INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 5, 2011 through April 6, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Path Incorporated 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 May 6, 2011.
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Plan of Correction
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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the fire drill record, the facility failed to ensure that fire drills are conduct on different times of the day.
The findings include:
The fire drill record was reviewed on April 5, 2011. There was no documentation of a drill conducted on the evening shift. All drills were conducted on either the morning or afternoon shifts. The following months were reviewed June 2010, July 2010, August 2010, September 2010, October 2010, November 2010, December 2010, January 2010 and February 2010. The facility's hours are Monday, Thursday and Friday 9 am - 5 pm and Tuesday and Wednesday 9am to 9pm. Facility staff was interviewed on April 5, 2011 and they confirmed that there was none done during the evening hours.
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Plan of Correction
A fire drill was conducted on April 5,2011 at 5:48 PM. PATH's Facilities Director is responsible for planning, documenting and maintaining documentation for all fire drills. The Facilities Director will ensure that a minimum of 2 fire drills per year are scheduled after 5 PM on evenings when the D&A program is open for service provision. |
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 a review of client records and a discussion with facility staff, the facility failed to document psychosocial evaluations within the facility's allotted time in two of seven client records.
The finding includes:
Twelve client records were reviewed on April 6, 2011. Psychosocial evaluations were to be documented in seven client records, #1, 2, 3, 4, 5, 7 and 8. The psychosocial evaluations were not documented within the facility's allotted time in four of seven required, #1, 3, 5 and 7. A discussion with facility staff on April 6, 2011 confirmed that the psychosocial evaluations were not completed within their allotted time. The policy and procedure manual was reviewed on April 6, 2011. Psychosocial evaluations will be conducted and documented within 30 days of the client's admission date into the drug and alcohol program.
Client record #1 was admitted to the program on January 14, 2011 and their psychosocial evaluation was to be conducted and documented on or before February 14, 2011. Client record #1 psychosocial evaluation was not completed until March 31, 2011.
Client record #3 was admitted to the program on November 3, 2010 and their psychosocial evaluation was to be completed on or before December 3, 2010. Client record #3 psychosocial evaluations were not completed until March 23, 2011.
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Plan of Correction
PATH's Adult Services Director has updated our policy to state that counselor assessments(ie psychosocial evaluations)will be completed for all individuals by the 4th visit to the D&A program but not to exceed 45 days from admission to the program.
PATH's Outpatient Director will train all staff regarding the updated timeframes. The training is scheduled to occur on 05/12/2011.
PATH's Quality Improvement Specialist conducts random quarterly audits and will monitor for compliance with the updated time frames. The QI Specialist will begin auditing for this requirement during the 4th quarter (4/01/2011-6/30/2011) audit. |
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 a review of client records and a discussion with facility staff, the facility failed to document treatment plans within the facility's allotted time in four of seven client records.
The finding includes:
Twelve client records were reviewed on April 6, 2011. Treatment plans were to be documented in seven client records, # 1, 2, 3, 4, 5, 7 and 8. The treatment plans were not documented within the facility's allotted time in four of seven required, # 1, 3, 7 and 8. A discussion with facility staff on April 6, 2011 confirmed that the treatment plans were not completed within their allotted time. The policy and procedure manual was reviewed on April 5, 2011. Treatment plans will be completed within 30 days of the client's admission date into the drug and alcohol program after the completion of the client's biopsychosocial histories and evaluation.
Client record # 1 was admitted to the program on January 14, 2011 and their treatment plan was to be completed on or before February 14, 2011. Client record # 1 treatment plan was completed on March 15, 2011 before the completion of the client's psychosocial evaluation which was completed on March 31, 2011.
Client record # 3 was admitted to the program on November 3, 2010 and their treatment plan was to be completed on or before December 3, 2010. Client record #3 treatment plan was not completed on December 14, 2010 before the completion of the client's psychosocial evaluation which was completed until March 23, 2011.
Client record # 7 was admitted to the program on September 30, 2010 and their treatment plan was to be completed on or before October 30, 2010. Client record # 7 treatment plan was not completed on November 1, 2010.
