INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 2, 2012 to April 3, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Holcomb Associates, Inc. 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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705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on observations on April 3, 2012, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents.
The findings include:
A physical plant inspection was conducted on April 3, 2012. It was observed during the inspection at approximately 10:10 A.M., that the facility has a dumpster in the parking lot. Two of the lids on the dumpster were bent in an upward position and were only partially closed.
The findings were confirmed during an ongoing dialogue with the facility director on April 3, 2012 from approximately 10:00 A.M. to 10:12 A.M.
This is a repeat citation. The facility was cited on March 24, 2011 for noncompliance with this standard.
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Plan of Correction
HBHS will arrange for a replacement dumpster, with secure lids.
HBHS Facilities Manager will contact our trash removal contractor, to arrange for delivery of a more secure dumpster, with more durable lids that sit securely on the container.
HBHS has a cleaning service that will ensure proper trash storage; this service will have oversight from our internal Building manager.
The Facility Director will monitor the new dumpsters effectiveness on a weekly basis. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment.
The findings include:
On April 2, 2012 and April 3, 2012, five personnel records requiring documentation of fire extinguisher training were reviewed. The facility did not provide documentation that they instruct staff in the use of the fire extinguisher upon staff employment in one of five personnel records reviewed, specifically, personnel record # 8.
Employee #8, the psychiatrist, was hired on March 5, 2012. Employee # 8 was due to complete fire extinguisher training upon employment. However, personnel record # 8 did not include documentation of fire extinguisher training as of April 3, 2012.
The findings were confirmed during an ongoing dialogue with the clinical supervisor on April 3, 2012 from approximately 9:30 A.M. to 10:00 A.M.
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Plan of Correction
HBHS Site safety manager will instruct all current staff on fire extinguisher safety, and train all new hires in the same.
All new hires will recieve Safety Training...including fire extinguisher training...within their first 7 days of employment at HBHS, from the Site Safety Manager. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill records, the facility failed to conduct unannounced fire drills at least once a month.
The findings include:
Fire drill records were reviewed on April 2, 2012. The records were reviewed from the period covering March 2011 to March 2012. The facility did not have documentation of an unannounced fire drill in one of twelve months reviewed, specifically, September 2011.
The findings were confirmed during an ongoing dialogue with the clinical supervisor and facility director on April 2, 2012 from approximately 3:30 P.M. to 4:00 P.M.
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Plan of Correction
It is the policy of Holcomb Behavioral Health Systems that unannounced Fire Drills will be planned and conducted monthly by the Site Safety Manager.
This person will plan such drills, including arranging new interior fire routes, and oversee the monthly execution of these drills, under the supervision of the Facility Director.
This will begin in May of 2012, and continue monthly. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
The findings include:
On January 31, 2012, five personnel records requiring documentation that all personnel on all shifts had been trained to perform assigned tasks during emergencies were reviewed. The facility did not provide documentation of the completion of emergency training in two of five personnel records, specifically, personnel records # 7 and 8.
Employee # 7, the medical director, was hired on May 11, 2011. Employee # 7 was due to complete emergency training upon employment. However, personnel record # 7 did not include documentation of emergency training as of April 3, 2012.
Employee # 8, the psychiatrist, was hired on March 5, 2012. Employee # 8 was due to complete emergency training upon employment. However, personnel record # 8 did not include documentation of emergency training as of April 3, 2012.
The findings were confirmed during an ongoing dialogue with the clinical supervisor on April 3, 2012 from approximately 9:30 A.M. to 10:00 A.M.
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Plan of Correction
HBHS Site Safety Manager will provide emergency training for all Medical Staff.
Our Site Safety Manager will meet with all new consulting staff, and ensure that Safety Training is completed for each staff within 7 days of their initial employment. This training will be documented, and kept with the appropriate HR records.
