D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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WOMEN'S INSTITUTE FOR FAMILY HEALTH
255 S.17TH STREET, SUITE 808
PHILADELPHIA, PA 19103

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Survey conducted on 08/08/2018

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on August 8, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Women's Institute for Family and Health, was found to not 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
709.28 (c) (1) 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 must be in writing and include, but not be limited to: (1) Name of the person, agency or organization to whom disclosure is made.
Observations The facility failed to include the name of the person, agency or organization to whom the disclosure was being made in one out of seven client records. The facility also failed to have a witness sign the consent form. Client #3 was admitted on October 13, 2017 and was discharged on July 30, 2018. There was a consent to release information form filled out to "insurance carrier" which was not signed by a witness. There was a second consent to release form filled out to "parole officer or sentencing judge" which was not signed by a witness. These findings were reviewed with the facility staff during the licensing process.	Plan of Correction The Executive Director will provide training to clinical staff on how to properly complete disclosure forms. The primary counselor will be responsible for initialing disclosure forms to verify completion at the time of his/her first contact with the client and the Executive Director will during the course of chart reviews confirm that consents are filled out to include the name of person or agency the information is being released to and that all forms contain a witness signature.
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.
Observations The facility failed to update client treatment plans in three out of seven treatment plans reviewed. Client # 1 was admitted on March 26, 2014 and was still active at the time of inspection. The comprehensive treatment plan was dated February 21, 2018 with the next update being due no later than April 21, 2018, however the update was not completed until April 24, 2018. The following treatment plan was due no later than June 24, 2018 however it was not completed and was not on record at the time of inspection. Client #2 was admitted on July 7, 2016 and was still active at the time of the inspection. The comprehensive treatment plan was dated November 22, 2017, with the next update being due no later than January 22, 2018 however it was not completed until February 7, 2018. The next update was due no later than April 7, 2018 however it was not completed until June 27, 2018. Client #3 was admitted on October 13, 2017 and was still active at the time of investigation. The comprehensive treatment plan was dated November 31, 2018, with the next update being due no later than January 31, 2018 however it was not completed until July 3, 2018. These findings were reviewed with facility staff during the licensing process. This was a repeat violation from the August 18, 2017 inspection.	Plan of Correction The Executive Director will conduct staff training on treatment protocols to assure that clinical staff is informed of when updates are due. The Executive Director will during the course of chart reviews inspect files on a weekly basis to assure that updates are being completed within the 60 day time frame. Counselors who after receiving training fail to prepare updates within the 60 day time frame will be removed from the counseling roster.
709.92(c) LICENSURE Treatment and rehabilitation services 709.92. Treatment and rehabilitation services. (c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
Observations The facility failed to provide counseling services according to the treatment plan in seven out of seven records reviewed. Client #1 was admitted on March 26, 2014 and was still active at the time of the inspection. The treatment plan indicated individual therapy weekly. The client did not have individual therapy session documented for the weeks of: August 20. 2017, September 10, 2017, September 24, 2017, October 22, 2017, November 12, 2017, November 19, 2017, November 26, 2017, December 24, 2017, January 1, 2018, January 14, 2018, January 28, 2018, February 4, 2018, February 11, 2018, February 25, 2018, March 4, 2018, March 11, 2018, March 18,2018, March 25, 2018, April 8, 2018, April 15, 2018, April 29, 2018, May 6, 2018, May 27, 2018, June 3, 2018, June 10, 2018, June 17, 2018, July 1, 2018 and July 8, 2018. Client #2 was admitted on July 7, 2016 and was still active at the time of the inspection. The treatment plan indicated individual therapy weekly. The client did not have individual therapy sessions documented for the weeks of: September 3, 2017, September 10, 2017, October 8, 2017, October 15, 2017, November 12, 2017, December 3, 2017, December 10, 2017, December 17, 2017, December 31, 2017, January 7, 2018, January 28, 2018, February 11, 2018, February 25, 2018, March 4, 2018, March 18, 2018, March 25, 2018, April 1, 2018, April 8, 2018, April 15, 2018, April 29, 2018, May 6, 2018, May 13, 2018, May 20, 2018, June 17, 2018, July 1, 2018. July 8, 2018, July 15, 2018, July 22, 2018 and July 29, 2018. Client #3 was admitted on October 10, 2017 and was discharged on July 20, 2018. The treatment plan indicated individual therapy weekly. The client did not have individual therapy sessions documented for the weeks of: December 3, 2017, December 10, 2017, December 24, 2017, December 31, 2017, January 7, 2018, January 21, 2018, January 28, 2018, February 18, 2018, April 15, 2018, April 22, 2018, May 13, 2018, May 20, 2018, May 27, 2018, June 3, 2018, June 10, 2018, July 1, 2018, July 8, 2018, July 15, 2018 and July 22, 2018. Client #4 was admitted on December 5, 2017 and discharged on April 3, 2018. The treatment plan indicated individual therapy weekly. The client did not have individual therapy sessions documented for the weeks of: December 10, 2017, December 17, 2017, December 24, 2017, December 31, 2017, January 7, 2018, January 14, 2018 and February 4, 2018. Client #5 was admitted on March 19, 2018 and was discharged on July 31, 2018. The treatment plan indicated individual therapy sessions weekly. The client did not have individual therapy sessions documented for the weeks of : April 8, 2018, June 17, 2018, July 1, 2018, July 15, 2018, July 22, 2018 and July 29, 2018. Client #6 was admitted on April 10, 2018 and was still active at the time of the inspection. The treatment plan indicated individual therapy weekly. The client did not have individual therapy sessions documented for the weeks of May 13, 2018, May 20, 2018, May 27, 2018, June 3, 2018 and June 10, 2018. Client #7 was admitted on January 12, 2018 and was discharged on April 26, 2018. The treatment plan indicated individual therapy sessions weekly. The client did not have individual therapy sessions documented for the weeks of: March 4, 2018, March 18, 2018 and April 1, 2018. These findings were reviewed with the facility staff during the licensing process.	Plan of Correction The Executive Director will provide training to clinical staff on treatment protocols to assure understanding that treatment plans must be amended to reflect the frequency of treatment as per the treatment plan. The counselor will make a notation in the client record of absences that are due to emergencies. The program will allow for three emergency episodes. An episode could include several consecutive days absence due to illness or other emergency. Client's that are absent for more than 30 consecutive days due to an emergency illness will be discharged and will receive written notification that they are eligible to return to treatment through re-admission when the emergency has ended. Absences that are due to circumstances beyond the client's control such as cancellation of public transit due to inclement weather will not count towards the three allowed. Clients that fail to consistently attend treatment as per their treatment plan will be discharged after three consecutive absences and will receive written notification of their eligibility to return to treatment through re-admission. Counselor's that fail to follow treatment protocols after receiving training will be removed from the counseling schedule.