INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the December 29-30, 2008 licensure renewal inspection. The follow-up inspection was conducted on July 13, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 August 14, 2009.
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Plan of Correction
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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 July 13, 2009. The documentation of the fire drills conducted between January 2, 2009 and July 7, 2009 demonstrated that the pull alarms were utilized for all but the March 30, 2009 drill, 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. There was no indication of which method was utilized on the March 30, 2009 drill.
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Plan of Correction
A meeting was held with the Facilities manager, facility director and the captain of security. The smoke detectors will be activated at an upcoming fire drill. This will be documented on the fire drill log. The Facilities manager will monitor for compliance. |
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 collect the personal history in six of seven client records.
The findings include:
Fourteen client records were reviewed on July 13, 2009. Personal histories were reviewed in seven 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 the recreational history in client records # 1, 2, 3, 5, 6 and 8.
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Plan of Correction
The current psycho social assessment is being revised. The revisions will include a more extensive substance abuse history which will address the recreational history and the family relations. It will identify significant events/problems the clients had growing up. All staff will receive training on completing the assessment. The facility 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 eight of eight client records.
The findings include:
Fourteen client records were reviewed on July 13, 2009. Psychosocial evaluations were reviewed in eight client records. The facility did not document a clinical evaluation in client records # 3, 4, 6 and 8. In addition, the evaluations that were documented in client records # 1, 2, 5, and 12 did not address a composite picture of the client in relationship to the collected historical information, but only a generalized conclusion of the persons appearance, behavior and reaction during the intake process.
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Plan of Correction
Weekly chart reviews will occur during individual clinical supervision to insure that all client records are complete with psycho social assessments. Any staff needing to be retrained on this documentation protocol will receive additional training. The Facility 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 four of seven client records.
The findings include:
Fourteen client records were reviewed on July 13, 2009. Treatment plans were reviewed in seven client records. The facility did not document treatment plans in client records # 1, 2, 3 and 4.
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Plan of Correction
All client records will include an individual treatment plan. Weekly chart reviews during supervision sessions will insure that treatment plans are completed and in the charts. Staff will receive additional training on this protocol. The Facility 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 three of three client records.
The findings include:
Fourteen client records were reviewed on July 13, 2009. Three client record's treatment plans were reviewed for support services. There were no support services documented on client records # 5, 6 and 9. Instead, there was a generalized statement on each treatment plan of case management services as needed.
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Plan of Correction
Treatment plans will be more specific and document the support services that the client will receive. Staff will receive training on documentation protocol. The Facility 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 eight of nine client records.
The findings include:
Fourteen client records were reviewed on July 13, 2009. Treatment plan reviews were required in nine client records. There were no treatment plan update reviews for client records # 1, 2, 3, 4, 5, 6 and 9. Client record # 11 had a review due by April 10, 2009, and the last review was dated February 10, 2009.
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Plan of Correction
All treatment plans will be updated at least every 60 days. Staff will be counseled and receive necessary training to insure that protocol is followed. Facility Director or 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 in fourteen of fourteen client records reviewed.
The findings include:
Fourteen client records were reviewed on July 13, 2009. Complete records were required in fourteen client records. The facility did not maintain complete records in record # 1, missing a comprehensive treatment plan, treatment plan update, progress notes since May 11, 2009 and documentation of case consultations. Record # 2 was missing a comprehensive treatment plan, updated reviews and case consultations. Records
# 3 and 4 were both missing a comprehensive treatment plan, an update review and case consultation. Records # 5, 7, 8, 9, 10, 11, 12, 13 and 14 were missing follow up documentation. Records # 9 and 11 were missing a treatment plan update. Record # 14 was missing a discharge summary though the client had not been seen or contacted since April 9, 2009 and was listed as a discharged client on the facility discharge roster.
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Plan of Correction
There will be a complete client record on every individual. Weekly chart reviews during clinical supervision will insure that all charts are in compliance. Staff will be counseled and receive necessary training. The Facility 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 three of three client records.
The findings include:
Fourteen client records were reviewed on July 13, 2009. Aftercare plans were required in three client records. The aftercare plans for records # 8 and 9 contained support services without specific information. Client records # 8, 9 and 12 were 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 an aftercare plan containing specific information. The aftercare plans will include goals and timeframes, any services that can be provided by the program after discharge, the method and frequency of contact and the criteria for re-entry into the project.
Staff will receive training to insure that the aftercare plans are completed entirely. The Facility 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 a review of client records, the facility failed to document follow up information in nine of nine client records.
The findings include:
Fourteen client records were reviewed on July 13, 2009. Nine records required follow up documentation. Records # 5, 7, 8, 9, 10, 11, 12, 13 and 14 did not have any documentation of follow up attempts.
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Plan of Correction
A follow up contact will be documented on all clients upon discharge. Staff will receive training on documentation protocol. The Facility director or designee will monitor for compliance. |