INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 24, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cen-Clear Child 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.
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Plan of Correction
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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential 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, the facility failed to ensure fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
The findings include:
A physical plant inspection was conducted on August 24, 2011 from approximately 11:30 AM to 11:55 AM. The facility has three fire extinguishers. The fire extinguishers are required to be inspected and approved annually by the local fire department or fire extinguisher company. The fire extinguishers were inspected by a local fire extinguisher company in February 2010. The fire extinguishers were due to be inspected by the local fire department or fire extinguisher company no later than February 2011. There was no documentation that the fire extinguishers were inspected by the local fire department or fire extinguisher company since February of 2010, at the time of the review on August 24, 2011.
The project and facility directors were interviewed on August 24, 2011 at approximately 11:45 AM. The project director confirmed that the facility did not have documentation that the fire extinguishers had been inspected by the local fire department or fire extinguisher company since February 2010. The project director reported the facility has recently moved to this location in May of 2011. The project director reported this issue will be corrected as soon as possible.
This is a repeat citation from the August 25, 2010 licensing inspection.
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Plan of Correction
The Assistant to the Executive Director, has requested a copy of the inspection that occured on June 9, 2011 by a firefighter of the Lawrence Township Fire Department, Cleafield, PA.. The Fire Department forwarded a copy of the inspection of facility and extinguishers on June 9, 2011. From this point on all fire extinguisher tages will reflect the actual date they were inspected on an annual basis. Annual fire extinguishers inspections will be the responsibility of the Assistant to the Executive to ensure that they are completed annually. She has developed a schedule that all facilities will be inspected in the month June on an annual basis. The Assistant to the Executive will assure and is responsible for making sure that all facilities are within regulation. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to document the instruction of staff in the use of the fire extinguisher upon staff employment, in one of one personnel records.
The findings include:
Three personnel records were reviewed on August 22, 2011. One employee was a new hire and required fire extinguisher training upon employment. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel record # 3.
Employee # 3 was hired on June 28, 2011. Employee # 3 completed fire extinguisher training on August 16, 2011. Fire extinguisher training was not completed upon staff employment, as required.
The facility director was interviewed throughout the licensing process and confirmed that employee # 3 had not completed fire extinguisher training upon staff employment.
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Plan of Correction
The faciity director and CenClear human resource department worked collaberatively in implementing new hire policy at time of hire and during orientation on the first day all new DA employees will fire extinguisher training and sign off as such. the human resource director will assure and have documentation signed by said staff that they have completed the fire extinguisher/safety training at each orientation which occurs the first day of hire. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of policies and procedures, client records and staff interviews, the facility failed to document medical, drug/alcohol and personal histories according to the facility's written procedures for the management of treatment/rehabilitation services for clients in two of five client records. In addition, the facility failed to document a written procedure that requires the development of a psychosocial evaluation based on the collected historical information of the client.
The findings include:
The facility's policy and procedure manual was reviewed on August 22, 2011. Five client records were reviewed on August 24, 2011. Five client records were reviewed for client histories and psychosocial evaluations. Per regulation, the governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to: written procedures for the management of treatment/rehabilitation services for clients.
The facility utilizes a file check-in list, documented as D & A form 22. Per the facility's written procedure and D & A form 22, the counselor is required to complete the psychosocial evaluation by the client's second counseling session. The counselor then is required to complete the intake paperwork, which includes the medical, drug/alcohol and personal histories, by the fifth counseling session. Per regulation, the psychosocial evaluation should provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation. The facility procedure requires the counselor to complete the psychosocial evaluation prior to actually collecting the historical information. This is inconsistent with the regulation; which requires the psychosocial evaluation to be based on the collected historical information. The facility failed to document a written procedure that requires the development of a psychosocial evaluation based on the collected historical information of the client.