Client record # 8 was admitted to the program on September 27, 2010 and their treatment plan was to be completed on or before October 27, 2010. Client record # 8 treatment plan was not completed until November 1, 2010.
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Plan of Correction
The treatment plan is completed based on the psychsocial evaluation. PATH's Adult Services Director has updated PATH's policy to state that the treatment plan will be completed after the psychosocial evaluation but not to exceed 45 days of admission to the D&A program.
PATH's Outpatient Director will train staff on the updated timelines. The training is scheduled to occur on May 12,2011.
PATH's Quality Improvement Specialist conducts quarterly record audits and will audit for compliance with the updated guidelines during the 4th quarter (4/1-6/30,2011) audit. Results of the audit will be givven to the Outpatient Director who will address any noncompliance issues with staff. |
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 client records and a discussion with facility staff, the facility failed to document treatment plan updates within the facility's allotted time in two of four client records.
The finding includes:
Twelve client records were reviewed on April 6, 2011. Treatment plan updates were to be documented in four client records, #2, 3, 4 and 5. The treatment plan updates were not documented within the facility's allotted time in two of four required, # 3 and 4. A discussion with facility staff on April 6, 2011 confirmed that the treatment plan updates were not completed within their allotted time. The policy and procedure manual was reviewed on April 5, 2011. Treatment plan updates will be completed within 60 days of the client ' s comprehensive treatment plan.
Client record #3 comprehensive treatment plan was developed on December 14, 2010 and their treatment plan update should be documented on or before February 14, 2011. Client record #3 treatment plan update was not documented until March 8, 2011.
Client record #4 comprehensive treatment plan was developed on September 22, 2010 and their treatment plan update should be documented on or before November 22, 2010. Client record #4 treatment plan update was not documented until December 1, 2010 and the second treatment plan was not documented until February 28, 2011.
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Plan of Correction
The outpatient Directoe will retrain staff regasrding PATH's existing policy that requires treatment plans to be updated every 60 days. The training will occur on May 12,2011.
PATH's Quality Improvement Specialist conducts quarterly record audits and will audit for this requirement. Audit feedback is given to the Outpatient Director who will address any noncompliance issues with staff. |
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 and an interview with facility staff, the facility failed to document client follow-up information in five of seven discharge records.
The findings include:
Twelve client records were reviewed on April 6, 2011. Seven client records, #6, 7, 8, 9, 10, 11 and 12 were reviewed for follow-up information. An interview with the facility staff on April 5, 2011 and April 6, 2011 revealed that the facility sends aftercare plans to any client who does not successfully complete treatment or was not being referred, on the day of discharge. Staff reported that the mailing of the aftercare plan was considered as the follow-up contact with discharge client. There was no follow-up information documented in the client records and the facility's current procedure failed to comply with the regulations regarding follow-up communication with a discharge client.
Client # 8 was admitted on September 27, 2010 and discharged on December 21, 2010. Per the interview with facility staff, an aftercare letter was sent out the day of discharge.
Client # 9 was admitted on September 22, 2010 and discharged on November 10, 2010. Per the interview with facility staff, an aftercare letter was sent out the day of discharge.
Client # 10 was admitted on April 8, 2010 and discharged on November 11, 2010. Per the interview with facility staff, an aftercare letter was sent out the day of discharge.
Client # 11 was admitted on May 26, 2010 and discharged on November 15, 2010. Per the interview with facility staff, an aftercare letter was sent out the day of discharge.
Client # 12 was admitted on May 7, 2010 and discharged on December 1, 2010. Per the interview with facility staff, an aftercare letter was sent out the day of discharge.
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Plan of Correction
Staff will receive retraining on PATH's existing follow-up procedure regarding communication with an individual discharged from service. This procedure states that a follow-up letter be sent within 60 days of discharge. The training will occur on May 12th,2011.
The Program Director,who reviews all discharges, will ensure that a follow-up letter is sent whenever an individual is discharged and not referred to an outside service. |