INITIAL COMMENTS
|
Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on July 30, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Berks Counseling Center, Inc. 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
|
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
|
Observations
Based on a review of client records, the facility failed to ensure that employee #1 had an annual written individual performance evaluation for the prior reviewed year. The last documented performance evaluation was dated July 16, 2018.
The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
CEO will work with the Board of Directors to identify a method for annual performance evaluation for the CEO. This process will be implemented by 1/1/2021. The Human Resources department will be responsible for ensuring that all annual performance evaluations will be completed by the due date. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
|
Observations
Based on an administrative review, the facility failed to file a written unusual incident report with the Department within 3 business days following an incident involving the facility becoming aware of an offsite death of a client in four of six reportable incidents.
The facility was notified of the offsite death of clients on May 4, 2019, December 15, 2019, February 27, 2020, and May 16, 2020. However, the facility reported these incidents to the Department on May 10, 2019, January 17, 2020, March 20, 2020, and May 21, 2020, respectively.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Expectations surrounding unusual incident reporting were reviewed with all staff during team huddles during the first week of August 2020.
Effective immediately all Unusual Incidents will be reported within the daily Team Huddle. This has been added to the Team Huddle agenda.
Upon reviewing the incident in the Team Huddle, the appropriate employee who has information related to the incident will complete the Unusual Incident Report by end of day during which the incident occurred and submit a copy of that report to the CQI Director and the Team Leader.
Then the CQI Director and/or the Team Leader, upon his/her absence. will be responsible for submitting the report within the 3 day time frame.
|
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, the facility failed to ensure that treatment plan updates were updated within the regulatory timeframe in three of seven client records reviewed.
Client #1 was admitted on January 13, 2020 and was active at the time of the inspection. A treatment plan update was completed on March 23, 2020 and the next update was due no later than May 23, 2020; however, the update was not documented in the record as of the date of the inspection.
Client #3 was admitted on December 10, 2019 and was active at the time of the inspection. A treatment plan update was completed on January 20, 2020 and the next update was due no later than March 20, 2020; however, the update was completed on May 11, 2020. Additionally, the next treatment plan update was due no later than July 11, 2020; however, the update was not documented in the records as of the date of the inspection.
Client #7 was admitted on November 22, 2017 and was discharged on April 16, 2019. A treatment plan update was completed on January 16, 2019 and the next update was due no later than March 16, 2019; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Berks Counseling Center will submit a letter requesting a waiver for the timeframe of treatment plans by 9/30/2020. If this plan is not approved, BCC's policy regarding treatment plans will be adjusted to reflect the 60 day update requirement and review with staff. This will be completed within 2 weeks of receiving a response from DDAP regarding an extension of the time frame. Team Leaders will maintain responsibility for ensuring that treatment plans are completed within the required time frames. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
|
Observations
Based on an administrative review, the facility failed to notify the Department within 90 days of a change in the authorized maximum capacity. The facility provided documentation showing that they are serving 523 clients; however, the facility's authorized maximum capacity is 350.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Berks Counseling Center submitted a letter requesting an increase in capacity to 600. This request was approved with an effective date of 8/11/2020.The Clinical Director will be responsible for monitoring how close BCC is to capacity on a monthly basis. When BCC is within 50 clients of full capacity, Clinical Director will submit a request for an increase in capacity. |