INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 11, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Aldie Counseling Center 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 and a plan of correction is due on February 15, 2011.
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Plan of Correction
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on an inspection of the facility ' s physical plant and an interview with the facility director, the facility failed to ventilate toilet and wash rooms by exhaust fan or window.
The findings include:
An inspection of the facility ' s physical plant was conducted on January 11, 2011 between the hours of approximately 1:00 PM - 2:00 PM. At approximately 2:00 PM it was observed that the men ' s communal bathroom was not ventilated by exhaust fan or window.
An interview with the facility director on January 11, 2011 confirmed that the ventilation system did not create a noticeable airflow.
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Plan of Correction
The office manager will solicit proposals from contractors for the installation of an exhaust fan for the indicated bathroom. The executive director will select an acceptable proposal and authorize the work to be done. Once the installation of the exhaust fan is completed, the facility director (i.e., operations director)will check the operation of the fan and monitor its proper operation throughout the year; and will have it repaired if ever necessary. The facility director will make sure that any new bathrooms built at this facility shall meet this licensing standard. |
705.27 (3) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
Based on an inspection of the facility ' s physical plant and an interview with the facility director, the facility failed to limit smoking to designated smoking areas.
The findings include:
A physical plant inspection was conducted on January 11, 2011 between the hours of approximately 1:00 PM - 2:00 PM. At approximately 1:00 PM it was observed that the facility did not prohibit smoking on facility property as per facility policy.
The facility ' s smoking policy states:
" Aldie Counseling Center does not permit smoking on the entire property (both indoors and outdoors). "
On January 11, 2011 at multiple times throughout the day clients were observed smoking cigarettes outside of the facility.
An interview with the facility director on January 11, 2011 confirmed the facility failed prohibit smoking on facility property.
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Plan of Correction
The operations director will make revisions to the facility's smoking policy that will limit smoking to designated outside areas which are in compliance with the DOH's Clean Indoor Air Act recommendation of at least 20 feet from building entrances. Notices to this effect will be posted at entrances.
All staff will be instructed to enforce this policy by telling any observed violators that they must limit their smoking to the designated areas. Clients who refuse to comply or are repeat offenders are to be reported to the assigned primary therapist and/or program coordinator who will address this non-compliance with the client.
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709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on an inspection of the facility ' s physical plant, and an interview with the facility director, the facility failed to secure all client records within locked storage containers.
The findings include:
An inspection of the facility ' s physical plant was conducted on January 11, 2011 at approximately 2:00 PM. The facility was required to secure all client records within locked storage containers. The facility maintained closed client records in boxes on shelves in a locked records room, but the records room was not dedicated solely for the purpose of record storage. At the time of inspection, the records room was also being used to store Christmas decorations.
An interview with the facility director on January 11, 2011 confirmed that the closed records storage room was not dedicated solely for the purpose of record storage.
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Plan of Correction
The Christmas decorations have been moved to a storage room that is not used for client records. The operations director (i.e., facility director) has instructed the office manager of the requirement that non-record related items are not to be stored in the secured records room, and an announce about this was also made at an all-staff meeting. The operations director and office manager will periodically check the room for continued compliance with this requirement. |
709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
Based on a review of the facility ' s client census reports and an interview with the project director, the facility failed develop a data collection and record-keeping system that allows for the efficient retrieval of data needed to measure the project's performance.
The findings include:
The client census reports were reviewed January 17, 2011. The client census reports did not include the date of admission for clients currently enrolled in the program.
An interview with the project director on January 7, 2011, confirmed that the facility ' s computer system was not currently set up to provide a census report with client admission dates.
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Plan of Correction
The executive director (i.e., project director) has created a separate data field within the agency's electronic data system which has been assigned to specifically track the admission date separate from all other sentinel date fields.
The operations director shall make the appropriate revisions/additions to the agency's applicable policies and procedures to clarify and differentiate the admission date that is to be utilized according to each of the agency's various programs.
The program coordinators shall insure compliance with this procedure through the quality assurance record review process.
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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 the review of client records and a review of the facility ' s policy manual, the facility failed to document a treatment plan update in five of nine client records.
The findings include:
Nine client records were reviewed on January 11, 2010 for documentation of treatment plan updates. The facility did not document a treatment plan update, as per facility policy, in client records # 3, 6, 7, 8 and 9.
The facility ' s policy titled " PHASE 3: Treatment Begins " states:
" Regardless of treatment tract the client may be assigned to, the Primary Therapist is responsible for completing the following paperwork:
Intake Assessment of the client within 30 days of admission.
Treatment Plan and Intake Aftercare Plan within 30 days of admission.
Plan updates every 60 days.
Consults every 90 days. "
In client record #3, the treatment plan was documented on 9/30/10, but a treatment plan update was not documented at the time of review.
