INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 2, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, NASR Consultant Group Incorporated 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:
|
Plan of Correction
|
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of personnel records, the facility failed to document instruction in the use of the fire extinguisher upon staff employment, in one of one record reviewed.
The findings include:
One personnel record which required documentation of the completion of fire extinguisher training was reviewed on October 2, 2013. The facility failed to document the completion of fire extinguisher training upon employment in personnel record # 2.
Employee # 2 was hired on 3/4/13. Fire extinguisher training is due to be completed upon employment. Fire extinguisher training was completed on 4/5/13.
The Project Director confirmed the findings.
|
Plan of Correction
Facility Director will instruct staff in the use of the fire extinguisher upon staff employment no later than seven (7) days from the date of employment. The Facility Director will also document this instruction in the employee training attendance record.
In addition, the Facility Director will review all new hires personnel charts to ensure they receive fire extinguisher training within the appropriate timeframes. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies, in one of one personnel records reviewed.
The findings include:
One personnel record requiring documentation that personnel on all shifts were trained to perform assigned tasks during emergencies, was reviewed on October 2, 2013.
Employee # 2 was hired on 3/4/2013. The training for assigned tasks during emergencies was documented on 4/5/2013.
The Project Director confirmed the findings.
|
Plan of Correction
Facility Director will ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies no later than seven (7) days from the date of employment. The Facility Director will also document this instruction in the employee training attendance record.
In addition, the Facility Director will review all new hires personnel charts to ensure they receive emergency training within the appropriate timeframes. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
|
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 three of three records reviewed.
The findings include:
Three client records which required documentation of the disclosure to the client of criteria for admission, treatment, completion and discharge were reviewed on October 2, 2013. The facility failed to document this disclosure in records # 1, 2, and 3.
Client # 1 was admitted on 6/6/13 and discharged on 6/26/13. This client record did not contain documentation of disclosure to the client of criteria for admission, treatment, completion and discharge.
Client # 2 was admitted on 9/25/13 and was still an active client at the time of the inspection. This client record did not contain documentation of disclosure to the client of criteria for admission, treatment, completion and discharge.
Client # 3 was admitted on 9/27/13 and was still an active client at the time of the inspection. This client record did not contain documentation of disclosure to the client of criteria for admission, treatment, completion and discharge.
The Project Director confirmed the findings.
|
Plan of Correction
It has been the practice of the facility to verbally disclose to the client criteria for admission, treatment, completion and discharge but that has not been stated in the facility's manual. On October 16, 2013, the Facility Director created a document entitled, Client Rights and Responsibilities that discloses to the client criteria for admission, treatment, completion and discharge. This document will be reviewed by the therapist with all clients upon admission and will require signatures from both client and therapist.
The Facility Director will review all new client records on a monthly basis to ensure all intake paperwork is completed according to facility policy. Additionally, an addendum will be added to the record for all clients outlined in the citation, stating that the criteria for admission, treatment completion, and discharge was verbally reviewed with all clients at the time of intake.
|
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. 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 the following:
(i) Project policies.
|
Observations
Based on a review of client records, the facility failed to document client orientation to the project in three of three records reviewed.
The findings include:
Three client records which required documentation of client orientation to the project were reviewed on October 2, 2013. The facility failed to document the completion of client orientation in records # 1, 2, and 3.
Client # 1 was admitted on 6/6/13 and discharged on 6/26/13. This client record did not contain documentation of client orientation to the project.
Client # 2 was admitted on 9/25/13 and was still an active client at the time of the inspection. This client record did not contain documentation of client orientation to the project.
Client # 3 was admitted on 9/27/13 and was still an active client at the time of the inspection. This client record did not contain documentation of client orientation to the project.
The Project Director confirmed the findings.
|
Plan of Correction
It has been the practice of the facility to verbally orient client's to the program but that has not been stated in the facility's manual. On October 16, 2013, the Facility Director created a document entitled, Client Rights and Responsibilities that includes the clients' orientation to the program. That is, a familiarization to the program policy. This document will be reviewed by the therapist with all clients upon admission and will require signatures from both client and therapist.
The Facility Director will review all new client records on a monthly basis to ensure all intake paperwork is completed according to facility policy. Additionally, an addendum will be added to the record for all clients outlined in the citation, stating that the client orientation to the project was verbally reviewed with all clients at the time of intake. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
Based on a review of client records, the facility failed to document a complete personal history in three of three records reviewed.
The findings include:
Three client records which required documentation of a personal history which included family, legal, employment/vocation, educational, military, recreational, and sexual history were reviewed on October 2, 2013. The facility failed to document detailed personal histories in records # 1, 2, and 3.
Client # 1 was admitted on 6/6/13 and discharged on 6/26/13. The personal history was completed on 6/6/13 and failed to include recreational information.
Client # 2 was admitted on 9/25/13 and was still an active client at the time of the inspection. The personal history was completed on 9/25/13 and failed to include recreational information.
Client # 3 was admitted on 9/27/13 and was still an active client at the time of the inspection. The personal history was completed on 9/27/13 and failed to include recreational information.
The Project Director confirmed the findings.
|
Plan of Correction
Facility Director will ensure that all components of the clients' personal history are completed. On October 16, 2013. The Facility Director revised the Bio-psychosocial Assessment document to include a Recreational Activities section.
The Facility Director also informed all clinical staff and support staff of the revised document, distributed copies, and instructed to discard any copies of the previous Bio-psychosocial Assessment and replace them with the revised document, effective 10/16/13.
The Facility Director will review all new client records on a monthly basis to ensure the bio-psychosocial is completed according to facility policy. Additionally, an addendum will be added to include recreational activities in the bio-psychosocial for all clients outlined in the citation. |
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:
|
Observations
Based on a review of client records, the facility failed to develop an individual treatment and rehabilitation plan with the client in one of one record reviewed.
The findings include:
One record which required documentation of an individual treatment and rehabilitation plan was reviewed on October 2, 2013. The facility failed to develop an individual treatment and rehabilitation plan with the client in record # 1.
Client # 1 was admitted on 6/6/13 and discharged on 6/26/13. The individual treatment and rehabilitation plan in the record was completed on 6/12/13; however, there was no documentation of the client's signature on the plan.
The Project Director confirmed the findings.
|
Plan of Correction
Facility Director will ensure that each client admitted into the program will sign and date their individualized treatment plan, effective immediately.
In addition, the Facility Director will review all client records on a monthly basis to ensure the treatment plan is being signed by both the client and the clinician upon completion. Additionally, an addendum will be added to include the signature on the treatment plan for the client outlined in the citation. |
709.93(a)(11) 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:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to document follow-up attempts in one of one record reviewed.
The findings include:
One record which required documentation of follow-up attempts was reviewed on October 2, 2013. The facility failed to document follow-up attempts in client record # 1.
Client # 1 was admitted on 6/6/13 and was administratively discharged on 6/26/13 for non-compliance with treatment. Follow-up was due to be completed by 7/26/13. This client record did not contain documentation of follow-up as of the date of the inspection.
The Project Director confirmed the findings.
|
Plan of Correction
Facility Director will conduct monthly chart audits as well as monthly and/or quarterly supervision of clinical staff to assure ongoing compliance of this standard, effective immediately.
In addition, follow-up will be completed by 10/31/13 for the client outlined in this citation and documented in the client record. |