INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 17 - 20, 2011 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.
|
Plan of Correction
|
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to provide documentation of communicable disease training in two of three personnel records.
The findings include:
Nine personnel records were reviewed on May 18, 2011. Three personnel records were required to include documentation of communicable disease training. Per regulation, staff persons shall receive a minimum of 4 hours of TB/STD training and 6 hours of HIV/AIDS training. Counselors and counselor assistants shall complete the training within the first year of employment and all other staff shall complete the training with the first 2 years of employment. The facility did not document TB/STD training in personnel record # 7 and did not document HIV/AIDS training in personnel record # 8.
Employee # 7 was hired for the position of counselor on March 8, 2010. HIV/AIDS and TB/STD training were due to be completed no later than March 8, 2011. Personnel record # 7 did not include documentation of TB/STD training, as of the time of the review on May 18, 2011.
Employee # 8 was hired for the position of counselor on September 16, 2009. HIV/AIDS and TB/STD training were due to be completed no later than September 16, 2010. Personnel record # 8 did not include documentation of HIV/AIDS training, as of the time of the review on May 18, 2011.
The facility director was interviewed on May 18, 2011, and confirmed employees # 7 and 8 did not complete the required communicable disease training.
|
Plan of Correction
On July 7th, 2011 a mandatory staff meeting will be held with all staff to review mandatory training guidelines. Staff members who need to be scheduled for their Mandatory Communicable Disease Training will be scheduled and attend within the next six months. All new clinical staff will be scheduled for their Mandatory Communicable Disease training within the first year that they are employed. The Clinical Supervisor and Director will be responsible for this plan of correction and ongoing monitoring of same. |
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, administrative policy and procedures and an interview with the facility director, the facility failed to complete individual treatment and rehabilitation plans within 30 days of admission, as per facility policy, in four of fourteen outpatient client records.
The findings include:
Twenty-one client records were reviewed on May 18 - 20, 2011. Five client records pertained to the partial hospitalization activity. Fourteen outpatient client records required the completion of an individual treatment and rehabilitation plan. Two outpatient client records were from a time frame outside of the current licensing inspection. Per facility policy, individual treatment and rehabilitation plans will be completed within 30 days of admission. Individual treatment and rehabilitation plans were not completed within 30 days of admission in client records # 8, 9, 13 and 17.
Client # 8 was admitted into treatment on October 25, 2010. The individual treatment and rehabilitation plan was due to be completed no later than November 25, 2010. The individual treatment and rehabilitation plan was not completed until February 24, 2011.
Client # 9 was admitted into treatment on December 2, 2010. The individual treatment and rehabilitation plan was due to be completed no later than January 2, 2011. The individual treatment and rehabilitation plan was not completed until February 3, 2011.
Client # 13 was admitted into treatment on November 22, 2010. The individual treatment and rehabilitation plan was due to be completed no later than December 22, 2010. The individual treatment and rehabilitation plan was not completed until April 18, 2011. The individual treatment and rehabilitation plan was not signed by the client.
Client # 17 was admitted into treatment on March 29, 2011. The individual treatment and rehabilitation plan was due to be completed no later than April 29, 2011. There was no documentation of an individual treatment plan in client record # 17, at the time of the review on May 18 - 20, 2011.
The facility director was interviewed throughout the licensing process and confirmed these treatment plans were not completed within 30 days of admission, as required by agency policy.
|
Plan of Correction
On July 7th, 2011 a mandatory staff meeting will be held with all staff to review treatment plan timelines and regulations. Each staff member will be provided with a copy of our agency's policy and regulations in regard to treatment plan timelines. In addition, staff members who were responsible for charts that were missing treatment plan will correct these deficiencies no later than July 29th, 2011. To assure staff members are improving in this area internal chart audits will be conducted. The Clinical Supervisor and Director will be responsible for this plan of correction and ongoing monitoring of same. |
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.
|
Observations
Based on a review of client records, policy and procedures and staff interviews, the facility failed to document treatment and rehabilitation plan reviews and updates every 60 days, as per facility policy and regulation, in four of nine outpatient client records.
The findings include:
Twenty-one client records were reviewed on May 18 - 20, 2011. Five client records pertained to the partial hospitalization activity. Nine outpatient client records required the completion of treatment plan reviews and updates. Five outpatient client records were not yet due for treatment plan reviews and updates. Two outpatient client records were from a time frame outside of the current licensing inspection. Treatment plan reviews and updates were not documented in client records # 10, 11, 12 and 13.
