INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 26-27, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Cove Forge Behavioral Health System at Williamsburg, 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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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ventilate toilet and washrooms by exhaust fan or window. The ventilation fans in rooms #1 and #3 of the Divert building, were not operational. Additionally, the exhaust fans in the men's and women's lavatory in the upper recreational area of the barn, were not operational. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Dibert exhaust fans were fixed on 3/27/25.
The exhaust fans in the recreational area were fixed on 4/11/25.
Checking exhaust fans will be added to the weekly leadership rounds and maintenance rounding.
In the event a fan is not working, the facility director will be notified and it will be fixed immediately. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of partial hospitalization client records, the facility failed to document treatment plan updates within the timeframes established by it's policy in three out of seven client records reviewed. The facility's policy is to update treatment plans every fourteen days. Client #17 was admitted on February 13, 2025, and was still active at the time of the inspection. A treatment plan was completed on February 25, 2025, and the next update was due no later than March 11, 2025; however, the next treatment plan was completed March 14, 2025. Client #18 was admitted on December 13, 2024, and was discharged on January 16, 2025. A treatment plan was completed on December 13, 2024, and the next update was due no later than December 27, 2024; however, the next treatment plan was completed January 6, 2025. Client #19 was admitted on December 19, 2024, and was discharged on January 6, 2025. A treatment plan was completed on December 19, 2024, and the next update was due no later than January 2, 2025; however, the next treatment plan was completed on January 3, 2025. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PHP counseling staff will be re-educated on the importance of completing treatment plan updates every 14 days at the next two weekly PHP clinical staff meetings.
If the individual counselor is unable to complete the treatment plan update by day 14, he/she will let the clinical supervisor know so the supervisor or the group counselor can complete the update timely.
The PHP clinical supervisor will review 10 charts per week for the next 12 weeks, and randomly thereafter, to ensure timely completion of updates.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of residential client records, the facility failed to document a psychosocial evaluation in client records as of the date of the licensing inspection in four out of six applicable records reviewed. The facility's policy is to complete psychosocial evaluations within three days of admission to residential treatment. Client #8 was admitted on March 3, 2025, and was still an active client at the time of the inspection. A psychosocial evaluation was to be completed no later than March 6, 2025; however, this evaluation was completed March 7, 2025. Client #10 was admitted on March 18, 2025, and was still an active client at the time of the inspection. A psychosocial evaluation was to be completed no later than March 21, 2025; however, this evaluation was completed March 24, 2025.Client #13 was admitted on January 11, 2025, and was discharged on January 25, 2025. A psychosocial evaluation was to be completed no later than January 14, 2025; however, this evaluation was incomplete due to the missing clinical summary. Client #14 was admitted on February 11, 2025, and was discharged on February 26, 2025. A psychosocial evaluation was to be completed no later than February 14, 2025; however, this evaluation was incomplete due to the missing clinical summary. This is a repeat citation from March 7, 2024, licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The diagnostic summaries of clients #13 and #14 were completed on 4/14/25.
Counseling staff will be re-educated on the importance of timely and complete biopsychosocial assessments and diagnostic summaries in clinical staffing on April 16 and April 23.
Each of the four rehab clinical supervisors will review 10 charts per month for 4 months to monitor timely completion. |
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 on a review of residential client records, the facility failed to provide a complete client record, which is to include a discharge summary in two out of four applicable records reviewed. Client #13 was admitted on January 11, 2025, and discharged on January 25, 2025. There was no discharge summary documented in this client record. Client #14 was admitted on February 11, 2025, and was discharged on February 26, 2025. There was no discharge summary documented in this client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The discharge summaries of clients # 13 and #14 were completed on 4/15/25.
Counseling staff will be reminded of the importance of completing the discharge summary within 7 days of discharge at the next two clinical staff meetings.
Discharge summaries and their due dates are sent out daily by medical record staff. Each rehab clinical supervisor will review this list daily and if a discharge summary is not completed by day 5, the supervisor will ensure time is carved out for the counselor to complete the summary over the next two days.
Each residential clinical supervisor will review 15 charts per month from the counselors they supervise to ensure timely completion.
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709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of residential client records, the facility failed to provide a complete client record, which is to include: follow-up information, in two out of four applicable records reviewed. The facility's policy is to follow-up, for all clients, within seven days of discharge. Client #13 was admitted on January 11, 2025, and was discharged on January 25, 2025. The client record did not contain documentation of a follow-up contact. Client #14 was admitted on February 11, 2025, and was discharged on February 26, 2025. The client record did not contain documentation of a follow-up contact. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A follow up call was placed on client #13 on 1/28/25 and on client #14 on 3/3/25, however, only the box was checked that a message was not left due to confidentiality concerns in both cases.
The case management supervisor was educated on the need to add a statement to the comment section of the follow up call form stating that calls were made but messages not left and the reason for concern/not leaving a message.
The case management supervisor will train case management staff to do the aforementioned when they make follow up calls. This training will occur by 5/2/25.
The case management supervisor will monitor 15 charts for the next 4 months to ensure proper documentation is entered on the aftercare form. |