INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 8, 2008 through December 9, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHD Lower Marion Counseling 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 January 11, 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.
Findings:
The facility's fire drill record was reviewed on December 8, 2008. During the months of July 2008, August 2008, September 2008, October 2008 and November 2008 the fire drill record did not indicated alternate exit routes used during fire drills.
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Plan of Correction
The Director has already trained staff in documenting fire drills with a specific emphasis on documenting alternate exit routes for each monthly drill. Reviewing these drills will be part of the quarterly review of charts performed by the CQI committee which will next meet 3/4/09. The Director is responsible for making sure that these drills include the aternating exit routes. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on the review of client records, the facility failed to remove parent/guardian signature line on all consent to treatment forms in seven of seven records reviewed.
Findings:
Seven client records were reviewed on December 9, 2008. Consent to treatment forms were required in seven client records. 71 P.S. 1690.112 Consent of Minor, state law states no age of consent is required. Also, 42 CFR part (2) subpart (b) section 2.14 B states that state law does not require parental consent to treatment. Parent/guarding signature line were on all consent forms in records #1, 2, 3 4, 5, 6 and 7.
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Plan of Correction
The Director has supervised the revision of the form so that the parent/guardian line has been removed as of 1/9/09. Updating this form ensures that no signatures from parents or guardians will be obtained in the future.
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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 seven client records.
Findings:
Seven records were reviewed on December 9, 2008. Psychosocial evaluations were required in seven client records. The psychosocial evaluations did not include clinical assessments of the assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and the counselors' impression of the client in client records #1, 2, 3, 4 and 7.
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Plan of Correction
The Intake Assessment has been revised so that all information about assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and the counselor's impression of the client has been moved to the section entitled "Summary of Clinical Impressions". The Director and RHD Central staff have begun training the staff during staff meetings in how to write clinical impressions. The CQI committee will review the "Summary of Clinical Impressions" to make sure that the therapists are including all information and giving their impressions, not just summarizing facts. The Director is responsible for making sure these changes are made. |
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 the review of client records, the facility failed to document treatment plans in two of three client records.
Findings:
Seven client records were reviewed on December 9, 2008. Treatment plans were required in three client records. The facility did not document treatment plans in client records #3 and 7. During the review of the facility's policy and procedure manual on December 8, 2008, it was identified in the policy that all treatment plans are to be developed by the 3rd session following admission. Client #3 was admitted on 10/21/08; there was no treatment plan in the client's record. Client #7 was admitted on 10/6/08; there was not treatment plan in the client's record.
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Plan of Correction
The Director has already reminded staff that treatment plans are to be completed after the third therapy session. This treatment plan is in addition to the initial treatment plan completed at Intake. The Director with remind staff again in both staff meetings and in individual supervision to complete the more extensive treatment plan by the third session after the inidial Intake. The treatment plans will be reviewed by the CQI committee on 3/4/09 and quarterly after that date. |