The facility's written procedure regarding medical, drug/alcohol and personal histories states these histories will be completed by the fifth counseling session. Based on a review of client records, the facility failed to document medical, drug/alcohol and personal histories no later than the fifth counseling session in client records # 1 and 3.
Client # 1 was admitted into treatment on April 12, 2011. The medical, drug/alcohol and personal histories were due to be completed no later than the fifth counseling session which was conducted on May 26, 2011. The medical, drug/alcohol and personal histories were not documented until July 21, 2011.
Client # 3 was admitted into treatment on March 7, 2011. The medical, drug/alcohol and personal histories were due to be completed no later than the fifth counseling session which was conducted on May 31, 2011. The medical, drug/alcohol and personal histories were not documented until August 23, 2011.
The project and facility directors were interviewed throughout the licensing inspection. The facility director confirmed that the client histories were not completed by the fifth session, as required by facility policy. The project and facility directors both confirmed the procedure states staff will complete the psychosocial evaluation prior to the medical, drug/alcohol and personal histories. The project director reported this procedure will be revised.
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Plan of Correction
The facility director has updated our current policy that all intake, psycho/socials will be completed by the following timeline of sessions:
Policy has been changed to reflect that counselors will complete the preliminary treatment plan by the first session, intake and psychosocial by the fifth session of opening.
The facility director retrained all staff during her weekly supervision of September 5 to September 9, 2011 and will review client records once a month. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of policies and procedures, client records and an interview with the facility director, the facility failed to document treatment plan review and updates every 60 days, as per facility policy and regulation, in two of two client records.
The findings include:
Five client records were reviewed on August 24, 2011. Per facility policy and regulation, treatment plan review and updates will be completed every 60 days. Treatment plan review and updates were required in two client records. Three client records were not due for treatment plan review and updates. The facility failed to document treatment plan review and updates every 60 days in client records # 1 and 5.
Client # 1 was admitted into treatment on April 12, 2011. The comprehensive treatment plan was completed on June 9, 2011. A treatment plan review and update was due to be completed no later than August 9, 2011. The treatment plan review and update was not completed until August 24, 2011.
Client # 5 was admitted into treatment on February 7, 2011. The comprehensive treatment plan was completed on May 23, 2011. A treatment plan review and update was due to be completed no later than July 23, 2011. There was no documentation of a treatment plan review and update in client record # 5, at the time of the review on August 24, 2011.
The facility director was interviewed on August 24, 2011 at approximately 2:15 PM and confirmed these treatment plan review and updates were not completed within the required 60 day time frame.
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Plan of Correction
The facility director will be responsible for the review of all 60 day treatment updates. The program director will randomly select chart review to determine if policy is being followed within the timeframe of policy. |
709.93(a)(2) 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:
(2) Medication records.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to document medication records which indicate the dosage and frequency of use in two of three client records.
The findings include:
Five client records were reviewed on August 24, 2011. Medication records which indicate the name of the drug, dosage, and frequency of use were required in three client records. The facility failed to document medication records which indicate the dosage and frequency of use in client records # 1 and 5.
Client # 1 was admitted into treatment on April 12, 2011. Per the client's medical history documented in client record # 1, the client is prescribed Plavix and Crestor. There was no documentation in client record # 1 of the dosage or frequency of use of these medications, at the time of the review on August 24, 2011.
Client # 5 was admitted into treatment on February 7, 2011. Per the client's medical history documented in client record # 5, the client is prescribed prednisone. There was no documentation in client record # 5 of the dosage or frequency of use of this medication, at the time of the review on August 24, 2011.
The facility director was interviewed on August 24, 2011 at approximately 2:30 PM and confirmed the findings.
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Plan of Correction
Project Director will review intake paperwork for completeness. The medication information is obtained during the intake process. . Staff have been instructed to idnetify what medications, dosages and frequency. If unable to obtain from client document in space provided "dont know". The facility director will review all intake paperwork prior to her weekly supervision with staff and identify to them any issues that she discovers and have staff complete during next session. |