INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 18, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Insights, Inc. 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)(5) LICENSURE Partial Hosp Ratio
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.
(5) Partial hospitalization. Partial hospitalization programs shall have a minimum of one FTE counselor who provides direct counseling services to every ten clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report form completed by the facility on May 16, 2012, the facility failed to ensure that the staff to client ratios remained at or below 10:1.
The findings include:
On May 16, 2012 the Staffing Requirements Facility Summary Report form completed by the facility was reviewed. The form listed the project director/facility director, clinical supervisor and four counselors for the clinical staff.
The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 40 hours per week.
Based the total number of hours per week that the facility reported the employees devoted to their clients, the total number of hours in the facility's standard work week (40), and the total number of current clients as of May 16, 2012 exceeded the allowable maximum of 10:1.
The actual client ratio is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients treatment by the facility's standard work week.
The number of hours per week for the facility director, clinical supervisor and counselors was 34 hours. 34 divided by the facility work week of 40 hours equals 0.85 FTE. The number of current clients is 9 divided by the 0.85 FTE is 10.58823529. This results in a ratio of 11:1 which exceeds the maximum of 10:1.
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Plan of Correction
The Executive Director will make the necessary adjustments to the clinical workforce to assure adequate, required time is devoted to each partial hospitalization client. The Executive Director will check that these adjustments do not exceed the 10:1 maximum ratio by applying the standard formula. This will be achieved by June 29, 2012. |
709.81(b)(6) LICENSURE Intake and admission
709.81. 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 six of eight client records.
The findings include:
Sixteen client records were reviewed on May 18, 2012. Eight of the sixteen was reviewed from the partial hospitalization activity, #9, 10, 11, 12, 13, 14, 15 and 16. A psychosocial evaluation was required in eight client records, #9, 10, 11, 12, 13, 14, 15 and 16.
The psychosocial evaluations in client records #9, 10, 11, 13, 15 and 16 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records #9, 10, 11, 13, 15 and 16 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluations in client records #9, 10, 11, 13, 15 and 16 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 #9, 10, 11, 13, 15 and 16 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluation in client records #9 did not include an evaluation of the counselor conclusions/impressions of the client.
Additionally, per the facility's policy, the psychosocial evaluation will be completed at the psychosocial history.
Client #4's psychosocial evaluation was completed on December 23, 2011 and their psychosocial history completed on December 29, 2011, 6 days after the completed on client #4's psychosocial evaluation.
An interview with facility staff on May 18, 2012 confirmed the findings.
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Plan of Correction
The Clinical Coordinator will review with the clinical staff in the staff meeting on 7/12/12 that all composite pictures/psychosocial evaluation of the client must include the clients problems/needs, assets/strengths and how they would impact treatment, support systems and how they would relate to treatment, coping mechanisms and how they would relate to or impact treatment, negative factors and how they would impact treatment and the counselor's conclusions and impressions of the client including the client's attitude toward treatment and how it would impact treatment. Examples will be provided. The Clinical Coordinator will randomly audit charts for compliance by random audits of one clinical chart at each clinical supervision for 6 months. |
709.83(a)(10) LICENSURE Client records
709.83. 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 the review of client records, the facility failed to document the reason for treatment in the discharge summaries in four of four discharge client records.
The findings include:
Sixteen client records were reviewed on May 18, 2012. Eight of the sixteen were from the partial hospitalization activity, #9, 10, 11, 12, 13, 14, 15 and 16. Discharge summaries were required in four client records, #13, 14, 15 and 16. The facility did not completely record the reasons for entering into drug and alcohol services in four of four records, #13, 14, 15 and 16. An interview with facility staff on May 18, 2012 confirmed the findings.
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Plan of Correction
The Clinical Coordinator will review with the clinical staff in the staff meeting on 7/12/12 that all client records require a discharge summary that must include the reasons for entering drug and alcohol treatment services for all client records. Examples will be provided. The Clinical Coordinator will randomly audit charts for compliance by random audits of one clinical chart that has been discharged at each clinical supervision for 6 months |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative policies and procedures, the facility failed to complete the 2010-2011 audit by the end of the project's fiscal year, as required by regulation.
The findings include:
The administrative policies and procedures were reviewed on May 16, 2012. Per regulation, the project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services. The project's fiscal year is from July through June. The project's audit for July 1, 2010 through June 30, 2011 was due to be completed no later than December 31, 2011. The project failed to document the completion of an annual audit for the 2010-2011 fiscal year.
