INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 29-30, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, WES Corporation. 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 28, 2009.
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Plan of Correction
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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on the physical plant inspection conducted on 12-29-08 and again on 12-30-08, the facility failed to ensure proper hot water temperatures.
The findings include:
Two bathrooms were inspected and the water temperature was taken on 12-29-08. The men's bathroom hot water temperature measured 140 while the women's bathroom hot water temperature measured
64
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Plan of Correction
Effective 1/5/09 the Facilities Department has adjusted the water temperature to meet State regulations. The Director of Facilities Management will monitor weekly for compliance and it will be documented on a temperature chart. |
705.28 (b) (3) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(3) Repair inoperable smoke detectors or fire alarms within 48 hours of the time the detector or alarm is found to be inoperative.
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Observations
Based on a review of administrative documentation, the facility failed to determine the operability of the three installed smoke detectors located in the facility.
The findings include:
The fire drill safety log was reviewed on December 29, 2008. The documentation of the fire drills conducted between March 2008 and December 2008 demonstrated that the pull alarms were utilized for all of the fire drills conducted and none of the smoke detectors were utilized, therefore, it was impossible to determine if they were operable at the time of the inspection or during the monthly drills.
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Plan of Correction
Smoke detectors will be activated by use of an artificial smoker and it will be documented on the fire drill log. This will insure that the smoke detectors are operable. The Captain of Public Safety will monitor for compliance. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on a physical plant walk-through, the facility failed to secure client records within a locked storage container.
The findings include:
The physical plant walk through of the facility was conducted on 12-29-08. Upon inspection of what was described by the facility staff as a storage room that was unlocked at the time, there was a pile of client records sitting on the top of a pile of boxes as well as client records located within some of the boxes. There were other various items also being stored within the room at the time of the inspection. The facility does have a specific file room with file cabinets.
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Plan of Correction
Discharged charts that were being prepared for transfer to medical records will be stored in a secured locked area. Boxes have been ordered in order to transfer the medical charts. The various items have been removed so that only the charts are in this area. The area is secure and locked. The Program Director or Designee will maintain the key and will insure that the room remains locked at all times. The Program is in the process of transferring discharged medical charts from three (3) years or more to the Medical Records Department. The locked chart room housing current charts and more recent discharges has become overcrowded thus creating the need to transfer older charts to Medical Records. The Program Director will monitor for compliance. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the review of client records, the facility failed to document the length and patterns and client perceptions of their drug use in four of four client records, and failed to document any history in another record.
The findings include:
Six client records were reviewed on December 30, 2008. Drug and alcohol histories were required in five records. The facility did not document a drug and alcohol history in record # 2. The facility did not include the client's length and pattern of use or the client's perception of their use in records # 1, 3, 5 and 6.
This is a repeat deficiency. This was cited during the 2/6/08, 9/19/07, 4/18/07 and 9/26/06 inspections.
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Plan of Correction
Of the six (6) client records reviewed in chart #2 the history was missing due to the therapist failure to file. Weekly supervision will be held with all therapists to insure that all chart documentation is completed and filed in the charts. A meeting was held with the Director of the Assessment and Intake Unit, Program Director, Facility Director and the QA Director to discuss revisions needed to insure that all information is captured in the psychosocial and easily identifiable to the reader. The current psychosocial evaluation is being revised. It will include prompts that specifically include the client's perception of their use. Staff will be re-trained on documentation protocol using the revised form. The Program Director or Designee will monitor for compliance via individual supervision and on-going chart audits. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of client records, the facility failed to fully collect the personal history in five of five client records.
The findings include:
Six client records were reviewed on December 30, 2008. Personal histories were required in five client records. The facility did not fully document family and recreational sections of the personal history. The personal histories failed to address family relations, significant events/problems growing up and recreation interests in client records # 1, 3, 5 and 6. In addition, the facility failed to complete a personal history for # 2.
This is a repeat deficiency.
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Plan of Correction
The Psychosocial Evaluation will be revised to include prompts specific to the areas in the aforementioned. Staff will be re-trained on the documentation protocol to insure that the psychosocial is completed accurately. The Program Director or Designee will monitor for compliance. |
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 the review of client records, the facility failed to document psychosocial evaluations in four of five client records.
