INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 11-12, 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. The following deficiencies were identified during this inspection:
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Plan of Correction
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711.92(c) LICENSURE Individual TX Plan
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:
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Observations
Based on a review of client records, the facility failed to develop an individual treatment and rehabilitation plan upon completion of the intake process in three of seven client records.
The findings include:
Seven client records were reviewed for individual treatment plans on December 11-12, 2013. The facility failed to develop an individual treatment and rehabilitation plan, upon completion of the intake process, in client records # 1, 2 and 3.
Client #1 was admitted on July 24, 2013 and the preliminary treatment plan was completed that same day. The facility failed to develop the individual treatment and rehabilitation plan with the client, upon completion of the intake process, as it wasn't completed until October 7, 2013.
Client #2 was admitted on August 8, 2013 and the preliminary treatment plan was completed that same day. The facility failed to develop the individual treatment and rehabilitation plan with the client, upon completion of the intake process, as it wasn't completed until October 24, 2013.
Client #3 was admitted on June 20, 2013 and the preliminary treatment plan was completed on June 27, 2013. The facility failed to develop an individual treatment and rehabilitation plan with the client upon completion of the intake process. The record did not include an individual treatment and rehabilitation plan as of the date of inspection.
The facility director confirmed the findings.
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Plan of Correction
In the clinical meeting on January 8, 2014 the facility director will review with the counselors the need to document an individualized treatment and rehabilitation plan for each client, and to complete the individualized treatment and rehabilitation plan by the third session. The facility director will be responsible for monitoring compliance with regulation 711.92(c) 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 review and update treatment and rehabilitation plans at least every 60 days in two of seven client records.
The findings include:
Seven client records were reviewed for treatment plan updates on December 11-12, 2013. The facility failed to document treatment plan updates at least every 60 days in client records # 5 and 6.
Client record # 5 included a comprehensive treatment plan that was dated June 10, 2013, and a treatment plan update that was dated July 24, 2013. The facility failed to document 60 day treatment plan updates that were due no later than September 24, 2013 and November 24, 2013.
Client record # 6 included a comprehensive treatment plan that was dated August 20, 2013. A 60 day treatment plan update was due no later than October 19, 2013. The facility failed to complete the 60 day treatment plan update until November 14, 2013.
The facility director confirmed the findings.
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Plan of Correction
In clinical team meeting on January 08,2014 the facility director will review with the counselors the need to complete a treatment plan review and update every 60 days. The facility director will be responsible for monitoring compliance with regulation 711.92(d) via periodic record reviews |