INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 30 - 31, 2012 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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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 a composite picture of the client, the client problems and needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and the counselor conclusions and/or impressions of the client in eight of eight client records.
The findings include:
Eight client records were reviewed on January 31, 2012. A psychosocial evaluation was required in eight of those records, #1, 2, 3, 4, 5, 6, 7 and 8. A discussion with facility staff on February 1, 2012 confirmed the findings.
The psychosocial evaluations in client records #1, 2, 3, 4, 5, 6, 7 and 8 did not include a composite picture and the client's problems/needs and how they would impact their 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 client's attitude towards treatment and how it 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/impression and how they would impact treatment.
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Plan of Correction
Facility Director will provide staff training on Wed. 2/29/12 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(c)(2) LICENSURE Type & Frequency of TX
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document type and frequency on the comprehensive treatment plans in three of eight records reviewed.
The findings include:
Eight client records were reviewed on January 30, 2012. Type and frequency was required on the comprehensive treatment plans in all eight client records. The following client records did not have documentation of the type and frequency for treatment goal objectives on the comprehensive treatment plan, # 1, 2 and 3.
Client #1 was admitted on December 9, 2011 and their comprehensive treatment plan was documented on December 20, 2011. The comprehensive treatment plan didn't document type and frequency in record # 1.
Client #2 was admitted on November 28, 2011 and their comprehensive treatment plan was documented on December 7, 2011. The comprehensive treatment plan didn't document type and frequency in record # 2.
Client #3 was admitted on September 23, 2011 and their comprehensive treatment plan was not documented.
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Plan of Correction
Facility Director will provide staff training on Wed. 2/29/12 to review page 16 of our intake assessment to assure type and frequency is completed on all treatment plans. The facility director will monitor compliance with 711.92(c)(2) via periodic record reviews. |
711.92(c)(3) LICENSURE Support Service
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document support services on the comprehensive treatment plans in four of eight records reviewed.
The findings include:
Eight client records were reviewed on January 30, 2012. Support services was required on the comprehensive treatment plans in all records. Client records #3, 4, 5 and 6 did not have documentation of support services on the comprehensive treatment plan.
Client # 3 was admitted on September 23, 2011; the comprehensive treatment plan was not documented.
Client #4 was admitted on August 31, 2011; the comprehensive treatment plan was documented on September 12, 2011. The comprehensive treatment plan did not document support services in client record # 4.
Client #5 was admitted on July 26, 2011; the comprehensive treatment plan was documented on August 17, 2011. The comprehensive treatment plan did not document support services in client record # 5.
Client #6 was admitted on August 16, 2011 and their comprehensive treatment plan was documented on September 19, 2011. The comprehensive treatment plan didn't document support services in record #6.
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Plan of Correction
Facility Director will provide staff training on Wed. 2/29/12 to review the importance of including written documentation of support services. The facility director will monitor compliance with 711.92(c)(3) 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 the review of client records, the facility failed to document treatment plan updates in four of eight records.
The findings include:
Eight client records were reviewed on January 31, 2012. Treatment plan updates were required in four client records, # 4, 5, 6 and 8. Treatment plan updates are to be documented every 60 days after the completion of the comprehensive treatment plan.
Client # 4 was admitted on August 31, 2011 and their comprehensive treatment plan was completed on September 12, 2011. The first treatment plan was documented on October 17, 2011 and the treatment plan update was to be documented by December 17, 2011. The treatment plan updated for December 17, 2011 was not documented in client record #4 for review as of January 31, 2012.
Client #5 was admitted on July 26, 2011 and discharged on November 23, 2011. Their comprehensive treatment plan was completed on August 17, 2011. The treatment plan update, due to be completed by October 17, 2011, was not documented in the client record as of January 31, 2012.
Client #6 was admitted on August 16, 2011 and discharged on December 12, 2011. Their comprehensive treatment plan was completed on September 19, 2011. The treatment plan update, due to be completed by November 19, 2011, was not documented in the client record as of January 31, 2012.
Client #8 was admitted on July 14, 2011 and discharged on December 8, 2011. Their comprehensive treatment plan was completed on July 21, 2011. The first treatment plan was documented on September 27, 2011, which was late, and the next was to be documented by November 27, 2011; this treatment plan update was not documented in client record # 8 for review as of January 31, 2012.
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Plan of Correction
Facility Director will provide staff training on Wed. 2/29/12 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 four of eight client records.
Findings:
Eight client records were reviewed on January 31, 2012. Group progress notes were required in all eight client records. The facility did not have documentation of the client's participation in group notes in client records #1, 3, 5 and 7. The groups notes stated only that the client participated in or contributed to the discussion. Also, group notes pertaining to the plan only documented what the topic will be for the next session, but did not document the plan for each client in records, #1, 3, 5 and 7.
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Plan of Correction
Facility Director will provide staff training on Wed. 2/29/12 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)(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 a review of client records, the facility failed document follow-up information in accordance with facility policy in two of four discharge records.
The findings include:
Eight client records were reviewed on January 31, 2012. Four client records were reviewed for follow-up information. Follow up documentation late in records, #6 and 7. Per the facility's policy follow-ups are to be done within 30 days after their discharge date and 7 days if being referred.
Client #6 was admitted on August 16, 2011 and discharged on December 12, 2011. The follow-up contact was due by January 12, 2012. The follow-up was documented as having been completed on January 16, 2012.
Client #7 was admitted on August 17, 2011 and discharged on December 8, 2011. The follow-up was due by January 8, 2012. The follow-up was documented on January 9, 2012.
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Plan of Correction
Facility Director will provide staff training on Wed. 2/29/12,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. |