INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 22 - 23, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, York Hospital Behavioral Health Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report form completed by the facility on January 22, 2013, the facility failed to ensure that staff caseloads remained at or under 35:1.
The findings include:
The Staffing Requirements Facility Summary Report form completed by the facility was reviewed on January 22, 2013. The form listed one facility/clinical supervisor and five counselors.
Employee # 1 has documented 3 hours dedicated to drug and alcohol clients and has a case load of 16 drug and alcohol clients. At the time of the inspection employee #3 exceeded the required 35:1 FTE and currently had a FTE of 187:1.
Employee # 5 has documented 7 hours dedicated to drug and alcohol clients and has a case load of 9 drug and alcohol clients. At the time of the inspection employee #5 exceeded the required 35:1 FTE and currently had a FTE of 45:1.
An interview with facility staff on January 22, 2013 confirmed the findings.
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Plan of Correction
Caseloads were exceeded due to the loss of 2 providers. One retirement and one deceased. This was a temporary situation and will be resolved once these positions are filled. Currently interviewing to replace open position and should be filled by 3/15/13. New clients will not be accepted on the provider case load. The facility director will assure the corrective action is implemented. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. 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 assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in eight of eight client records.
The findings include:
Eight client records were reviewed on January 23, 2013. All records were reviewed for psychosocial evaluations.
The psychosocial evaluations in client records #1, 2,3, 4, 5, 6, 7 and 8 did not include an evaluation of the client's problems/needs and how they would impact treatment.
The psychosocial evaluations in client records #1, 2,3, 4, 5, 6, 7 and 8 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records #1, 2,3, 4, 5, 6, 7 and 8 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluations in client records #1, 2,3, 4, 5, 6, 7 and 8 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records #1, 2,3, 4, 5, 6, 7 and 8 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluations in client records #1, 2,3, 4, 5, 6, 7 and 8 did not include an evaluation of the counselor conclusions/impressions of the client.
An interview with facility staff on January 23, 2013 confirmed the findings.
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Plan of Correction
Facility Director will provide staff training on Wed. 2/20/13 to review pages 14-16 of our intake assessment to improve psychosocial evaluations upon intake. The facility director will monitor compliance with 711.91(b)(6) via periodic record reviews. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document a treatment plan update in accordance with the regulations and facility policy in two of four client records.
The findings include:
Eight client records were reviewed on January 23, 2013. Four client records were required to have a treatment plan update. Per the facility policy, treatment plan updates are required to be completed within 60 days of the comprehensive treatment plan and every 60 days thereafter. The facility failed to document a treatment plan update in client records #1 and 3.
Record #1 - The client was admitted on October 3, 2012. The comprehensive treatment plan was completed on November 8, 2012. A treatment plan update was due by January 8, 2013 and was not completed. The facility failed to document the completion of a treatment plan update as of January 23, 2013.
Record #3 - The client was admitted on October 17, 2012. The comprehensive treatment plan was completed on November 5, 2012. A treatment plan update was due by January 5, 2013 and was not completed. The facility failed to document the completion of a treatment plan update as of January 23, 2013.
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Plan of Correction
Facility Director will provide staff training on Wed. 2/20/13 to remind providers of that treatment and rehabilitation plans must be reviewed and updated every 60 days. The facility director will monitor compliance with 711.92(d) via periodic record reviews. |
711.93(a)(4) LICENSURE Progress Notes
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(4) Progress notes.
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Observations
Based on the review of client records, the facility failed to document a complete progress note in six of eight client records.
Findings:
Eight client records were reviewed on January 23, 2013. Group progress notes were required in eight client records. The facility did not have documentation of the client's participation in group notes in client records #1, 2, 3, 7 and 8 only documenting "Contribute to discussion" or documenting nothing at all. Also, three of the eight client records had documentation of the client's plan that tended to repeat the same plan for each notes in records #1, 5, 7 and 8.
Client #1 group notes documented under plan "maintain abstinence; practice skills".
Client #5 group notes documented under plan "maintain sobriety, attend meetings practice coping skills".
Client's #7 and 8 group notes documented under plan "attend 12 meetings and practice skills, discussed in group".
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Plan of Correction
Facility Director will provide staff training on Wed. 2/20/13 and staff will be trained on data assessment/planning and progress plan formats. The facility director will monitor compliance with 711.93(a)(4) via periodic record reviews. |
711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in one of one required client record.
The finding includes:
Eight client records were reviewed on January 23, 2013. Four of the eight client records were discharge records, #4, 5, 6 and 7. One of the four discharge records were required to have documented in their record an aftercare plan, #7. Per the facility's policy, aftercare plans will be developed prior to the client discharge date. An interview with facility staff on January 23, 2013 confirmed the findings.
Client #7 was admitted on August 8, 2012 and discharged on November 13, 2012. As of the date of the client's discharge of November 13, 2012 there was no documentation of client #7's aftercare plan.
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Plan of Correction
Facility Director will provide staff training on Wed. 2/20/13 to review requirements of documenting aftercare plans. The facility director will monitor compliance with 711.93(a)(6) via periodic record reviews. |
711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based on client record review, the facility failed to document a follow up attempt in one of four discharge client records.
The findings include:
Eight client records were reviewed on January 23, 2013. A follow up attempt is required in four of the discharge records. The facility did not document a follow up in one client record, #7. The facility policy states that follow up will be attempted within seven days for referrals, 30 days for successful completions. An interview with facility staff on January 23, 2013 confirmed the findings.
Client #7 was admitted on August 8, 2012 and discharged on November 13, 2012. The follow-up attempt was to be documented by December 13, 2012. There was no follow-up attempt documented in client record #7.
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Plan of Correction
Facility Director will provide staff training on Wed. 2/20/13, time requirements for follow-up documentation will be reviewed with staff. The facility director will monitor compliance with 711.93(a)(7) via periodic record reviews. |