and monitor compliance.
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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 information in three of seven client records.
The findings include:
Seven client records were reviewed on February 11, 2010. Of those seven records, only four were required to have documentation of follow-up information due to being discharged. Follow-up was not documented in client records #4, 5 and 7. An interview with the counselor and the facility director confirmed that follow-up was not being done.
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Plan of Correction
The Outpatient Counselor shall ensure
that, in accordance with ADAPPT policy, and with the written consent of the client, that within seven (7) working days from the date of discharge the counselor shall phone the referred program to determine the disposition of the referral.
This follow-up contact shall be documented in the clinical record, as aa "follow-up note" using a progress note format.
The Clinical Supervisor shall meet with the Outpatient Counselor at least weekly to monitor and ensure that "follow-up" is occurring within the appropriate time frame as required by the regulation and in accordance with ADAPPT policy. |
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
Based on a review of personnel records and staff interview, the facility failed to ensure CPR certification and first aid training were provided to a sufficient number of staff so that at least one person trained in these skills is onsite during the facility's hours of operation.
The findings include:
Two staff work at this location. Staff #3 has first aid training, but no CPR certification. Staff #4 has neither first aid training nor CPR certification.
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Plan of Correction
The Facility Director shall ensure that CPR/First Aid shall be provided to to a sufficient number of staff so that at least one person, on site during the facility's hours, is trained in these skills.
Both Staff #3 and Staff #4 shall be attending the appropriate training within the next 21 days from the Corrective Action date. During that period of time a staff person certified in CPR & First Aid will be on
site at the Outpatient facility.
The Clinical Supervisor shall ensure that Outpatient counselors receive current CPR/First-Aid certifications within the appropriate timeframe. |