INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 25, 2011 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. The following deficiencies were identified during this inspection.
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Plan of Correction
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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the fire drill log, the facility failed to ensure the fire drills were conducted at different times of the day and on different staffing shifts.
The findings include:
Fire drill logs were reviewed on May 23, 2011. Per regulation, a nonresidential facility shall conduct fire drills on different days of the week, at different times of the day and on different staffing shifts. The facility is open from 9:00 AM to 9:00 PM Monday through Thursday and 9:00 AM to 5:00 PM on Friday. The facility conducted only one fire drill during the evening shift between June 2010 and May 2011. This was conducted at 5:45 PM on July 20, 2010.
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Plan of Correction
The Executive Director will require that all fire drills at both sites will be required to rotate the times of day when they are conducted. These three time frames of morning, afternoon and evening drills will rotate each succeeding month. The Executive Director regularly receives a copy of all fire drill logs from both sites which will be the method to monitor this activity. This new policy will be addended to the manuel and will be in effect as of June 2011.
The Executive Director will provide instruction and conduct a practice fire drill on utilizing an alternate route. This will be presented at the bi-weekly staff meeting at both sites on the following dates:
(Lemoyne)July 6, 2011
(York) July 13,2011
Therefore, this action plan will be fully satisfied on July 13, 2011. |
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 the review of client records, the facility failed to ensure an evaluation of the historical data collected during the intake process in five of five client records.
The findings include:
Fourteen client records were reviewed May 25, 2011. Six of the fourteen client records were partial hospital clients. Five client records were reviewed specifically for psychosocial evaluations. While the evaluations were completed, documentation listed client responses rather than a clinical assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, client's attitude toward treatment and overall impressions/conclusions.
Client # 9 was admitted April 18, 2011. The psychosocial evaluation was completed April 21, 2011. The composite picture was a repeat of the client's treatment history. There was no documentation of a clinical assessment.
Client # 10 was admitted December 13, 2010. The psychosocial evaluation was completed December 9, 2010. The composite picture was a list of the drug use and reasons for treatment. There was no documentation of a clinical assessment.
Client # 11 was admitted November 16, 2010. The psychosocial evaluation was completed November 30, 2010. The composite picture was a repeat of the drug and alcohol history and the client's treatment history. There was no documentation of a clinical assessment.
Client # 12 was admitted December 20, 2010. The psychosocial evaluation was completed December 17, 2010. The composite picture did not evaluate the collected historical data, but repeated and listed more client data. There was no documentation of a clinical assessment.
Client # 13 was admitted November 22, 2010. The psychosocial evaluation was completed November 29, 2010. The composite picture was a list of historical data. There was no documentation of a clinical assessment.
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Plan of Correction
At staff meeting on 6/29/2011, the Program Supervisor will provide training to clinical staff on effective psycho-social evaluation, including appropriate clinical assessment of client's problems/needs, assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment or clients's attitude toward treatment and overall impressions/conclusions. Example of satisfactory psycho-social evaluations and composites will be provided to clinicians and placed in the clinical orientation handbook for future clinicians. The Program Supervisor will randomly review one file at each supervision session for each clinician biweekly to ensure quality and compliance. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on the review of client records, the facility failed to update the client's treatment plan with an assessment of the client's progress in relationship to the stated goals in two of four client records.
The findings include:
Fourteen client records were reviewed May 25, 2011. Six of the fourteen client records were partial hospital clients. Four client records required at least one treatment plan update.
Client # 10 was admitted December 13, 2010. The comprehensive treatment plan was documented December 19, 2010. The treatment plan was updated January 19, 2011. The client's progress was not assessed in relationship to the stated goals of the comprehensive treatment plan. Instead, the treatment update included statements that the objectives were either met and deleted or continued and revised. There was no further documentation.
Client # 14 was admitted December 13, 2010. The comprehensive treatment plan was documented December 19, 2010. The treatment plan was updated January 13, 2011. The client's progress was not assessed in relationship to the stated goals of the comprehensive treatment plan. Instead, the update included statements the objectives were either met and deleted or continued and revised. There was no further documentation.
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Plan of Correction
At staff meeting on 6/29/11, the Program Supervisor will provide training to clinical staff on effective treatment plan review to include assessments of progress stated goals of the comprehensive treatment plan, documentation of completion of goals, reasons for revision of goals and timeline for completion of treatment plan reviews. Examples of satisfactory treatment plan reviews will be provided and placed in the clinicians' orientation handbook for future clinicians. The Program Supervisor will randomly review one file at each supervision session, for each clinician, biweekly to ensure quality and compliance. |
709.83(a)(9) 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:
(9) Progress notes.
