INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Women's Institute for Family Health 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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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on an inspection of the facility's physical plant, the facility failed to ensure that exits from the facility were unobstructed.
The findings include:
A physical plant inspection was conducted with the project director on June 9, 2014 at around 4:15 PM. During the inspection it was found that the second (rear) exit from the building had two mops in the grates of the screen door.
The findings were confirmed by the project director.
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Plan of Correction
The Executive Director has removed the mops from the grates and has identified another location away from the door for the mops to be stored. The Executive Director will assure that the mops are never left near the rear door again. Written instructions have been given to all staff regarding the proper storage of mops. |
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 the review of client records, the facility failed to document a complete client record to include progress notes in three out of ten client records reviewed.
The findings include:
Ten client records were reviewed for documentation of progress notes on June 9, 2014. The facility failed to document individual progress notes in client records # 1, 5 and 7.
Client # 1 was admitted on February 27, 2014 and was still active during the time of inspection. The record of services for client #1 included documentation of a counseling session that had occurred on 6/3/14. As of the date of inspection, there was no documentation of the corresponding progress note for client # 1.
Client # 5 was admitted on December 3, 2013 and discharged on March 24, 2014. Record # 5 included nine progress notes that were missing the following information:
-The note representing an individual counseling session conducted on 2/18/14 had no data, plan, or counselor signature.
-The note representing an individual counseling session conducted on 1/16/14 had no assessment or plan.
-The notes representing individual counseling sessions conducted on 1/28/14, 1/2/14, 12/19/13, 12/11/13, and 12/3/13 were blank and unsigned.
Client # 7 was admitted on October 1, 2013 and was discharged on April 17, 2014. The record of services for client # 7 included documentation of individual sessions that had occurred on 2/27/14, 2/17/14, and 12/24/13. As of the date of inspection, there was no documentation of the corresponding progress notes for client # 7.
The findings were reviewed and confirmed by the project director.
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Plan of Correction
The person responsible for the missing notes has been terminated. To assure that progress notes are completed as per regulations counseling staff must present a progress note for each counseling session along with time sheets. Staff will not be compensated for sessions without documentation of progress notes. The Executive Director through monitoring submission of progress notes will assure that there will not be a re-occurrence of missing notes. |