INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 17 - 18, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Care 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.
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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 a physical plant inspection conducted on April 18, 2014, the facility failed to ventilate the staff bathroom by exhaust fan or window.
The findings include:
A physical plant inspection was conducted with the facility director and clinical supervisor on April 18, 2014 at approximately 9:00 AM. The staff bathroom did not have a window and the exhaust fan was not operative.
The findings were confirmed by the facility director and clinical supervisor.
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Plan of Correction
The agency will work with the landlord and maintenance to repair the defective vent. This will be resolved no later than June 15th, 2014. In the future, the program supervisor will check the fan operation monthly during site inspections. Any site problems, including fans, will be reported to the Program Director, maintenance and landlord and checked daily until corrected. |
709.81(b)(1) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document the disclosure to the client of criteria for admission, treatment, completion and discharge in two of six partial hospitalization client records.
The findings include:
Six partial hospitalization client records were reviewed on April 17 - 18, 2014. The facility failed to document the disclosure to the client of criteria for admission, treatment, completion and discharge in client records # 4 and 5.
Client # 4 was admitted into the partial hospitalization activity on February 27, 2014. The intake process was completed on November 26, 2013. The facility failed to document the disclosure to client # 4 of criteria for admission, treatment, completion and discharge as of April 18, 2014.
Client # 5 was admitted into the partial hospitalization activity on July 9, 2013 and discharged on September 24, 2013. The intake process was completed on July 8, 2013. The facility failed to document the disclosure to client # 5 of criteria for admission, treatment, completion and discharge as of April 18, 2014.
The clinical supervisor confirmed the findings on April 18, 2014.
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Plan of Correction
The referenced clients' records will be corrected where it is possible and remains relevant. The referred clients will receive criteria for admission, treatment, completion, and discharge and will be documented in the record. The Clinical Supervisor will provide training and supervision to all staff regarding procedures for intake and review the importance of obtaining documentation of providing criteria for admission, treatment, completion and discharge. This will be completed by July 1, 2014. Clinical Supervisor will continue to review and monitor intakes. This will be an ongoing process. |
709.81(b)(2)(i) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to a familiarization with:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project in two of six partial hospitalization client records.
The findings include:
Six partial hospitalization client records were reviewed on April 17 - 18, 2014. The facility documents client orientation with a sign off sheet during the intake process. The facility failed to document client orientation to the project in client records # 4 and 5.
Client # 4 was admitted into the partial hospitalization activity on February 27, 2014. The intake process was completed on November 26, 2013. The facility failed to document client orientation to the project including project policies and services provided, as of April 18, 2014.
Client # 5 was admitted into the partial hospitalization activity on July 9, 2013 and discharged on September 24, 2013. The intake process was completed on July 8, 2013. The facility failed to document client orientation to the project including project policies and services provided, as of April 18, 2014.
The clinical supervisor confirmed the findings on April 18, 2014.
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Plan of Correction
The referenced clients' records will be corrected. The referred client will receive orientation to the project and it will be documented in the record where it is possible and remains relevant. The Clinical Supervisor will provide training and supervision to all staff regarding procedures for intake and review the importance of obtaining documentation of a referred client receiving orientation to the project. This will be completed by July 1, 2014. Clinical Supervisor will continue to review and monitor intakes. This will be an ongoing process. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to develop an individual treatment and rehabilitation plan including the frequency of individual treatment and rehabilitation services in two of five partial hospitalization client records.
The findings include:
Six partial hospitalization client records were reviewed on April 17, 2014. Five individual treatment plans were reviewed for the type and frequency of treatment and rehabilitation services. Partial hospitalization clients are required to receive at least two individual counseling sessions weekly. The facility failed to develop a treatment plan including the frequency of individual treatment and rehabilitation services in client records # 1 and 3.
Client # 1 was admitted into treatment on February 17, 2014. An individual treatment plan was developed with the client on March 10, 2014. The client was participating in the partial hospitalization activity and required to receive individual counseling, at least twice weekly. The individual treatment plan indicated the client was only required to participate in individual counseling one time per week. The facilty failed to document the required frequency of individual treatment and rehabilitation services in client record # 1.
Client # 3 was admitted into treatment on March 13, 2014. An individual treatment plan was developed with the client on April 14, 2014. The client was participating in the partial hospitalization activity and required to receive individual counseling, at least twice weekly. The individual treatment plan indicated the client was only required to participate in individual counseling one time per week. The facilty failed to document the required frequency of individual treatment and rehabilitation services in client record # 3.
The clinical supervisor confirmed the findings on April 18, 2014.
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Plan of Correction
A mandatory staff meeting will be held with all staff to review treatment plan timelines and regulations which will include standards for frequency in relationship to level of care held by the Clinical Supervisor. Each staff member will be provided with a copy of our agency's policy and regulations in regard to treatment plan timelines. This will be completed by July 1, 2014.. To assure staff members are improving in this area internal chart audits will be conducted. The Clinical Supervisor will be responsible for this plan of correction and ongoing monitoring of same. |
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 a written, informed and voluntary consent from the client for the disclosure of information contained in the client record in five of fourteen client records.
The findings include:
Eighteen client records were reviewed on April 17 - 18, 2014. Fourteen client records were reviewed for written, informed and voluntary consents from the client. The facility failed to obtain a written, informed and voluntary consent from the client prior to disclosing information contained in the client record to a funding entity in client records # 2, 4, 5, 8 and 9.
Client # 2 was admitted into treatment on April 7, 2014. The facility failed to obtain a written, informed and voluntary consent from client # 2 prior to disclosing information contained in the client record to the funding entity.
