INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 11-12, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Conewago Snyder 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.
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Plan of Correction
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705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection and an interview with the facility director, the facility failed to ensure that all fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
The findings include:
A physical plant inspection was conducted with the project director and the facility director on June 12, 2014 from approximately 9:00 AM until 10:00 AM. During the inspection of the kitchen and dining room area, it was found that there were three fire extinguishers that were not up to date with their inspections. Two of the extinguishers were located near the two exits of the dining hall and the third extinguisher was located in the kitchen next to the staff restroom. The expiration dates on all three extinguishers were April 2014.
The Project Director and the Facility Director confirmed the findings.
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Plan of Correction
Fire Extenguishers located in the kitchen /dining area have been inspected by KINT Fire Protection Serviceson 6/19/2014. Corporate Compliance Officer and Facility Director on a monthly basis will conduct audits of the fire extinguisher tags to ensure that the extinguishers are operational and that the yearly inspection is completed in a timely manner. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain a complete informed and voluntary consent for the disclosure of information, which includes the dated signature of a witness, the purpose of disclosure, and complying with 4 PA Code 255.5 in three of fifteen records reviewed.
The findings included:
Fifteen client records requiring complete releases of information were reviewed on June 11-12, 2014. The facility failed to include the purpose of disclosure in client record #3. The facility also failed to stay within the limits imposed by 4 Pa. Code 255.5 in relation to the release of information in client record #6. Additionally, the facility failed to include the date of signature on 4 consent to release information forms in client record #8.
Client #3 was admitted to treatment on 05/09/2014 and was still an active client at time of the inspection. A consent to release form to a government agency signed by the client on 5/9/2014 was in the client record; however, there was no purpose of release identified on the consent form.
Client #6 was admitted to treatment on 08/28/2014 and was dishcarged on 10/10/2013. A release of information to a government agency was signed by the client on 10/8/2013 and allowed for the disclosure of information (aftercare plan, discharge summary, and certificate of completion), which exceeded 255.5
Client #8 was admitted to treatment on 9/19/2013 and was discharged on 11/15/2013. Three separate releases of information consent forms to three different government agencies and one release of information consent form to a parent were signed by the client; however all four consent forms did not have the date of when they were signed by the client.
The Project Director and the Facility Director confirmed the findings.
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Plan of Correction
On June 25, 2014 a staff meeting was conducted with facility staff by the facility director and a staff re-training regarding completion of consent to release forms. Training included ensuring the proper completion of signature and date from the client and witness. Training included a full breakdown of what section tabs are to be completed regarding who the consent is for. Training included staff completing a blank consent form for demonstration of skill. The Facility Director, Facility Clinical Director, and the Corporate Compliance Officer will conduct monthly audits of current and discharge clients to ensure that documentation shows client involvement in their treatment plan creation. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 provide an individual treatment and rehabilitation plan that was developed with the client in one of fifteen client records.
The findings included:
Fifteen client records requiring an individual treatment and rehabilitation plan developed with the client were reviewed on June 11-12, 2014.
Client #2 was admitted to treatment on 5/5/2014 and was still an active client at the time of the on-site inspection. There was a completed individualized treatment and rehabilitation plan in the client's record; however there was no client signature, counselor signature, clinical supervisor signature, and medical doctor signature (which was required) included on the plan. Additionally, there was no indication in any of the progress notes that clearly identified that the counselor and the client created the treatment and rehabilitation plan together.
The Project Director and the Facility Director confirmed the findings.
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Plan of Correction
On June 23, 2014 a clinical staffing was conducted for the purpose of training the clinical team on the proper procedures for completing a master treatment plan. The training included how to properly sign a master treatment plan, completing an individual session note for documentation which includes the clients feedback on the creation of the master treatment plan. The Facility Director and the Corporate Compliance Officer will conduct monthly audits of current and discharge client charts to ensure client participation in the creation of their treatment plans. |
709.53(a) LICENSURE Complete Client Record
709.53. 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:
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Observations
Based on a review of client records and an interview with the Facility Director and Corporate Compliance Officer, the facility failed to ensure that there is a complete client record on an individual which includes information relative to the client's involvement with the project and shall include follow-up information in four of fifteen client records.
The findings include:
Fifteen client records were reviewed on June 11-12, 2014. Nine client records were for discharged clients and required documentation of a follow-up. The facility did not document a follow-up in client records # 6, 8, 9 and 10.
Client #6 was admitted on 8/28/2013 and was successfully discharged on 10/10/2013. There was no documentation of a follow up attempt or that a follow up was scheduled as of the date of the on-site licensing inspection.
Client #8 was admitted on 9/19/2013 and successfully discharged on 11/15/2013. There was no documentation of a follow up attempt or that a follow up was scheduled as of the date of the on-site licensing inspection.
Client #9 was admitted on 10/17/2013 and unsuccessfully discharged on 11/19/2013. There was no documentation of a follow up attempt or that a follow up was scheduled as of the date of the on-site licensing inspection.
Client #10 was admitted on 10/10/2013 and was unsuccessfully discharged on 11/23/2013. There was no documentation of a follow up attempt or that a follow up was scheduled as of the date of the on-site licensing inspection.
The Project Director and the Corporate Compliance Officer confirmed the findings.
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Plan of Correction
On June 23, 2014 a clinical staff meeting was conducted for the training of the clinical team on how to set up a discharge clients follow up contact screen. The training included where to locate the follow up screen, how to enter contact information, and what questionairre to select for follow up contact. The Facility Director and thr Corporate Compliance Officer will conduct monthly audits of client discharge list to ensure that client follow ups are scheduled and being conducted. |