INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 20, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northeast Family Healthcare, LLC 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential 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.
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Observations
Based on observation, the facility failed to ensure privacy so that counseling sessions could not be seen or heard outside a counseling room.
The findings include:
During the inspection, the Licensing Specialist utilized a vacant office located towards the rear of the building. It was observed by this writer that in the adjacent room an individual counseling session was being conducted with the office door open. After the Licensing Specialist noted his concerns with the Lead Counselor, the door was immediately shut; however, the session could still be heard through the wall of the office. Thus, enabling a person in the common hallway and in the adjacent offices to view and/or overhear the counseling sessions.
The Facility Director confirmed the findings.
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Plan of Correction
The facility director will assess the building layout and provide noise/sound machines for all staff offices to increase sound blockage.
Additionally, the facility director will facilitate a confidentiality training for all staff disciplines, including nursing and clinical staff to ensure that information in regards to confidentiality within the office space is communicated.
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709.28(c)(5) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to obtain a complete informed and voluntary consent for the disclosure of information, to include the dated signature of a witness in one of seven records reviewed.
The findings included:
Seven client records requiring complete releases of information were reviewed on May 20, 2014. The facility failed to include the dated signature of a witness in client record #4.
Client #4 was admitted to treatment on 01/08/2014 and was still an active client at time of the inspection. Three releases of information to three separate government agencies, one release of information to an insurance company, and one release of information to an emergency contact were signed on 01/08/2014 and did not include the dated signature of a witness.
The Facility Director confirmed the findings.
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Plan of Correction
The facility director reviewed the deficiency and will conduct a staff training within the next 30 days to ensure that all staff is trained on how to complete a consent in it's entirety.
The facility director and therapist whom the patient record is assigned to, will review the chart, and sign the witness signature to ensure that the chart is completed.
Facility director will conduct monthly chart reviews to review the consents that are signed are completed correctly. |
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, the facility failed to document a treatment and rehabilitation plan update at least every 60 days in three of five records.
The findings include
Seven client records were reviewed on May 20, 2014, whereas five records required documentation of treatment and rehabilitation plans reviewed and updated at least every 60 days. Treatment plans were not reviewed and updated every 60 days in client records # 1, 2, and 4.
Client #1 was admitted to treatment on 11/13/2013 and was still an active client at the time of the inspection. The comprehensive treatment and rehabilitation plan was completed on 12/19/2013. The treatment and rehabilitation plan was reviewed and updated on 02/19/2014 and was again due to be reviewed and updated no later than 04/19/2014. The treatment and rehabilitation plan update was not completed until 05/11/2014.
Client #2 was admitted to treatment on 08/07/2013 and was still an active client at the time of the inspection. The comprehensive treatment and rehabilitation plan was completed on 09/05/2013. The treatment and rehabilitation plan was reviewed and updated on 11/05/2013, 01/05/2014, 05/05/2014, and 05/12/2014. There was no documentation that the treatment and rehabilitation plan was reviewed and updated during the period of 03/05/2014.
Client #4 was admitted to treatment on 01/08/2014 and was still an active client at the time of the inspection. The comprehensive treatment and rehabilitation plan was completed on 02/10/2014. The treatment and rehabilitation plan was to be reviewed no later than 04/10/2014. The treatment and rehabilitation plan was reviewed and updated on 05/01/2014.
The Project Director confirmed the findings.
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Plan of Correction
The facility director reviewed the findings. The facility director will conduct a training on correct timelines of treatment plans that meet the requirements of state guidelines as provided.
The lead counselor will assist the facility director in conducting monthly random audits to ensure all information and timelines are correct. |
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 a review of client records, the facility failed to document a complete client record on an individual, which includes case consultation notes, discharge summary, and follow-up information in three of seven client records reviewed.
The findings include:
Seven client records requiring a complete client record on an individual were reviewed on May 20, 2014. The facility did not provide a complete client record for client #s 4, 5, and 7.
Client #4 was admitted to treatment on 01/08/2014 and was still active at the time of the on-site inspection. The facility failed to include documentation of case consultation notes in the client record.
Client #5 was admitted to treatment on 07/07/2013 and was discharged on 10/18/2013. The facility failed to include documentation of case consultation notes in the client record. Additionally, a follow up was to be completed no later than 10/25/2013; however there was no follow up documented as of the date of this inspection.
Client #7 was admitted to treatment on 08/07/2013 and was discharged on 10/25/2013. The facility failed to document a discharge summary in the client record.
The Facility Director confirmed the findings.
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Plan of Correction
The facility director reviewed the findings.
For client #4, director will review the chart and follow up with therapist assigned to ensure that case consultations are done as scheduled to meet state requirements.
Client #5:director will review with the chart and follow up with therapist assigned to the case to ensure that case consultations are done within the state required time frame.
Client #7: Client's chart will be reviewed by facility director and discharge summary will be completed within 5 days.
In order to ensure that the defiencies do not occur again, facility director and lead counselor will conduct a training within 7 days to train the staff on effective timelines for discharge summaries and document all case consults and due dates so they are completed within a timely manner. |