Client # 10 was admitted into treatment on November 15, 2010. The individual treatment and rehabilitation plan was completed on November 16, 2010. Treatment plan reviews and updates were due to be completed no later than January 16, 2011, March 16, 2011 and May 16, 2011. There was no documentation of treatment plan review and updates in client record # 10. On January 18 and March 16, 2011, new individual treatment and rehabilitation plans were developed with the client. These individual treatment and rehabilitation plans did not include a review and update of the treatment plan developed on November 16, 2010.
Client # 11 was admitted into treatment on November 22, 2010. The individual treatment and rehabilitation plan was completed on November 22, 2010. Treatment plan reviews and updates were due to be completed no later than January 22, 2011 and March 22, 2011. There was no documentation of treatment plan reviews and updates in client record # 11. On January 26 and March 29, 2011, new individual treatment and rehabilitation plans were developed with the client. These individual treatment and rehabilitation plans did not include a review and update of the treatment plan developed on November 22, 2010.
Client # 12 was admitted into treatment on December 14, 2010. The individual treatment and rehabilitation plan was completed on December 30, 2010. Treatment plan reviews and updates were due to be completed no later than March 2, 2011 and May 2, 2011. There was no documentation of treatment plan reviews and updates in client record # 12, at the time of the review on May 18 - 20, 2011.
Client # 13 was admitted into treatment on November 22, 2010. The individual treatment and rehabilitation plan was due to be completed no later than December 22, 2010; but was not completed until April 18, 2011. Treatment plan reviews and updates were due to be completed no later than February 22, 2011 and April 22, 2011. There was no documentation of treatment plan reviews and updates in client record # 13, at the time of the review on May 18 - 20, 2011.
The facility director and clinical supervisor were interviewed throughout the licensing process and confirmed treatment plan reviews and updates were not completed every 60 days in client records # 10, 11, 12 and 13.
|
Plan of Correction
On July 7th, 2011 a mandatory staff meeting will be held with all staff to review treatment plan timelines and regulations. Each staff member will be provided with a copy of our agency's policy and regulations in regard to treatment plan timelines. In addition, staff members who were responsible for charts that were missing treatment plan updates will correct these deficiencies no later than July 29th, 2011. To assure staff members are improving in this area internal chart audits will be conducted. The Clinical Supervisor and Director will be responsible for this plan of correction and ongoing monitoring of same. |
709.93(a)(8) 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:
(8) Case consultation notes.
|
Observations
Based on a review of the facility's policy and procedure manual, client records and staff interviews, the facility failed to document a case consultation every 90 days, as per facility policy, in five of eleven outpatient client records.
The findings include:
Twenty-one client records were reviewed on May 18 - 20, 2011. Five client records pertained to the partial hospitalization activity. Case consultations were required in eleven outpatient client records. Four outpatient client records were not yet due for a case consultation. Two client records were from a time frame outside of the current licensing inspection. The facility policy requires a case consultation to be completed every 90 days. The facility did not document case consultations every 90 days in client records # 8, 9, 10, 11 and 13.
Client # 8 was admitted into treatment October 25, 2010. Case consultations were due to be completed no later than January 25, 2011 and April 25, 2011. Only one case consultation was competed on April 25, 2011. There was no documentation of the case consultation due on January 25, 2011 at the time of the review on May 18 - 20, 2011.
Client # 9 was admitted into treatment December 2, 2010. The first case consultation was due to be completed no later than March 2, 2011. There was documentation of a case consultation on February 2, 2011. A second case consultation was due on May 2, 2011. There was no documentation of the case consultation due on May 2, 2011 at the time of the review on May 18, 2011.
Client # 10 was admitted into treatment November 15, 2010. Case consultations were due to be completed no later than February 15, 2011 and May 15, 2011. There was no documentation of any case consultations at the time of the review on May 18 - 20, 2011.
Client # 11 was admitted into treatment November 22, 2010. A case consultation was due to be completed no later than February 22, 2011. There was no documentation of any case consultations at the time of the review on May 18 - 20, 2011.
Client # 13 was admitted into treatment November 22, 2010. A case consultation was due to be completed no later than February 22, 2011. There was no documentation of any case consultations at the time of the review on May 18 - 20, 2011.
The facility director and clinical supervisor were interviewed throughout the licensing process and confirmed these client records did not contain the required case consultations.
|
Plan of Correction
On July 7th, 2011 a mandatory staff meeting will be held with all staff to review case consultation timelines and regulations. Each staff member will be provided with a copy of our agency's policy and regulations in regard to case consultation timelines. In addition, staff members who were responsible for charts that were missing case consultation will correct these deficiencies no later than July 29th, 2011. To assure staff members are improving in this area internal chart audits will be conducted. The Clinical Supervisor and Director will be responsible for this plan of correction and ongoing monitoring of same. |