INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 7, 2009 through January 8, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Perry Human Services Inc. 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 February 7, 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 the review of the facilities fire drill record, the facility failed to document alternate exit routes used during the fire drills.
Findings:
The fire drill record was reviewed on January 7, 2009. For the months of March 2008, April 2008, May 2008, July 2008, August 2008, September 2008, October 2008, November 2008 and December 2008 the only exit route documented was the front exit.
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Plan of Correction
705.28-Fire Safety
Executive Director will review with staff the fire drill exit procedure, including using alternate exits, at the 2/2/09 staff meeting. Executive Director will conduct monthly fire drills and document in the fire safety notebook which exits are used. This correction will be completed by February 20, 2009. |
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 complete psychosocial evaluations in five of six client records.
Findings:
Six client records were reviewed on January 8, 2009. Psychosocial evaluations were required in five client records. The psychosocial evaluations were disjointed with listed responses and client stated comments rather than a clinical assessment of the client when it came to the client composite picture, clients problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, clients attitude toward treatment and the counselors impression/impression of the client in client records #1, 2, 3, 4 and 5.
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Plan of Correction
709.91-Intake and Admissions
Executive Director contacted the licensure specialist the week of January 19 for technical assistance regarding changes needed for the agency's psychosocial evaluation form. The Executive Director will revise the current form to expand areas for clinical assessment by counselors. The revised psychosocial evaluation form will be reviewed by counselors during their monthly treatment meeting on February 16, 2009. Counselors will begin using the revised form by February 28. During each initial client file review the Executive Director/Clinical Supervisor will monitor closely counselor's clinical assessment in the psychosocial evaluation form. |
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 the review of client records, the facility failed to document aftercare plans in one of six records.
Findings:
Six client records were reviewed on January 8, 2009. After care plans were required in two client records. The facility did not document aftercare plan in client record #5.
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Plan of Correction
709.93-Client records
The agency has an aftercare plan form that is to be completed by the counselors and client upon discharge. The Executive Director/Clinical Supervisor will review the aftercare plan procedure with counselors at their monthly treatment meeting on February 16, 2009. The Executive Director/Clinical Supervisor will review each client file at discharge to verify that an aftercare plan has been completed. |