Client # 4 was admitted into treatment on February 27, 2014. The facility failed to obtain a written, informed and voluntary consent from client # 4 prior to disclosing information contained in the client record to the funding entity.
Client # 5 was admitted into treatment on July 9, 2013. The facility failed to obtain a written, informed and voluntary consent from client # 5 prior to disclosing information contained in the client record to the funding entity.
Client # 8 was admitted into treatment on December 9, 2013. The facility failed to obtain a written, informed and voluntary consent from client # 8 prior to disclosing information contained in the client record to the funding entity.
Client # 9 was admitted into treatment on December 19, 2013. The facility failed to obtain a written, informed and voluntary consent from client # 9 prior to disclosing information contained in the client record to the funding entity.
The findings were confirmed by the facility director and clinical supervisor on April 18, 2014.
This is a repeat citation from the May 6 - 9, 2013 licensing inspection.
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Plan of Correction
The facility will obtain appropriate Consents to Release Information for clients #2, 4, 5, 8, and 9 where obtaining the consents are possible and remains relevant. The Clinical Supervisor will develop and provide a training update of the accurate and appropriate completion of consents to release information by July 1, 2014. Information to be covered will include appropriate type of release, the appropriate release for funding sources, appropriate choice of information to be released; and limitations of 4 Pa. code subsection 255.5, at a minimum. This will be completed by July 1, 2014. Clinical Supervisor will continue to review and monitor consents and releases through internal chart reviews and supervision on an ongoing basis.
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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 a review of client records, the facility failed to document a treatment plan update at least every 60 days in four of eight outpatient client records.
The findings include:
Twelve outpatient client records were reviewed on April 17 - 18, 2014. Eight client records required documentation of treatment plan updates at least every 60 days. The facility failed to document a treatment plan update at least every 60 days in client records # 8, 9, 12 and 16.
Client # 8 was admitted into treatment on December 9, 2013. A comprehensive treatment plan was developed with the client on January 23, 2014. A treatment plan update was due to be completed no later than March 23, 2014. There was no documentation of any treatment plan updates in client record # 8, as of April 18, 2014.
Client # 9 was admitted into treatment on December 19, 2013. A comprehensive treatment plan was developed with the client on December 18, 2013. Treatment plan updates were due to be completed no later than February 18 and April 18, 2014. There was no documentation of any treatment plan updates in client record # 9, as of April 18, 2014.
Client # 12 was admitted into treatment on October 28, 2013. A comprehensive treatment plan was developed with the client on January 31, 2014. A treatment plan update was completed on January 31, 2014. The second treatment plan update was due to be completed no later than March 31, 2014 but was not completed until April 16, 2014.
Client # 16 was admitted into treatment on May 14, 2013 and discharged on September 4, 2013. A comprehensive treatment plan was developed with the client on June 4, 2013. A treatment plan update was due to be completed no later than August 4, 2013. There was no documentation of any treatment plan updates in client record # 16, as of April 18, 2014.
The clinical supervisor confirmed the findings on April 18, 2014.
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Plan of Correction
The referenced client records will be corrected. The Clinical Supervisor will review the requirement to complete the treatment plan update and regulatory standards with an emphasis on due dates and time lines. A training will be held for staff as part of the staff meetings and clinical support to provide direct instruction on effectively documenting treatment plan update within the specific due dates. This will be conducted by the Clinical Supervisor and completed by July 1, 2014. Clinical Supervisor will continue to review and treatment plan updates through internal chart reviews and supervision on an ongoing basis. |
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 a review of client records, the facility failed to document a complete client record on an individual which includes information relative to the client's involvement with the project in five of twelve outpatient client records.
The findings include:
Twelve outpatient client records were reviewed on April 17 - 18, 2014. The facility failed to document quarterly case consultations in client records # 7, 9 and 10. The facility failed to document discharge summaries within one week of discharge in client records # 15 and 18. The facility failed to document an aftercare plan in client record # 18.
Client # 7 was admitted into treatment on September 9, 2013. Case consultations were due to be completed no later than December 31, 2013 and March 31, 2014. There was no documentation of any case consultations in client record # 7, as of April 18, 2014.
Client # 9 was admitted into treatment on December 19, 2013. A case consultation was due to be completed no later than March 31, 2014. There was no documentation of any case consultations in client record # 9, as of April 18, 2014.
Client # 10 was admitted into treatment on November 14, 2013. A case consultation was due to be completed no later than March 31, 2014. There was no documentation of any case consultations in client record # 10, as of April 18, 2014.
Client # 15 was admitted into treatment on July 15, 2013 and discharged on August 15, 2013. A discharge summary was due to be completed no later than August 22, 2013. A discharge summary was not documented until August 29, 2013.
Client # 18 was admitted into treatment on July 22, 2013 and successfully discharged on September 30, 2013. A discharge summary was due to be completed no later than October 7, 2013. A discharge summary was not documented until December 4, 2013. There was no documentation of an aftercare plan for client # 18, as of April 18, 2014.
The findings were confirmed by the clinical supervisor on April 18, 2014.
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Plan of Correction
A mandatory staff meeting will be held with all staff to review case consultation and discharge and aftercare timelines and regulations. This will occur no later than July 31, 2014. Each staff member will be provided with a copy of our agency's policy and regulations in regard to case consultation and discharge summary and aftercare timelines. In addition, staff members who were responsible for charts that were missing case consultation will correct these deficiencies no later than May 31, 2014. To assure staff members are improving in this area internal chart reviews and supervision will take place by the Clinical Supervisor on ongoing basis. |