INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 28-29, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Cove Forge Behavioral Health System at Williamsburg 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:
|
Plan of Correction
|
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
|
Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of counseling area. The window on the door to the group space in Sobriety House was not covered allowing counseling sessions to be seen. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The window has been covered with film that cannot be seen through to ensure privacy.
Leadership rounds are conducted weekly and the managers have been reminded to check that all windows in areas where counseling occurs have been covered.
The facility director will unsure compliance with this regulation.
|
709.83(a)(11) LICENSURE Client records
709.83. 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.
|
Observations
Based on a review of seven client detox records, the facility failed to provide a complete client record, which is to include follow up information in two of three applicable records.Client #20 was admitted on January 25, 2022 and discharged on February 18, 2022. There was no documentation of follow up information in the client record. Client #21 was admitted on December 16, 2021 and discharged on February 14, 2022. There was no documentation of follow up information in the client record. These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The case management team have been re-educated on the importance of doing a 7 day follow up on all patients regardless of where they are going upon discharge from treatment. Follow up will occur even when patients decline aftercare or move to a different state in an effort to see if the patient is in need of treatment/recommendations at that time.
The case management supervisor will ensure compliance.
The case management supervisor will audit 15 charts for the next 3 months to ensure compliance. |
709.63(a)(6) LICENSURE Aftercare plan
709.63. 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:
(6) Aftercare plans, if applicable.
|
Observations
Based on a review of seven client detox records, the facility failed to provide a complete client record, which is to include aftercare plans in one of one applicable record.Client #5 was admitted on December 15, 2021 and discharged on December 21, 2022. There was no documentation of an aftercare plan in the client record. These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The detox counselors have been re-educated on the importance of providing an aftercare appointment and documenting that aftercare arrangement for all detox patients who do not transition internally to the residential or partial hospital level of care.
The detox supervisor will ensure compliance.
The detox supervisor will audit 5 charts for the next 3 months to ensure compliance. |
709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
|
Observations
Based on a review of seven client detox records, the facility failed to provide a complete client record, which is to include a discharge summary in one of one applicable record.Client #7 was admitted on March 11, 2022 and discharged on March 15, 2022. There was no documentation of a discharge summary in the client record. These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The discharge summary on patient #7 will be completed by May 1, 2022.
The clinical staff have been reeducated on the importance of completing discharge summaries within 7 days of discharge.
If the discharge summary is not completed within 5 days, the clinical supervisor will aid in it's completion.
The medical records staff will send out a list of non completed discharge summaries on day 5.
The medical records director and clinical supervisors will oversee the timeliness of discharge summary completion.
The clinical supervisors will audit 5 charts each for the next 3 months to ensure timely completion. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
|
Observations
Based on a review of seven client detox records, the facility failed to provide a complete client record, which is to include follow up information in two of three applicable records.Client #5 was admitted on December 15, 2021 and discharged on December 21, 2022. There was no documentation of follow up information in the client record. Client #6 was admitted on February 7, 2022 and discharged on February 10, 2022. There was no documentation of follow up information in the client record. These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The case management team has been asked to complete a 7 day follow up on all detox only patients.
Follow up will occur even when patients decline aftercare or move to a different state in an effort to see if the patient is in need of treatment/recommendations at that time.
The case management supervisor will ensure compliance.
The case management supervisor will audit 15 charts for the next 3 months to ensure compliance. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
|
Observations
Based on a review of seven client detox records, the facility failed to provide a complete client record, which is to include an aftercare plan in two of three applicable records.Client #13 was admitted on February 12, 2022 and discharged on March 7, 2022. There was no documentation of an aftercare plan in the client record. Client #14 was admitted on January 11, 2022 and discharged on February 8, 2022. There was no documentation of an aftercare plan in the client record. These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The detox counselors have been re-educated on the importance of providing an aftercare appointment and documenting that aftercare arrangement for all detox patients who do not transition internally to the residential or partial hospital level of care.
The detox supervisor will ensure compliance.
The detox supervisor will audit 5 charts for the next 3 months to ensure compliance. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
|
Observations
Based on a review of seven client detox records, the facility failed to provide a complete client record, which is to include a discharge summary in two of three applicable records.Client #13 was admitted on February 12, 2022 and discharged on March 7, 2022. There was no documentation of a discharge summary in the client record. Client #14 was admitted on January 11, 2022 and discharged on February 8, 2022. There was no documentation of a discharge summary in the client record. These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The discharge summary on patients #13 and #14 will be completed by May 16, 2022.
The clinical staff have been reeducated on the importance of completing discharge summaries within 7 days of discharge.
If the discharge summary is not completed within 5 days, the clinical supervisor will aid in it's completion.
The medical records staff will send out a list of non completed discharge summaries on day 5.
The medical records director and clinical supervisors will oversee the timeliness of discharge summary completion.
The clinical supervisors will audit 5 charts each for the next 3 months to ensure timely completion. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
|
Observations
Based on a review of seven client detox records, the facility failed to provide a complete client record, which is to include a follow up information in two of three applicable records.Client #13 was admitted on February 12, 2022 and discharged on March 7, 2022. There was no documentation of follow up information in the client record. Client #14 was admitted on January 11, 2022 and discharged on February 8, 2022. There was no documentation of follow up information in the client record. These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The case management team has been asked to complete a 7 day follow up on all detox only patients.
Follow up will occur even when patients decline aftercare or move to a different state in an effort to see if the patient is in need of treatment/recommendations at that time.
The case management supervisor will ensure compliance.
The case management supervisor will audit 15 charts for the next 3 months to ensure compliance. |