INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 3, 2008 through November 4, 2008 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. The following deficiencies were identified during this inspection and a plan of correction is due on December 9, 2008.
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Plan of Correction
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704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the facilities policy and procedure manual on November 3, 2008, the facility failed to have an annual evaluation of the overall training plan for training year June 2007 through May 2008.
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Plan of Correction
On or before 12/31/08, Facility Director will meet with a representative from WellSpan Education Services to develop a procedure for completing an annual evaluation of the overall training plan. This procedure will then be incorporated into the Policy and Procedure Manual. An evaluation of the training plan will occur at the conclusion of the June 2008-May 2009 training year, and every subsequent training year. |
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 complete psychosocial evaluations in three of three client records.
Five records were reviewed on November 4, 2008. Psychosocial evaluations were required in three client records. The facility failed to document the client's problems/needs, client's assets/strengths, support systems, coping mechanisms and the client's negative factors that may inhibit treatment and clients attitude towards treatment in the psychosocial evaluations in records #1, 2 and 3.
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Plan of Correction
On or before 112/19/08, the Facility Director will remind clinical staff, both via an-email and during clinical team meetings, of the need to clearly document the client's problems/needs, assets/strengths, support systems, coping mechanisms, the negative factors that may inhibit treatment, and the client's attitude toward treatment in the psychosocial evaluation. Through periodic, random chart reviews, the Facility Director will monitor for compliance with this regulation. |
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 treatment plan updates every sixty days in four of five records reviewed.
Findings:
Five client records were reviewed on November 4, 2008. Treatment plan updates were required in four client records. The facility did not document treatment plan updates in the following client records:
Client record #2: The treatment plan update was due on 10/17/08 and had not been documented as of the last date of the licensing inspection.
Client record #3: The treatment plan update was due on 9/27/08 and had not been documented as of the last date of the licensing inspection.
Client record #4: The treatment plan update was due on 9/28/08 and had not been documented as of the last date of the licensing inspection.
Client record #5: The treatment plan update was due on 8/17/08 and had not been documented as of the last date of the licensing inspection.
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Plan of Correction
On or before 12/19/08, the Facility Director will remind clinical staff, both via an-email and during clinical team meetings, of the need to complete treatment plan updates every 60 days from the date of the development of the comprehensive treatment plan. Furthermore, the treatment plan update form will be revised to include an assessment of the client's progress in relationship to the stated goals, rather than list what percentage of the goal has been accomplished thus far. This new form will be implemented on or before 12/31/08. Through periodic, random chart reviews, the Facility Director will monitor for compliance with this regulation. |