INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the May 9, 2011 compliant investigation. The follow-up inspection was conducted on September 19, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Parkside Recovery was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential 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 interviews with patients and staff, the facility failed to ensure privacy so that counseling cannot be seen or heard outside the counseling room.
The findings include:
A follow-up inspection took place on September 19, 2011. During the follow-up inspection, staff and patients disclosed that counseling room doors are sometimes open during group sessions due to temperature issues. Leaving the counseling doors open does not ensure the patient's privacy since any patient or staff member can walk past the counseling offices and overhear and/or view the counseling sessions at any given time.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the May 9, 2011 complaint investigation.
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Plan of Correction
On October 28, 2011 counselor were re-trained by clinical supervisor of the importance of confidentiality and the need to ensure all doors are closed during group and individual sessions. To ensure that no further violation will occur this area of concern has been placed on the security daily safety round checklist for security officer to monitor and inform clinical supervisor when this area is not being addressed. Security officers are sceduled to complete this rounding at least once every 2 hours during an 8hr work schedule. The Clinical Supervisor and/or Program Director will review these reports at weekly staff meetings. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on interviews with patients and staff, the facility failed to comply with the Department of Public Welfare Medical Assistance Manual requirements relative to the number of participants in group counseling sessions.
The findings include:
A follow-up inspection took place on September 19, 2011. During the investigation, staff and patients disclosed that the group counseling sessions included between 10 and 25 patients, depending on the counselor and the type of group. If one patient in a group counseling session is funded through the Office of Medical Assistance, the facility must comply with the Department of Public Welfare's Medical Assistance Manual requirement that group treatment sessions be limited to 10 patients. The facility failed to limit group counseling sessions to 10 patients.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the May 9, 2011 complaint investigation.
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Plan of Correction
The average group size continues to be within the standards. Effective October 28, 2011 all clients will be directed to attend their regularly scheduled groups and will be directed to a make-up group as needed if regular times are missed. This will be closely monitored by the clinical supervisor in collaboration with the counseling staff. |