The findings include:
Six client records were reviewed on December 30, 2008. Psychosocial evaluations were required in five client records. The facility did not document an evaluation in client records # 1, 2 and 5. In addition, the evaluations that were documented contained client reported statements and repeat of the historical data collected in client record # 3.
This is a repeat deficiency. This was cited during the 2/6/08, 9/19/07, 4/18/07 and 9/26/06 inspections.
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Plan of Correction
The evaluation did not clearly provide all information therefore the psychosocial evaluation will be revised and staff will be re-trained on the protocol for completing the psychosocial evaluation accurately. The Program Director or Designee will monitor for compliance. |
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 four client records.
The findings include:
Six client records were reviewed on December 30, 2008. Treatment plans were required in four client records. The facility did not document treatment plans in client records # 1 and 5. In addition, client record # 6 was one month late in being developed, according to program policy of 30 days post admission.
This is a repeat deficiency. This was cited during the 2/6/08, 9/19/07, 4/18/07 and 9/26/06 inspections.
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Plan of Correction
The facility will document treatment plans on every client according to agency policy. All staff will be trained on treatment plan protocol and the Program Director or Designee will monitor for compliance. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to document support services on the treatment plan in one of two client records.
The findings include:
Six client records were reviewed on December 30, 2008. Treatment plans with support services were required in two client records. the facility did not document support services needed in client record # 6.
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Plan of Correction
Treatment plans requiring support services for clients will be documented to reflect same. Staff will receive training on treatment plan protocol. Program Director or Designee will monitor for compliance. |
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 the review of client records, the facility failed to document treatment plan reviews at least every 60 days in three of three client records.
The findings include:
Six client records were reviewed on December 30, 2008. Treatment plan reviews were required in three client records. The last documented review for client record # 4 was May 2, 2008. Another was due by July 2, 2008. There were no treatment plan reviews documented for records # 5, due by November 7, 2008 and 6, due by November 12, 2008.
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Plan of Correction
All treatment plans will be updated at least every 60 days as per program policy. If client is unavailable to participate documentation will be provided to substantiate that. Staff will receive training in treatment plan protocol. Program Director of Designee will monitor for compliance. |
709.93(a) 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:
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Observations
Based on the review of client records, the facility failed to maintain complete records on all clients reviewed.
The findings include:
Six client records were reviewed on December 30, 2008. Complete records were required in five client records. One of the six reviewed was an intake only. The facility did not maintain complete records in record # 1, missing a psychosocial evaluation, preliminary treatment plan, comprehensive treatment plan and documentation of follow up attempt. Record # 2 was missing all client history and evaluation and follow up attempt. Record # 3 was missing follow up attempt. Record # 5 was missing an evaluation,a comprehensive treatment plan and case consultation. Record # 6 was missing a treatment plan update. All records reviewed are missing the person providing the service on the client record of service logs.
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Plan of Correction
All client records will include a complete record of all activity relative to the client's involvement in the program. Staff will receive training to insure that all charts are complete and in compliance with State regulations. Program Director or Designee will monitor for compliance. |
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 complete an aftercare plan in two of two client records.
The findings include:
Six client records were reviewed on December 30, 2008. Aftercare plans were required in two client records. The facility did not document an aftercare plan for client record # 4. The aftercare plan for record # 2 contained support services without specific information. It was missing goals with time frames, services that could be provided by the project after discharge, the method and frequency of contact and criteria for re-entry into the project.
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Plan of Correction
All client records will include a preliminary aftercare plan due on admission and a final aftercare plan due when a client has successfully completed the program. The discharge and aftercare plan will include goals, time frames and any services that can be provided by the program after discharge. The discharge and aftercare plan will include criteria for re-entry into the program. The program does provide a re-entry protocol that is usually a second page which is attached to the final discharge and aftercare plan, however to insure that it is present and available to the client it will be formatted as a double sided form on the back of the discharge and aftercare form. Staff will receive training on completion of the discharge and aftercare plan. The Program Director or Designee will monitor for compliance. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on the review of client records, the facility failed to complete follow up attempts in three of four client records.
The findings include:
Six client records were reviewed on December 30, 2008. Follow up contact attempts were required in four client records. The facility did not document follow up contact in client records # 1, 2 and 3.
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Plan of Correction
All clients will receive a follow-up contact and it will be documented in the client record. This will be reiterated to all staff and training will be provided to insure that a follow-up contact is completed on all discharged clients and documented. Program Director or Designee will monitor for compliance. |