INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 2, 2013 to April 3, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, MCP/Caring Together 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of first aid cards, Cardio Pulmonary Resuscitation (CPR) certifications, the facility failed to ensure that a sufficient number of staff persons trained in CPR skills were present during all the project's hours of operation.
The findings include:
From April 2, 2013 to April 3, 2013, the facility's first aid cards and CPR certifications were reviewed. Also, on April 2, 2013, the Licensing Specialist asked what standard hours the staff work and if any staff were off work in the past four weeks. The facility's hours of operation are Monday to Friday from 9:00 A.M. to 5:00 P.M. Only one staff member, the secretary, has both first aid training and CPR certification. In addition, a counselor and the project director have first aid training. The facility director reported that the secretary has taken at least two days off work within the past four weeks. Therefore, the facility did not have CPR coverage during the hours of operation on the days the secretary was off work.
The findings were confirmed during an interview with the facility director on April 3, 2013 at approximately 9:15 A.M.
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Plan of Correction
Program Manager (PM) will ensure that additional staff will be certified in first aid and CPR and going forward PM and Medical Director will ensure that the sufficient number of staff have CPR training. Plan is for child development specialist and program director to renew CPR certifications and obtain first aid certifications by June 30, 2013 |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill records, the facility failed to maintain a written fire drill record that included documentation of problems encountered in eleven of twelve fire drill months reviewed.
The findings include:
Fire drill records were reviewed on April 2, 2013. The records were reviewed from the period covering April 2012 to March 2013. The facility did not have documentation for problems encountered in eleven of twelve months reviewed, specifically, April 27, 2012; May 10, 2012; June 9, 2012; July 23, 2012; August 28, 2012; September 12, 2012; October 4, 2012; November 14, 2012; December 6, 2012; February 7, 2013; and March 28, 2013.
The findings were confirmed during an interview with the facility director on April 2, 2013 at approximately 3:00 P.M.
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Plan of Correction
Intending to file an exception. Caring Together will comply with cited regulation going forward. Program Manager (PM) will document any problems during fire drills and note in fire drill log. PM will put N/A in problem box if no problems are noted. Medical Director will review for compliance. |
711.91(b)((2)(iii) LICENSURE Fee Schedule
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project that includes a fee schedule in six of six records reviewed.
From April 2, 2013 to April 3, 2013, six client records requiring documentation of client orientation to the project that includes a fee schedule were reviewed. The facility did not document a fee schedule in six of six records reviewed, specifically, client records # 1, 2, 3, 4, 5, and 6.
Client # 1 was admitted August 3, 2012. Client orientation to the project that includes a fee schedule was due upon the client's admission by August 3, 2012. The client orientation to the project was completed on August 3, 2012 but did not include a fee schedule.
Client # 2 was admitted October 5, 2012. Client orientation to the project that includes a fee schedule was due upon the client's admission by October 5, 2012. The client orientation to the project was completed on October 5, 2012 but did not include a fee schedule.
Client # 3 was admitted July 16, 2012. Client orientation to the project that includes a fee schedule was due upon the client's admission by July 16, 2012. The client orientation to the project was completed on July 16, 2012 but did not include a fee schedule.
Client # 4 was admitted August 2, 2012. Client orientation to the project that includes a fee schedule was due upon the client's admission by August 2, 2012. The client orientation to the project was completed on August 2, 2012 but did not include a fee schedule.
Client # 5 was admitted August 24, 2012. Client orientation to the project that includes a fee schedule was due upon the client's admission by August 24, 2012. The client orientation to the project was completed on August 24, 2012 but did not include a fee schedule.
Client # 6 was admitted May 10, 2012 and discharged December 21, 2012. Client orientation to the project that includes a fee schedule was due upon the client's admission by May 10, 2012. The client orientation to the project was completed on May 10, 2012 but did not include a fee schedule.
The findings were confirmed during an interview with the facility director on April 3, 2013 at approximately 9:15 A.M.
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Plan of Correction
Intending to file an exception. If the exception is not granted, PM will post fee schedule in visible area of Program as required and inspect the facility on a routine basis to ensure that that the fee schedule remains posted in a visible area of the program. |
711.91(b)(3)(i) LICENSURE Medical History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document a medical history in accordance with their policy and procedures in four of six client records reviewed.