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Plan of Correction
The Bookkeeper will be responsible to arrange for the annual audit that will allow for adequate time to have it completed by the accounting firm before December 31st of each year. Therefore, an initiative will take place to schedule the audit in August (or) September to assure completion prior to that deadline. The accounting firm will be contacted to schedule the audit by June 29, 2012. |
709.91(b)(6) LICENSURE Intake and admission
709.91. 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:
Sixteen client records were reviewed on May 18, 2012. Eight of the sixteen was reviewed from the outpatient activity, #1, 2, 3, 4, 5, 6, 7 and 8. A psychosocial evaluation was required in eight client records, #1, 2, 3, 4, 5, 6, 7 and 8. An interview with facility staff on May 18, 2012 confirmed the findings.
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, 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, 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, 4, 5, 7 and 8 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluation in client records #1, 2 and 8 did not include an evaluation of the client's attitude toward treatment and how it would impact treatment.
The psychosocial evaluation in client records #1 and 2 did not include an evaluation of the counselor conclusions/impressions of the client.
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Plan of Correction
The Clinical Coordinator will review with the clinical staff in the staff meeting on 7/12/12 that all composite pictures/psychosocial evaluation of the client must include the clients problems/needs, assets/strengths and how they would impact treatment, support systems and how they would relate to treatment, coping mechanisms and how they would relate to or impact treatment, negative factors and how they would impact treatment and the counselor's conclusions and impressions of the client including the client's attitude toward treatment and how it would impact treatment. Examples will be provided. The Clinical Coordinator will randomly audit charts for compliance by random audits of one clinical chart at each clinical supervision for 6 months. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) 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 in the treatment plan update the client's progress as it relates to the goals identified in the individualized treatment and rehabilitation plan.
The findings were:
Sixteen client records were reviewed on May 18, 2012. Of the sixteen, eight were from the outpatient activity, #1, 2, 3, 4, 5, 6, 7 and 8. Of the eight, seven were required to show documentation of a treatment plan update, #1, 2, 3, 4, 5, 6 and 7. It was determined that the therapist failed to document in the treatment plan update the client's progress as it relates to the the goals identified in the individualized treatment and rehabilitation plan, #3, 4, 5 and 7. Additionally, per the facility's policy, treatment plan updates are to be completed within 60 days of the comprehensive treatment plan.
Client #2's comprehensive treatment plan was completed on January 4, 2012 and their updates completed on January 23, 2012 and May 17, 2012. The May 17, 2012 treatment plan update documented 24 days late. The May 17, 2012 treatment plan update should have been documented by March 23, 2012.
An interview with facility staff on May 18, 2012 confirmed the findings.
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Plan of Correction
The Clinical Coordinator will review with the clinical staff in the staff meeting on 7/12/12 that all treatment and rehabilitation plans shall be reviewed and updated at least every 60 days. It will also be reviewed that it is to be documented in the treatment plan update the progress as it relates to the goals identified in the individualized treatment plan. Examples will be provided. The Clinical Coordinator will monitor for compliance by reviewing treatment plan reviews when they are submitted for supervisor signature for 6 months. Each counselor is to submit their active client list at each bi-weekly supervision session. At that time a review of deadline dates for treatment plans, updates and case reviews will take place. |
709.93(a)(10) LICENSURE Client records
709.93. 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 the review of client records, the facility failed to document the reason for treatment in the discharge summaries in three of four discharge client records.
The findings include:
Sixteen client records were reviewed on May 18, 2012. Eight of the sixteen were from the outpatient activity, #1, 2, 3, 4, 5, 6, 7 and 8. Discharge summaries were required in four client records, 5, 6, 7 and 8. The facility did not completely record the reasons for entering into drug and alcohol services in three of four records, # 5, 6 and 7. An interview with facility staff on May 18, 2012 confirmed the findings.
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Plan of Correction
The Clinical Coordinator will review with the clinical staff in the staff meeting on 7/12/12 that all client records require a discharge summary that must include the reasons for entering drug and alcohol treatment services for all client records. Examples will be provided. The Clinical Coordinator will randomly audit charts for compliance by random audits of one clinical chart that has been discharged at each clinical supervision for 6 months |