INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 4 and August 5, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Lebanon Treatment 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 August 29, 2010.
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Plan of Correction
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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 the review of the fire drill log and an interview with the clinic director, the facility failed to include the evacuation route used for the fire drills and whether or not the alarm was sounded on the evacuation documentation.
The findings include:
The fire drill log was reviewed on August 4, 2010. The available fire drill information failed to document whether or not the alarm was sounded and what evacuation route was used during the drill. The clinic director was interviewed and reviewed the fire drill form that was utilized to document information regarding the fire drill and confirmed that the required information was not included on the fire drill form.
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Plan of Correction
Lebanon Treatment Center will return to using the approved Fire Drill Log which it had been using in years past. This Fire Drill Log has been approved by DOH in the past. This Fire Drill Log does include whether or not the alarm was sounded and what evacuation route was used during the drill. Health and Safety Manager will be responsible to make sure that the correct form is being used. The Clinic Director will follow up with Health and Safety Manager on a monthly basis during scheduled Managment Meetings to ensure compliance. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill logs were reviewed on August 4, 2010. The facility did not document any alternate exit used during fire drills for eleven of the past twelve months. The following months failed to include what exit routes were used during the fire drill: August 2009, September 2009, October 2009, November 2009, December 2009, January 2010, February 2010, March 2010, April 2010, May 2010, June 2010 and July 2010.
An interview with the clinic director confirmed that the facility did not possess documentation that identified what exits were used during those fire drills.
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Plan of Correction
Lebanon Treatment Center will return to using DOH approved Fire Drill Log as it has in years past. This Fire Drill Log does provide documenation for any alternate exit's used during the fire drills. Health and Safety Manager will be responsible to make sure that the correct form is being used. The Clinic Director will follow up with Health and Safety Manager on a monthly basis during scheduled Managment Meetings to ensure compliance. |
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 patient records and administrative policy and procedures, the facility failed to document psychosocial evaluations within thirty days of admission, as per agency policy, in five of eleven patient records.
The findings include:
Thirteen patient records were reviewed on August 5, 2010. Eleven client records required the completion of psychosocial evaluations within the thirty day period following admission. Per agency policy, psychosocial evaluations will be completed within thirty days of the admission date. Psychosocial evaluations were not completed within the required time frames in client records # 4, 5, 7, 9, and 10.
Patient # 4 was admitted on February 25, 2010. The psychosocial evaluation was due to be completed no later than March 25, 2010. The psychosocial evaluation was not completed until July 27, 2010.
Patient # 5 was admitted on April 16, 2010. The psychosocial evaluation was due to be completed no later than May 16, 2010. The psychosocial evaluation was not completed until July 24, 2010.
Patient # 7 was admitted on April 21, 2010. The psychosocial evaluation was due to be completed no later than May 21, 2010. The psychosocial evaluation was not completed until June 11, 2010.
Patient # 9 was admitted on June 11, 2009. The psychosocial evaluation was due to be completed no later than July 22, 2009. The patient was discharged on August 19, 2009. The facility failed to complete a psychosocial evaluation for this patient record.
Patient # 10 was admitted on May 6, 2009. The psychosocial evaluation was due to be completed no later than June 6, 2009. The psychosocial evaluation was not dated by the clinician and therefore the licensing specialist was unable to determine if the psychosocial evaluation was completed within the required timeframe.
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Plan of Correction
Agency policy is completion of psychosocial evaluation/interpretive summaries within 30 days of admission. Clinical staff will receive updated training on this policy 8/12/2010 with immediate compliance. Charts will be audited by the clinical supervisor at 3 weeks following admission for compliance. Clinical supervisor will monitor for compliance. |
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 the project's policies and procedures manual and patient records, it was determined that the facility failed to complete individualized treatment and rehabilitation plans per the project's policy in five out of eleven records reviewed. .
The findings include:
The facility policy and procedure manual was reviewed on August 4, 2010. According to the facility policy and procedure manual, an individualized treatment and rehabilitation plan will be completed thirty days from the patient's admission date. Thirteen records were reviewed on August 5, 2010. Eleven client records required the completion of psychosocial evaluations within the thirty day period following admission. The facility failed to complete treatment and rehabilitation plans within the facility specified time frame in patient record # 4 , 6, 7, 8, and 10.
Patient # 4 was admitted on February 25, 2010. A treatment and rehabilitation plan was due no later than March 25, 2010. The treatment and rehabilitation plan was not completed until May 27, 2010.
Patient # 6 was admitted on May 20, 2010. A treatment and rehabilitation plan was due no later than June 20, 2010. The treatment and rehabilitation plan was not completed until July 14, 2010.
Patient # 7 was admitted on April 21, 2010. A treatment and rehabilitation plan was due no later than May 21, 2010. The treatment and rehabilitation plan was not completed until July 19, 2010.
Patient # 8 was admitted on March 26, 2009. The patient was discharged October 9, 2009. A treatment and rehabilitation plan was due no later than April 26, 2009. The treatment and rehabilitation plan was not completed for this patient record.
Patient # 10 was admitted on May 6, 2009. A treatment and rehabilitation plan was due no later than June 6, 2009. The treatment and rehabilitation plan was not completed until June 18, 2009.
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Plan of Correction
Comprehensive treatment plans are to be completed within 30 days of admission, and Treatment plan updates are to be completed every 60 days per policy. This policy will be reviewed at clinical staff meeting on 08/12/2010 for immediate compliance. Clinical supervisor will monitor time frame of completion when signing off on treatment plans presented by clinical team. Clinical supervisor will monitor for compliance. |