The findings include:
The facility's policy titled: "709.91 Intake and Admission," states:
"Medical History: A history documenting the client's personal medical history, and history of illness and symptoms. The Addictions Counselor during the initial intake evaluation will document in the chart information within seventy two (72) hours. Family Medical: A history documenting the client ' s family medical history of illness and symptoms."
From April 2, 2013 to April 3, 2012, six client records requiring documentation of a medical history were reviewed. The facility did not document a medical history according to their policy and procedures in four of six client records reviewed, specifically, client records # 2, 4, 5, and 6.
Client # 2 was admitted October 5, 2012. The medical history was due October 8, 2012. However, the medical history was not completed until November 3, 2012.
Client # 4 was admitted August 2, 2012. The medical history was due August 5, 2012. However, the medical history was not completed until August 10, 2012.
Client # 5 was admitted August 24, 2012. The medical history was due August 27, 2012. However, the medical history was not completed until September 14, 2012.
Client # 6 was admitted May 10, 2012 and discharged December 21, 2012. The medical history was due May 13, 2012. However, the medical history was not completed until May 23, 2012.
The findings were confirmed during an interview with the facility director on April 3, 2013 at approximately 3:00 P.M.
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Plan of Correction
As noted by the reviewer during the inspection, Caring Together has an unusually stringent time frame in its policy manual for obtaining initial medical hx. At his suggestion, Progam Manager has changed its policy for gathering this info to "within 30 days of admission". The facility has changed the policy for completing medical histories and the project director has approved the policy. PM will ensure that medical histories for all clients are completed on time according to the facility's policies and procedures and Medical Director will review to ensure compliance.
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711.91(b)(3(ii) LICENSURE D & A History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document a drug or alcohol history in accordance with their policy and procedures in four of six client records reviewed.
The findings include:
The facility's policy titled: "709.91 Intake and Admission," states:
"Drug and/or alcohol history: A history documenting, as a minimum, the substances most frequently abused, the length and patterns of use and prior treatment episodes will be obtained. The client's perception of the impact of substance abuse on her social, psychical and mental state will be included. A history of substance abuse among other family members will be obtained. This will be documented in the chart within 72 hours."
From April 2, 2013 to April 3, 2012, six client records requiring documentation of a drug or alcohol history were reviewed. The facility did not document a drug or alcohol history according to their policy and procedures in four of six client records reviewed, specifically, client records # 2, 4, 5, and 6.
Client # 2 was admitted October 5, 2012. The drug or alcohol history was due October 8, 2012. However, the drug or alcohol history was not completed until November 3, 2012.
Client # 4 was admitted August 2, 2012. The drug or alcohol history was due August 5, 2012. However, the drug or alcohol history was not completed until August 10, 2012.
Client # 5 was admitted August 24, 2012. The drug or alcohol history was due August 27, 2012. However, the drug or alcohol history was not completed until September 14, 2012.
Client # 6 was admitted May 10, 2012 and discharged December 21, 2012. The drug or alcohol history was due May 13, 2012. However, the drug or alcohol history was not completed until May 23, 2012.
The findings were confirmed during an interview with the facility director on April 3, 2013 at approximately 3:00 P.M.
This is a repeat citation. The facility was cited on April 10, 2012 for noncompliance with this standard.
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Plan of Correction
As noted by the reviewer during the inspection, Caring Together has an unusually stringent time frame in its policy manual for obtaining D/A hx. At his suggestion, Progam Manager has changed its policy for gathering this info to "within 30 days of admission". The facility has changed the policy for completing D/A histories and the project director has approved the policy. PM will ensure that D/A histories for all clients are completed on time according to the facility's policies and procedures and Medical Director will review to ensure compliance. |
711.91(b)(3)(iii) LICENSURE Personal History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document a personal history in accordance with their policy and procedures in four of six client records reviewed.
The findings include:
The facility's policy titled: "709.91 Intake and Admission," states:
"Personal history: Historical and pertinent personal data including: family, legal, employment, vocational, educational, military, recreational, sexual and other history, where appropriate, will be obtained by the Addictions Counselor during the intake evaluation and will be documented in the chart within 72 hours."
