INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 29, 2015, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, Women's Institute for Family Health 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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709.91(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 client records, the facility failed to provide a psychosocial evaluation to include the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and/or counselor conclusions and impressions in two of ten records reviewed.
The findings include:
Ten client records were reviewed for a psychosocial evaluation on July 29, 2015.
The psychosocial evaluations in client records # 2 and # 4 did not include an evaluation of the counselor conclusions/impressions of the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will increase supervision of project staff to include weekly review of client records to assure that clinical forms are completed in their entirety as per state regulations. The facility will also provide staff in service training on required clinical treatment forms to assure that all staff are aware of this requirement and how to complete forms. The training event will be provided to all existing staff and will be offered to newly hired staff within the first 30 days of employment.
Staff will sign a document to verify participation of the training and their understanding of disciplinary action for failure to complete forms. The Project Director will assure that files are reviewed weekly and will also schedule a training event. To be completed by September 2,2015 |
709.17(a)(1) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
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Observations
Based on a review of administrative documentation, the facility failed to comply with the directive issued by the Department requiring the facility to develop and implement policies and procedures for the reporting of unusual incidents.
The findings include:
As per the directive within Chapter 709 Subchapter C enacted on 10/18/2014, the facility was required to develop and implement policies and procedures for the reporting of unusual incidents. The facility's administrative records were reviewed for documentation of policies and procedures for the reporting of unusual incidents on 7/29/2015. As of the date of the inspection, the facility has not developed policies and procedures for the reporting of unusual incidents.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will develop policies for immediate implementation for reporting of unusual incidents.
The Project Director developed on August 19, 2015 a policy for the reporting of unusual incidents and the policy has been added to the agency's standard operating procedures for immediate implementation. |