INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Penn Foundation for Mental Health, 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 and a plan of correction is due on February 14, 2010.
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Plan of Correction
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of client records and discussion with facility staff, the facility failed to document a fire drill during sleeping hours at least every six months.
The findings include:
Fire drill records were reviewed on January 26, 2010. Documentation showed that a fire drill was conducted during sleeping hours on August 20, 2009. Documentation for the remainder of the fire drills did not show that a drill was conducted during sleeping hours because the times that the drills were conducted was not documented for the months of January 2009, February 2009, March 2009, June 2009 or July 2009.
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Plan of Correction
Person in charge of fire drills was made aware again of the need to document the time the fire drill took place. Director of Inpatient services will montitor the log book to assure times are being documented. Semi-annual fire drills will be added to the calender to assure they are taking place. |
709.82(a) 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:
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Observations
Based on a review of client records and discussion with facility staff, the facility failed to document an individualized treatment plan in four of four client records.
The findings include:
Five client records were reviewed on January 27, 2010 through January 28, 2010. Four of those records were reviewed for individualized treatment plans. The treatment plans in client records #11, 12, 13 and 14 had the same goals documented word for word. The treatment plans were not individualized to each client's needs.
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Plan of Correction
A clinical staff meeting will be held to discuss with clinicians what is expected in an individualized treatment plan. Staff will be instructed on what constitutes individualized goals and will be made aware of the need to personalize the treatment plans. Clinical supervisors will oversee the staff meeting and monitoring clinical charts for compliance. |
709.83(a)(11) LICENSURE Client records
709.83. 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 and discussion with facility staff, the facility failed to document follow-up information in one of two client records.
The findings include:
Five client records were reviewed on January 27, 2010 through January 28, 2010. Two of those records required follow-up. Follow-up was not documented in client record #14.
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Plan of Correction
It was discovered at the site visit that follow ups were not being done consistently. Director will meet with addictions technicians, who are resonsible for doing the follow ups, to discuss our policy and procedure for follow ups. Staff will be made aware of the fact that these follow ups are a priority. Chart check, an internal system we use to assure all necessary paperwork is done, will be utilized to assure this does not re-occur. Chart check is to be completed within 7 days of discharge, so we will be immediately aware if follow up calls were not placed. Director of Inpatient Services will oversee the implementation of this POC. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 and discussion with facility staff, the facility failed to document an individualized treatment plan in three of four client records.
The findings include:
Five client records were reviewed on January 27, 2010 through January 28, 2010. Four of those records were reviewed for individualized treatment plans. The treatment plans in client records #6, 7 and 9 had the same goals documented word for word. The treatment plans were not individualized to each client's specific needs in treatment.
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Plan of Correction
A clinical staff meeting will be held to discuss with clinicians what is expected in an individualized treatment plan. Staff will be instructed on what constitutes individualized goals and will be made aware of the need to personalize the treatment plans. Clinical supervisors will oversee the staff meeting and monitoring clinical charts for compliance.
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709.53(a)(11) LICENSURE Follow-up information
709.53. 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 and discussion with facility staff, the facility failed to document follow-up information in three of three client records.
The findings include:
Five client records were reviewed on January 27, 2010 through January 28, 2010. Three of those records required follow-up. Follow-up was not documented in client records # 8, 9 and 10.
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Plan of Correction
It was discovered at the site visit that follow ups were not being done consistently. Director of Outpatient services will meet with support staff, who are resonsible for doing the follow ups, to discuss our policy and procedure for follow ups. Staff will be made aware of the fact that these follow ups are a priority. Chart check, an internal system we use to assure all necessary paperwork is done, will be utilized to assure this does not re-occur. Chart check is to be completed within 7 days of discharge, so we will be immediately aware if follow up calls were not placed. Director of Recovery Center is also looking into developing a computer monitoring system that would flag the counselor and the Director of Outpatient Services when follow ups are due. Director of Outpatient Services will oversee the implementation of this POC. |
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 and discussion with facility staff, the facility failed to document psychosocial evaluations in three of six client records.
The findings include:
Six client records were reviewed on January 27, 2010 through January 28, 2010. Six of those records required psychosocial evaluations. A psychosocial evaluation was not documented in client records #17, 19 and 20.
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Plan of Correction
It was discovered during the site visit that psychosocials were not being completed consistently. Director of Outpatient services will have a meeting with clinical staff to discuss what is required in the psychosocial evaluation. Director of Outpatient services will monitor completion of these evaluations by clinical supervision and random chart check. |
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 and discussion with facility staff, the facility failed to document an individualized treatment plan in five of six client records.
The findings include:
Six client records were reviewed on January 27, 2010 through January 28, 2010. Six of those records were reviewed for individualized treatment plans. The treatment plans in client records #16, 17, 18, 20 and 21 had the same goals documented word for word. The treatment plans were not individualized to each client's needs.
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Plan of Correction
A clinical staff meeting will be held to discuss with clinicians what is expected in an individualized treatment plan. Staff will be instructed on what constitutes individualized goals and will be made aware of the need to personalize the treatment plans. Clinical supervisors will oversee the staff meeting and monitoring clinical charts for compliance.
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records and discussion with facility staff, the facility failed to document an aftercare plan in one of two client records.
The findings include:
Six client records were reviewed on January 27, 2010 through January 28, 2010. Two of those records required an aftercare plan. An aftercare plan was not documented in client record #19.
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Plan of Correction
It was discovered during the site visit that aftercare plans were not being done consistently in outpatient. Director of the Recovery Center will develop a computer program to monitor the completion of the aftercare plans. Clinical records without aftercare plans documented will be flagged for review by the clinical supervisor. Director will oversee the implementation of this POC. |