From April 2, 2013 to April 3, 2012, six client records requiring documentation of a personal history were reviewed. The facility did not document a personal history according to their policy and procedures in four of six client records reviewed, specifically, client records # 2, 4, 5, and 6.
Client # 2 was admitted October 5, 2012. The personal history was due October 8, 2012. However, the personal history was not completed until November 3, 2012.
Client # 4 was admitted August 2, 2012. The personal history was due August 5, 2012. However, the personal history was not completed until August 10, 2012.
Client # 5 was admitted August 24, 2012. The personal history was due August 27, 2012. However, the personal history was not completed until September 14, 2012.
Client # 6 was admitted May 10, 2012 and discharged December 21, 2012. The personal history was due May 13, 2012. However, the personal history was not completed until May 23, 2012.
The findings were confirmed during an interview with the facility director on April 3, 2013 at approximately 3:00 P.M.
This is a repeat citation. The facility was cited on April 10, 2012 for noncompliance with this standard.
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Plan of Correction
As noted by the reviewer during the inspection, Caring Together has an unusually stringent time frame in its policy manual for obtaining initial personal hx. At his suggestion, Progam Manager has changed its policy for gathering this info to "within 30 days of admission". The facility has changed the policy for completing personal histories and the project director has approved the policy. PM will ensure that personal histories for all clients are completed on time according to the facility's policies and procedures and Medical Director will review to ensure compliance. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. 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, the facility failed to document a psychosocial evaluation in accordance with their policy and procedures in four of six client records reviewed.
The findings include:
The facility's policy titled: "709.91 Intake and Admission," states:
"The Bio-Psychosocial evaluation provides a composite picture of the client in relationship to the compilation of the historical information in order to identify possible relationships, conditions and causes leading to the client's current situation ... ...This form shall be completed within 5 days after the date of admissions."
From April 2, 2013 to April 3, 2012, six client records requiring documentation of a psychosocial evaluation were reviewed. The facility did not document a psychosocial evaluation according to their policy and procedures in four of six client records reviewed, specifically, client records # 2, 4, 5, and 6.
Client # 2 was admitted October 5, 2012. The psychosocial evaluation was due October 10, 2012. However, the psychosocial evaluation was not completed until November 3, 2012.
Client # 4 was admitted August 2, 2012. The psychosocial evaluation was due August 7, 2012. However, the psychosocial evaluation was not completed until August 10, 2012.
Client # 5 was admitted August 24, 2012. The psychosocial evaluation was due August 29, 2012. However, the psychosocial evaluation was not completed until September 14, 2012.
Client # 6 was admitted May 10, 2012 and discharged December 21, 2012. The psychosocial evaluation was due May 15, 2012. However, the psychosocial evaluation was not completed until May 23, 2012.
The findings were confirmed during an interview with the facility director on April 3, 2013 at approximately 3:00 P.M.
This is a repeat citation. The facility was cited on April 10, 2012 for noncompliance with this standard.
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Plan of Correction
As noted by the reviewer during the inspection, Caring Together has an unusually stringent time frame in its policy manual for obtaining a psychosocial evaluation. At his suggestion, Progam Manager has changed its policy for gathering this info to "within 30 days of admission". The facility has changed the policy for completing psychosocial evaluations and the project director has approved the policy. PM will ensure that psychosocial evaluation for all clients are completed on time according to the facility's policies and procedures and Medical Director will review to ensure compliance. |
711.92(a)(3) LICENSURE Mngt of Treatment Services
711.92. Treatment and rehabilitation services.
(a) The project shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the development, approval and ongoing management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to develop a written plan for the coordination of client treatment and rehabilitation services that accurately reflects the process for completing the preliminary treatment and rehabilitation plan.
The findings include:
On April 2, 2013, the facility's policy and procedures manual was reviewed. The facility had two conflicting policies regarding the completion of the preliminary treatment and rehabilitation plan.
The facility's policy titled: "709.91 Intake and admission," states:
"A preliminary treatment plan developed with the client will have short term goals, be based on identified problems, and will be developed after four (4) visits."
The facility has a second policy titled: "709.92 Treatment and Rehabilitation Services," that states:
"A Preliminary Treatment Plan developed with the client will have short term goals, be based on identified problems, and will be developed during the first two visits."
