INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 17, 2011 through August 19, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Conewago Snyder 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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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on an interview with the Project Director and a letter from the Controller, the project failed to document the completion of an annual audit of financial activities by the end of the the project's fiscal year.
The findings include:
The Project Director was interviewed on August 5, 2011 and confirmed that an annual audit of financial activities has not been completed since June 24, 2010, which was for the fiscal year July 1, 2008 through June 30, 2009. The inspector was also presented with a letter from the Controller of Firetree, Ltd that indicated the 2010 audit was late and had not yet been completed as of August 8, 2011.
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Plan of Correction
Project director will review DOH standard 709.25(a) relating to the completion of an independent annual audit with the governing body of
Firetree, Ltd. on 8/29/11 to ensure their understanding and support.
Project director will secure the 2010 annual audit from the governing body by 9/30/11.
Governing body will secure completion of subsequent annual audits within six months following the end of the project's fiscal year to ensure ongoing compliance. |
709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
Based on a review of client records and the facility's policy and procedures, the facility failed to document treatment plans to include proposed types of supportive services in three of eight client records.
Findings:
The facility's policy, titled, 6-061D, Treatment and Rehabilitative Services Comprehensive Individual Treatment Plan (Initial, states:
The Individualized Comprehensive Treatment and Rehabilitation Plan shall include, but not be limited to, written documentation of the following:
1. Realistic goals that are stated in terms of measurable criteria.
2. Types and frequency of treatment and rehabilitative services i.e. group counseling three times per week, family therapy one time every three weeks, or daily relaxation etc.
3. Proposed methods and type of support service(s), economic, legal, AA, NA etc. designated on the treatment plan.
On August 18, 2011, eight client records requiring treatment plans were reviewed. The facility did not document treatment plans to include proposed types of supportive services in three of eight client records reviewed, specifically, # 5, 6, and 7.
Client # 5 was admitted on March 18, 2011 and discharged on April 22, 2011, the treatment plan was completed on March 24, 2011 and did not include proposed support services.
Client # 6 was admitted on March 18, 2011 and discharged on April 10, 2011, the treatment plan was completed on March 24, 2011 and did not include proposed support services.
Client # 7 was admitted on May 21, 2011 and discharged on August 6, 2011, the treatment plan was completed on May 26, 2011 and did not include proposed support services.
A conversation was held with the Clinical Director on August 18, 2011, the lack of documentation of support services was confirmed.
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Plan of Correction
Project director will retrain all clinical staff of the facility on the appropriate completion of client treatment plan forms;specifically addressing the need for a support system to be listed on each treatment plan during the weekly clinical meeting on 9/2/11.
Facility director will monitor weekly during regular clinical chart reviews beginning 9/9/11 to ensure compliance and the corporate compliance officer will review monthly during internal clinical chart audits by 9/30/11 to ensure ongoing compliance. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility's policy and procedures, and a conversation with the Clinical Director, the facility failed to document case consultations in two of seven client records.
Findings:
The facility's policy, titled, 6-051D, Treatment /Rehabilitation Management Treatment Services, stated:
10. CASE CONSULTATION NOTES: Case consultation notes will be made when the client's case is discussed at the clinical team meeting/utilization review meeting. They will also be recorded at the time of any treatment plan updates and in cases of any additional client interventions. Case consultation will occur at a minimum of once each 15 day period for the 28-day client and each 30-day period for the 90-day client.
On August 18, 2011, seven client records requiring case consultations were reviewed.
The facility did not document case consultations in two of seven client records reviewed, specifically, # 2 and 8.
Client # 2 was admitted on July 5, 2011, a case consultation was due by August 5, 2011. As of the date of the inspection, a case consultation had not been documented for client # 2.
Client # 8 was admitted on June 30, 2011 and successfully discharged on July 27, 2011. A case consultation was due by July 15, 2011. As of the date of the inspection, a case consultation had not been documented for client # 8.
A conversation was held with the Clinical Director on August 18, 2011, the lack of case consultations was confirmed.
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Plan of Correction
Project director will retrain all clinical staff of the facility on the appropriate completion of client case consultation forms; specifically addressing the content and time frames for completion during the weekly clinical meeting on 9/2/11.
Facility director will monitor weekly during regular clinical chart reviews beginning 9/9/11 to ensure compliance and the corporate compliance officer will monitor monthly during internal client chart audits by 9/30/11 to ensure ongoing compliance. |
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 conversation with the Quality Assurance Director, a review of facility staff CPR and First Aid documentation, and staff schedules, the facility failed to ensure that a sufficient number of staff persons trained in CPR skills are present during the project's hours of operation.
The findings include:
On August 17, 2011 the facility presented staff schedules for the period covering July 17, 2011 to August 17, 2011. The CPR cards presented were reviewed and four of the staff members were trained for CPR certification and First Aid on July 22, 2011. The facility was unable to verify if the staff were CPR certified and trained in First Aid prior to July 22, 2011. Additionally, two staff members were trained for First Aid and CPR certification on July 29, 2011 but the facility could not furnish cards for these staff at all.
The facility did not have documentation of CPR certified and First Aid trained staff for the following time periods:
Sunday, July 17, 2011 from 2:30 pm to 8:00 pm
Monday, July 18, 2011 from 4:00 pm to 8:00 pm
Tuesday, July 19, 2011 from 5:00 pm to Wednesday July 20, 2011, 7:30 am
Wednesday, July 20, 2011 from 5:00 pm to Thursday July 21, 2011, 7:30 am
Saturday, July 23, 2011 from 2:30 pm to 8 pm
Saturday, August 6, 2011 from 6:30 am to 8:30 am and from 7 pm to 10 pm
Sunday, August 7, 2011 from 6:30 am to 8:30 am
Friday, August 12, 2011 from 6:30 am to 7:30 am
A conversation was held with the Director of Quality Assurance on August 18, 2011, in which he was asked to provide verification of coverage for the above referenced time periods, he advised the facility was unable to furnish the required documentation.
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Plan of Correction
Project director will retrain facility director on the training requirements for First Aid/CPR for facility staff on 9/2/11 to ensure her understanding.
Facility director will coordinate the First Aid/CPR training of all current facility staff by 9/13/11 and will place training certificates in the staff personnel files for documentation of completion.
Facility director will coordinate future trainings with the corporate training officer through the employee software system to ensure ongoing compliance by 9/30/2011. |