INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 18, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Interim House West 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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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records, the facility failed to document a mechanism to consistently collect feedback on completed training in one of four personnel records reviewed.
The findings include:
Four personnel records which required documentation of feedback on completed training were reviewed on June 18, 2015. The facility failed to consistently document the submission of completed feedback forms after the completion of employee training in employee record #4.
Employee #4 has been in the counselor position since 7/1/10. The employee's record failed to consistently document feedback on completed training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on a review of personnel records, IHW failed to document a mechanism to consistently collect feedback on completed training in one of four personnel records reviewed.
Training forms will be completed in its entirety by all staff attending onsite trainings. Supervisors will review all training forms before signing to ensure their completion. The Administrative Assistant will review all training plans quarterly to ensure feedback on evaluation forms are completed. |
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 an informed and voluntary consent which includes the specific information to be disclosed in four of four client records reviewed.
The findings include:
Four client records were reviewed on June 18, 2015 for informed and voluntary consents. The facility failed to document an informed and voluntary consent in client records, #1, 2, 3 and 4.
Client #1 was admitted into treatment on 1/2/15 and was still active at the time of the inspection. The facility failed to document, on the consent to release form dated 1/5/15, the specific information to be disclosed to the Faciltiy's health clinic.
Client #2 was admitted into treatment on 9/4/14 and was discharged on 12/26/14. The facility failed to document, on the consent to release form dated 9/4/14, the specific information to be disclosed to the facility's health clinic.
Client #3 was admitted into treatment on 9/10/14 and was discharged on 1/14/15. The facility failed to document, on the consent to release form dated 9/11/14, the specific information to be disclosed to the facility's health clinic.
Client #4 was admitted into treatment on 8/25/14 and was discharged on 3/23/15. The facility failed to document, on the consent to release form dated 8/25/14, the specific information to be disclosed to the facility's health clinic.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
IHW failed to obtain an informed and voluntary consent which includes the specific information to be disclosed in four of four client records reviewed. In the charts audited, IHW failed to complete the release of information form correctly and failed to identify the specific information to be disclosed to the facility's health clinic.
IHW's Clinical Director will hold a staff training to review 709.28 regulations as it pertains to release of information. Trainings will be documented by signature of attendance sheets. All current releases will be reviewed and updated to meet this regulation. |
709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on the review of client records, the facility failed to ensure that counseling services were provided to the client on a regular and scheduled basis in one of four client records reviewed.
The findings include:
Four client records were reviewed on June 18, 2015. The facility failed to ensure that counseling services were provided to the client on a regular and scheduled basis in client record #4.
Client #4 was admitted into treatment on 8/25/14 and was discharged on 3/23/15. The client's individual treatment and rehabilitation plan dated 9/24/14 stated the client was to receive individual counseling sessions once a week. Scheduled individual counseling sessions for the client were canceled by the counselor on the following dates: 9/25/14, 11/28/14, 1/2/15, 1/16/15, 2/6/15, and 3/6/15. The canceled sessions were not rescheduled to recur during the same week.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In the charts audited, IHW failed to ensure that counseling services were provided on a regular basis in one of four client records reviewed.
The Clinical Director will review therapists' schedules in weekly supervision to ensure sessions are held and reassign or reschedule participants as needed. IHW's Clinical Director and TQM department will also perform monthly and quarterly chart audits respectively to ensure compliance with this standard. |
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 the review of client records, the facility failed to ensure that a complete record was documented in three of four client records reviewed.
The findings include:
Four client records were reviewed for documentation of a complete client record during the renewal inspection on June 18, 2015. The facility failed to document a complete record in client records # 1, 2, and 3.
Client #1 was admitted into treatment on 1/2/15 and was still active at the time of the inspection. A record of service for the client indicated that the client attended individual counseling sessions on 5/21/15 and 4/29/15. Progress notes for these individual counseling sessions were not documented in the client's record.
Client #2 was admitted into treatment on 9/4/14 and was discharged on 12/26/14. A record of service for the client indicated that the client attended group therapy sessions on 12/23/14 and 11/27/14. Progress notes for these group therapy sessions were not documented in the client's record. Additionally, a progress note documented in the client's record indicated that the client attended a group therapy session on 11/25/14. This group therapy session was not documented on the record of service for the client.
Client #3 was admitted into treatment on 9/10/14 and was discharged on 1/14/15. A record of service for the client indicated that the client attended individual counseling sessions on the following dates: 1/5/15, 1/9/15, 11/11/14, and 11/5/14. The record of service also indicated that the client attended group therapy sessions on 12/11/14 and 11/25/14. Progress notes for these individual counseling sessions and group therapy sessions were not documented in the client's record. Additionally, progress notes documented in the client's record indicated that the client attended group therapy sessions on 12/11/14 and 11/25/14. These group therapy sessions were not documented on the record of service for the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
IHW failed to ensure that a complete record was documented in three of four client records reviewed. IHW failed to document a complete record in client records #1,2, & 3.
IHW's Clinical Director will review Record of Services to documentation submitted by staff during their weekly supervision. The Clinical Director and TQM departments will perform monthly and quarterly chart audits respectively to ensure compliance with this standard. The Program Director will monitor the overall compliance on a monthly basis. |
709.53(b) LICENSURE Standardized Forms
709.53. Client records.
(b) The project shall develop and maintain client records on standardized project client record forms.
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Observations
Based on a review of client records, the facility failed to develop and maintain client records on standardized project client record forms in one of four client records reviewed.
The findings include:
Four client records were reviewed on June 18, 2015. The facility failed to maintain client records on standardized project client record forms for client record # 1.
Client # 1 was admitted into treatment on 1/2/15 and was still active at the time of the inspection. The client's treatment plan updates dated 5/2/15 and 6/1/15 were not on standardized project client record forms.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In one of four client records audited, IHW failed to maintain client records on standardized project record forms.
Due to computer malfunction,
staff failed to use the standardized project client record forms when completing treatment plan updates. The Clinical Director will ensure compliance through weekly individual supervision with program therapists. When computer generated forms are not available, standardized copies of forms will be accessible to all staff. |