The findings were confirmed during an interview with the facility director on April 2, 2013 at approximately 3:00 P.M.
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Plan of Correction
Program Director has changed and had approved the program manual to eliminate the second of the two conflicting policy descriptions, specifically: "709.92 Treatment and Rehabilitation Services," that states:
"A Preliminary Treatment Plan developed with the client will have short term goals, be based on identified problems, and will be developed during the first two visits" was deleted.
Going forward, Program Manager and Medical Director will ensure that the approved policy remains in place at Caring Together and that the policy manual contains no further conflicting policies. |
711.92(c)(3) LICENSURE Support Service
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services in the individual treatment and rehabilitation plan in three of seven client records reviewed.
The findings include:
From April 2, 2013 to April 3, 2013, seven client records requiring documentation of the proposed type of support services in the individual treatment and rehabilitation plan were reviewed. The facility did not document the proposed type of support services in the individual treatment and rehabilitation plan in three of seven client records reviewed, specifically, client records # 1, 3, and 5.
Client # 1 was admitted August 3, 2012. The individual treatment and rehabilitation plan was completed September 3, 2012, but did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of April 3, 2013.
Client # 3 was admitted July 16, 2012. The individual treatment and rehabilitation plan was completed August 16, 2012, but did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of April 3, 2013.
Client # 5 was admitted August 24, 2012. The individual treatment and rehabilitation plan was completed September 24, 2012, but did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of April 3, 2013.
The findings were confirmed during an interview with the facility director on April 3, 2013 at approximately 3:00 P.M.
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Plan of Correction
Intending to file an exception. If the exception is not granted, the cited treatment plans will be amended within 30 days of the denial of the exception. Amnendments will be completed by each client's counselor and review by Program Manager for compliance. PM will further revised the tx plan form to specially require support services to be listed and review subsequent plans to ensure compliance. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) 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 an individual treatment and rehabilitation plan update and/or subsequent individual treatment and rehabilitation plan update in four of six client records reviewed.
The findings include:
The facility's policy titled: "709.92 Treatment and Rehabilitation Services," states:
"Treatment and rehabilitation plans shall be reviewed and updated at least every sixty days."
From April 2, 2013 to April 3, 2013, six client records requiring documentation of an individual treatment and rehabilitation plan update were reviewed. The facility did not document an individual treatment and rehabilitation plan update and/or subsequent individual treatment and rehabilitation plan update in four of six records reviewed, specifically, client records # 1, 2, 3, and 5.
Client # 1 was admitted August 3, 2012 and the individual treatment and rehabilitation plan was completed September 3, 2012. The individual treatment and rehabilitation plan update was due November 2, 2012. However, client record # 1 did not include documentation of an individual treatment and rehabilitation plan update as of April 3, 2013.
Client # 2 was admitted October 5, 2012. The individual treatment and rehabilitation plan was completed November 5, 2012 and the individual treatment and rehabilitation plan update was completed January 5, 2013. The subsequent individual treatment and rehabilitation plan update was due March 6, 2013. However, client record # 2 did not include documentation of a subsequent individual treatment and rehabilitation plan update as of April 3, 2013.
Client # 3 was admitted July 16, 2012 and the individual treatment and rehabilitation plan was completed August 16, 2012. The individual treatment and rehabilitation plan update was due October 15, 2012. However, client record # 3 did not include documentation of an individual treatment and rehabilitation plan update as of April 3, 2013.
Client # 5 was admitted August 24, 2012 and the individual treatment and rehabilitation plan was completed September 24, 2012. The individual treatment and rehabilitation plan update was due November 23, 2012. However, client record # 5 did not include documentation of an individual treatment and rehabilitation plan update as of April 3, 2013.
The findings were confirmed during an interview with the facility director on April 3, 2013 at approximately 3:00 P.M.
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Plan of Correction
Program Manager will increase frequency of chart reviews to bi-weekly to address potential problem areas prior to violations occuring. Also, additional supplmental staffing has been obtained to enhance quality of overall clinical documentation. Program Manager will be responsible for reviewing tx plans to ensure updates are provided as scheduled. Treatment plan updates for clients # 1, 2, 3, and 5 have been completed. |