INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 5-6, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Care Center dba SPHS Care Center 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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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to document that a written unusual incident report was submitted to the Department within 3 business days for reports reviewed on June 5-6, 2017.
An ambulance was called to the facility on December 1, 2016 and May 5, 2017. No documentation was provided that the incidents were reported to the Department.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility Director will review the unusual incident policy and procedure with Supervisors by 6/15/17. Supervisors will be aware that a report needs to be sent to the Department within 3 business days of the incident. The facility Director will review all unusual incidents and ensure proper reporting. |
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
The facility failed to document that the treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of seven client records reviewed on June 5-6, 2017.
Client # 4 treatment plan update was due on January 28, 2017. The update was completed February 28, 2017. Update due by April 28, 2017 was not documented.
Client # 5 treatment plan update was due on March 3, 2017. The update was completed on April 13, 2017.
Client # 13 treatment plan update was due on December 19, 2016. Update documented was completed on Feburary 8, 2017.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A mandatory staff meeting will be held with all staff to review treatment plan timelines and regulations. The supervisor will stress that the plan of care updates will be completed every 60 days as per regulation. The supervisor will remind staff that plan of care updates may completed with out the client present and reviewed and signed at their next scheduled appointment to not miss due dates. Each staff member will be provided with a copy of our agency's policy and regulations in regard to treatment plan timelines. This will be completed by July 1, 2017. To assure staff members are improving in this area internal chart audits will be conducted. The Clinical Supervisor will be responsible for this plan of correction and ongoing monitoring of same. |