In client record #6, the treatment plan was documented on 8/28/10, but a treatment plan update was not documented at the time of review.
In client record #7, the treatment plan was documented on 7/30/10, but a treatment plan update was not documented at the time of review.
In client record #8, the treatment plan was documented on 8/9/10, but a treatment plan update was not documented at the time of review.
In client record #9, the treatment plan was documented on 9/30/10, and a treatment plan update was documented on 7/20/10, but a subsequent treatment plan update was not documented 60 days later.
An interview with the facility director on January 11, 2011 confirmed that the identified client records did not contain a treatment plan update in accordance with facility policy.
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Plan of Correction
A review of client records # 3, 6, 7, 8 and 9 indicated that for some records the treatment plan updates were completed within the required timeframes but had not yet been filed in the clinical record; and for other records the updates were not completed on time, but now all of the records have current updates.
The program supervisors and office manager will meet with staff on 03/15/11 and review with clinical and support staff the importance of promptly completing documents and filing documents in client records. Program supervisors will conduct weekly reviews of a sample of records from each clinician's caseload for the next two months; and then, if documentation has remained up to date, will conduct random reviews of records for continued compliance.
The operations director will make revisions to the agency's "Internal Utilization Review Policy" to indicate that program coordinators are to increase the number and/or frequency of chart reviews for individual clinicians who have a pattern of continued incomplete or non-compliance with mandated client record documentation, including treatment plan updates; and that the clinician will be subject to the agency's policy and procedure on disciplinary action for failure to work at an acceptable quality.
Program coordinators will review the revised policy and procedures with their clinicians and implement it accordingly. The operations director's ongoing supervision of the coordinators will include ensuring that compliance is being either maintained or addressed as needed.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records and a review of the facility ' s policy manual, the facility failed to document a case consultation in eight of nine client records.
The findings include:
Nine client records were reviewed on January 11, 2011 for documentation of case consultations. The facility did not document a case consultation at least every 90 days, as per facility policy in client records # 1, 2, 3, 5, 6, 7, 8 and 9.
The facility ' s policy titled " PHASE 3: Treatment Begins " states:
" Regardless of treatment tract the client may be assigned to, the Primary Therapist is responsible for completing the following paperwork:
Written Intake Assessment of the client within 30 days of admission.
Comprehensive Treatment Plan and Intake Aftercare Plan within 30 days of admission.
Treatment Plan updates every 60 days.
Case Consults every 90 days. "
Client #1 was admitted to the program on 7/20/10 and discharged on 11/3/10, but a case consultation was not documented at the time of review on 1/11/10.
Client #2 was admitted to the program on 8/31/10 and discharged on 12/6/10, but a case consultation was not documented at the time of review on 1/11/10.
Client #3 was admitted to the program on 8/31/10, but a case consultation was not documented at the time of review on 1/11/10.
Client #5 was admitted to the program on 6/24/10, but the only case consultation was documented on 9/14/10.
Client #6 was admitted to the program on 8/21/10, but a case consultation was not documented at the time of review on 1/11/10.
Client #7 was admitted to the program on 9/21/10, but a case consultation was not documented at the time of review on 1/11/10.
Client #8 was admitted to the program on 6/23/10, but the only case consultation was documented on 10/6/10.
Client #9 was admitted to the program on 6/8/10, but case consultations were only documented on 7/20/10 and 9/7/10.
An interview with the facility director on January 11, 2011, confirmed that the identified client records did not contain a case consultation in accordance with facility policy.
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Plan of Correction
A review of client records # 3, 5, 6, 7, 8 and 9 indicated that for some records the case consultations were completed within the required timeframes but had not yet been filed in the clinical record; and for other records the case consultations were not completed on time, but now all of the records have current case consultations. Records # 1 and 2 were closed and the assigned clinicians no longer work at the facility.
The program supervisors and office manager will meet with staff on 03/15/11 and review with clinical and support staff the importance of promptly completing documents and filing documents in client records. Program supervisors will conduct weekly reviews of a sample of records from each clinician's caseload for the next two months; and then, if documentation has remained up to date, will conduct random reviews of records for continued compliance.
The operations director will make revisions to the agency's "Internal Utilization Review Policy" to indicate that program coordinators are to increase the number and/or frequency of chart reviews for individual clinicians who have a pattern of continued incomplete or non-compliance with mandated client record documentation, including case consultations; and that the clinician will be subject to the agency's policy and procedure on disciplinary action for failure to work at an acceptable quality.
Program coordinators will review the revised policy and procedures with their clinicians and implement it accordingly. The operations director's ongoing supervision of the coordinators will include ensuring that compliance is being either maintained or addressed as needed.
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