Safety Taining for all other staff is performed as part of our Orientation program, which is a mandatory training held prior to the staff beginning their new responsibilities. The Human Resources Department representative is responsible for this function (this orientation is done by different HR staff).
The two staff referenced in our POC have both resigned, so we intend to move forward training all of our new consulting staff. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on review of administrative documentation, the facility failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services at the end of the fiscal year.
The findings include:
The administrative documentation was reviewed on April 2, 2012. The facility was required to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services at the end of their fiscal year. The facility's 2010 through 2011 fiscal year ended on June 30, 2011. However, the facility's financial audit for this period was not completed until March 22, 2012.
The findings were confirmed during an interview with the Chief Compliance Officer on April 2, 2012 at approximately 9:30 A.M.
This is a repeat citation. The facility was cited on March 24, 2011 for noncompliance with this standard.
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Plan of Correction
HBHS will arrange for an independent audit of our Drug and Alcohol programs, which will be completed within the required time frame.
The company Compliance Officer, and Facilities Manager will be responsible
for the timely completion of this task, beginning after the end of the 2011/2012 Fiscal Year.
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709.28(c) 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:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information.
The findings include:
On April 3, 2012, six client records requiring documentation of informed and voluntary consent were reviewed. The facility released information without the client's consent in four of six client records reviewed, specifically, client records # 1, 2, 5, and 6.
Client record # 1 contained one Eligibility Verification System form dated October 10, 2011 in which the facility released information about the client to a government agency, but the facility did not have a signed consent from the client to release the information.
Client record # 2 contained one Eligibility Verification System form dated October 7, 2011 in which the facility released information about the client to a government agency, but the facility did not have a signed consent from the client to release the information.
Client record # 5 contained one Eligibility Verification System form dated June 13, 2011 in which the facility released information about the client to a government agency, but the facility did not have a signed consent from the client to release the information.
Client record # 6 contained one Eligibility Verification System form dated October 10, 2011 in which the facility released information about the client to a government agency, but the facility did not have a signed consent from the client to release the information.
The findings were confirmed during an ongoing dialogue with the clinical supervisor on April 3, 2012 from approximately 3:00 P.M. to 3:30 P.M.
This is a repeat citation. The facility was cited on March 24, 2011 for noncompliance with this standard.
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Plan of Correction
It is HBHS Policy that all HBHS client charts will have specific and accurate Release of Information forms included. The Program Director will provide direct Training to her staff on this issue, then monitor charts in an ongoing fashion to ensure compliance.
In the future, permission will be obtained before consulting the state EVS system.This approval will be obtained by our Clinical Support Staff, under the guidance of the Coordinator of Clinical Support Services. This person reports to the Facility manager, who will ocersee and monitor the process. |
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, the facility failed to document a psychosocial evaluation in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Biopsychosocial Assessment", states:
"A complete biopsychosocial history/assessment will be conducted and recorded at the client's date of admission to the program .....Biopsychosocial assessment will include, at minimum:
A clear description of the client's presenting and underlying problems; client needs or problems that can or cannot be resolved through treatment or that might inhibit treatment.
The client's assets, strengths or other factors that can contribute to the resolution of identified problems; the potential or available client support systems; obstacles that might effect treatment are documented as well.
The client's preferred coping and defense mechanisms, conclusions regarding the client's appearance, behavior, and reactions during the evaluation will be documented and used to determined course of treatment.
Client's strengths/assets, support systems and preferred coping mechanisms. Potential treatment barriers that may impact the course of treatment. Mental status assessment.
Conclusions and treatment recommendations, including preliminary treatment planning. Recommendations should include treatment modalities and frequency."
On April 3, 2012, four client records requiring documentation of a psychosocial evaluation were reviewed. The facility did not document a psychosocial evaluation according to their policy and procedures in four of four records reviewed, specifically, client records # 1, 2, 3, 4.
