INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 2 through 4 , 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Conewago Place 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 November 6, 2007.
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Plan of Correction
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Base upon a physical plant tour conducted on October 3, 2007, the facility failed to ensure privacy so that counseling sessions could not be seen outside the counseling room. Both group rooms had side light vision panels in the corridor walls and they lacked any type of window treatment to ensure privacy.
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Plan of Correction
Provider will purchase window treatments to cover the windows for the two group rooms. This will ensure privacy when conducting group counseling and clients will not be seen from the corridor. |
705.5 (c) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(c) No more than four residents may share a bedroom.
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Observations
Base upon a physical plant tour conducted on October 3, 2007, the facility failed to ensure that no more than four residents shared a room. Rooms 729 a and 729 b are constructed as two areas of one large room separated by a partition wall and there were a total of six beds in this room.
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Plan of Correction
Provider is requesting an exemption from this deficiency. The new addition has been in operation for three years. We were informed to install a skylight to provide natural lighting in room (229b). This room has two beds in it. A skylight was installed so this room would meet that standard. Room (229a) is a four bedroom suite. These are two separate rooms and they share a common bathroom.
The plan of correction in the event that this exception is not granted is as follows: Facility will correct the problem by providing an entrance way to Room 229 B in the corridor. The doorway that is currently used for this room would be closed off to ensure privacy to this room. An additional door would be placed inside the corridor leading to Room 229 A. This would provide privacy to this room. There would not be any more than four beds in each room. There would be a small corridor that each room would have to access to for the shared bathroom. |
705.5 (e) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(e) Each bedroom shall have direct access to a corridor or external exit.
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Observations
Base upon a physical plant tour conducted on October 3, 2007, the facility failed to ensure that each room has direct access to a corridor or external exit. Room 201 lacks a direct access to the corridor nor does it have a direct exit to the outside. Room 201 requires residents to first go through the female lounge to reach a corridor.
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Plan of Correction
Provider is requesting an exemption from this deficiency. This is part of the new addition that has been in operation for three years. Room 201 is connected to a female lounge area. The lounge provides direct access to the corridor. The door on the lounge is never shut therefore direct access is available. However, in the event that this exeception is not granted the facility staff will remove the door to lounge and ensure the furniture is arranged to allow unobstructed access to the corridor. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based upon review of client records on October 4, 2007, the facility failed to allow the clients to revoke consents verbally. Consent to release information forms in six of six records reviewed only allowed for the client to revoke the consent by notifying their counselor in witting.
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Plan of Correction
Provider has added verbage to the consent form to allow clients to verbally revoke consents. Clinical Director has instructed staff of the changes made to the new form and have instructed staff to utilize the new form. The old form has been removed from the EM system ( electronic files). Clinical Director and Compliance officer will monitor the implementation of the forms by pulling records weekly and reveiw the forms for one month. Records will then be pulled randomly on a quarterly basis to maintain compliance. This has been completed. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based upon review of discharge summaries completed in two of two client records reviewed it was determined that the facility failed to complete the summaries within seven days of discharge as per the facility policy. Client record #5 documented the date of discharge as 5/24/2007, however the discharge summary was not completed until 7/9/07. Client record #6 documented the date of discharge as 6/14/2007, however the discharge summary was not completed until 6/26/2007.
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Plan of Correction
Clinical Director will retrain clinical staff on timeliness of completing discharge summaries within five working days according to the company policy. Clinical director will monitor compliance and training will be recorded in all counselor's clinical supervision. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based upon review of treatment plans in client records reviewed on October 4, 2007, the facility failed to document how work done by the client at the project would be an integral part of treatment in three of six records reviewed. Treatment plans contained in client records #1, 3 & 4 indicated that the client would be responsible for completing daily tasks as assigned, however there was no mention in the treatment plan as to how the tasks would be used for treatment.
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Plan of Correction
Clincal Director will train clinical staff in the month of October on the importance of the clients developing healthy work habits throughout the course of treatment. This process will be documented on the comprehensive treatment plan for each individual client. The documentation on the comprehensive treatment plan will indicate the therapeutic relationship between living a sober lifestyle and one's work ethic. This documentation will also include any "special needs" of the client in regard to work performance, client's work history, or disability. Clinical Director will monitor compliance. |