Client# 1 was admitted October 26, 2011. The psychosocial evaluation was due October 26, 2011; however, the psychosocial evaluation in client record # 1 was not completed until November 2, 2011. Also, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, negative factors, and attitude toward treatment.
Client# 2 was admitted October 12, 2011. The psychosocial evaluation was completed on October 12, 2011; however, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, and coping mechanisms.
Client# 3 was admitted January 23, 2012. The psychosocial evaluation was due January 23, 2012; however, the psychosocial evaluation in client record # 3 was not completed until January 30, 2012. Also, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, negative factors, and attitude toward treatment.
Client# 4 was admitted February 2, 2012. The psychosocial evaluation was completed on February 2, 2012; however, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, negative factors and attitude toward treatment.
The findings were confirmed during an ongoing dialogue with the clinical supervisor on April 3, 2012 from approximately 3:00 P.M. to 3:30 P.M.
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Plan of Correction
All Biopsychcosocial Assessments will be completed within the required time frame, and be inclusive of all the areas required. The Program manager will arrange immediate, and ongoing training for all clinical staff, stressing the importance of addressing all relevant domains.
Begining immediately, weekly staff supervision will include a review of the paperwork for all newly admitted clients, to ensure accuracy in completing the form regularly, and to ensure timliness. |
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, the facility failed to document an individual treatment and rehabilitation plan in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Comprehensive Treatment Plan," states:
"A comprehensive treatment plan will be developed within 30 days of the date of admission."
On April 3, 2012, seven client records requiring documentation of an individual treatment and rehabilitation plan were reviewed. The facility did not document an individual treatment and rehabilitation plan according to their policy and procedures in two of seven records reviewed, specifically, client records # 1 and 7.
Client # 1 was admitted October 26, 2011. The individual treatment and rehabilitation plan was due November 25, 2011; however, the individual treatment plan in client record # 1 was not documented until November 30, 2011.
Client # 7 was admitted September 27, 2011. The individual treatment and rehabilitation plan was due October 27, 2011; however, the individual treatment plan in client record # 7 was not documented until November 15, 2011.
The findings were confirmed during an ongoing dialogue with the clinical supervisor on April 3, 2012 from approximately 3:00 P.M. to 3:30 P.M.
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Plan of Correction
Comprehensive Treatment Plans will be developed for all HBHS clients within 30 days of their date of admission.The Program manager will provide training to her staff on the importance of compliance, and then monitor each chart during staff supervision to ensure that the Treatment Plans are done on time.
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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, the facility failed to document follow-up information.
The findings include:
The facility's policy titled: "Drug and Alcohol Treatment Activities," states:
"Counselors will follow up with discharged clients by telephone within 30 days. Results of follow up will be documented in progress note in client chart. If a discharged client has been referred to an outside resource, the Counselor will attempt (with written consent of the client) and one week from the day the referral is to be completed, contact the resource to determine the disposition of the referral."
On April 3, four client records requiring documentation of follow-up information were reviewed. The facility did not document follow-up information in two of four records reviewed, specifically, client records # 8 and 9.
Client # 8 was admitted August 1, 2011 and was discharged March 2, 2012. The follow-up information was due March 9, 2012. However, client record # 8 did not include documentation of follow-up information as of April 3, 2012.
Client # 9 was admitted February 21, 2011 and was discharged August 3, 2011. The follow-up information was due September 2, 2011. However, client record # 9 did not include documentation of follow-up information as of April 3, 2012.
The findings were confirmed during an ongoing dialogue with the clinical supervisor on April 3, 2012 from approximately 3:00 P.M. to 3:30 P.M.
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Plan of Correction
All HBHS Discharged clients will have documented follow up contact within 30 days of the discharge. The program Coordinator provide training on this issue at all current and future staff.
She will establish a monitoring system that will ensure follow up
contact from HBHS for all discharged D&A clients that will enable her to verify this contact before charts are archived.
HBHS will reach out for follow up to the clients who's records were referenced in the DAPL site visit. |