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Observations
Based on the review of client records, the facility failed to document complete progress notes in four of five client records.
The findings include:
Fourteen client records were reviewed May 25, 2011. Six of the fourteen client records were partial hospital clients. Five records were reviewed specifically for client progress notes. There were progress notes documented after individual and group counseling sessions. The data, assessment and plan (DAP) format was utilized.
Client record # 10 contained group notes written in DAP format. The plan did not reflect actions to be taken by the counselor, action steps or client assignments or tasks. Instead, the date of the next group was the plan.
Client record # 11 contained group notes written in DAP format. The notes did not include the counselor's analysis or conclusions regarding the status. The plan did not reflect actions to be taken by the counselor, action steps or client assignments or tasks. Instead, the date of the next group was the plan.
Client record # 12 contained group notes written in DAP format. The plan did not reflect actions to be taken by the counselor, action steps or client assignments or tasks. Instead, the date of the next group was the plan.
Client record # 14 contained group notes written in DAP format. The notes did not include the counselor's analysis or conclusions regarding the status. The plan did not reflect actions to be taken by the counselor, action steps or client assignments or tasks. Instead, the date of the next group was the plan.
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Plan of Correction
At staff meeting on 6/29/11, the Program Supervisor will provide training to clinical staff on utilizing DAP format to produce effective group notes including plans reflecting actions to be taken by counselor and client assignments or tasks where appropriate. Examples of satisfactory group notes will be provided and placed in the clinical orientation handbook for future clincicians. The Program Supervisor will randomly review one file at each supervision session, for each clinician biweekly, to ensure quality and compliance. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on the review of administrative documentation and discussion with project director, the facility failed to make available to the public an annual report within six months of the end of the preceding year.
The findings include:
The facility presented documentation the public was notified of the annual report availability. A notice was posted in a local newspaper on February 4, 2011. It was required to have been posted by December 31, 2010.
The project director confirmed the notice was posted late.
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Plan of Correction
The Executive Director and the Chief Financial Council will both monitor the task of making sure the Public Annual Report be available to the public at the time of completing our auditing requirements. This public annual report will be available to the public no later than December 31, 2011. The fact that two Administrators are both responsible will provide an effective check and balance. |
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 the review of client records, the facility failed to ensure an evaluation of the historical data collected during the intake process in eight of eight client records.
The findings include:
Fourteen client records were reviewed May 25, 2011. Eight of the fourteen client records were outpatient clients. Eight client records required psychosocial evaluations. While the evaluations were completed, they had listed responses rather than a clinical assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, client's attitude toward treatment and overall impressions/conclusions.
Client # 1 was admitted January 6, 2011. The psychosocial evaluation was completed January 6, 2011. The composite picture was a repeat of the client's treatment history and a list of the areas to be evaluated. There was no documentation of a clinical assessment.
Client # 2 was admitted January 20, 2011. The psychosocial evaluation was completed February 1, 2011. The composite picture was a repeat of the client's treatment history and a list of the areas to be evaluated. There was no documentation of a clinical assessment.
Client # 3 was admitted January 26, 2011. The psychosocial evaluation was completed February 10, 2011. The composite picture was a repeat of the client's treatment history and a list of the areas to be evaluated. There was no documentation of a clinical assessment.
Client # 4 was admitted January 4, 2011. The psychosocial evaluation was completed January 26, 2011. The composite picture was a repeat of the client's treatment history and a list of the areas to be evaluated. There was no documentation of a clinical assessment.
Client # 5 was admitted November 16, 2010. The psychosocial evaluation was completed November 26, 2010. The composite picture was a repeat of the client's treatment history and a list of the areas to be evaluated. There was no documentation of a clinical assessment.
Client # 6 was admitted October 20, 2010. The psychosocial evaluation was completed October 26, 2010. The composite picture was a repeat of the client's treatment history and a list of the areas to be evaluated. There was no documentation of a clinical assessment.
Client # 7 was admitted December 23, 2010. The psychosocial evaluation was completed January 6, 2011. The composite picture was a repeat of the client's treatment history and a list of the areas to be evaluated. There was no documentation of a clinical assessment.
Client # 8 was admitted October 11, 2010. The psychosocial evaluation was completed October 26, 2010. The composite picture was a repeat of the client's treatment history and a list of the areas to be evaluated. There was no documentation of a clinical assessment.
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Plan of Correction
At staff meeting on 6/29/11, the Program Supervisor will provide training to clinical staff on effective psycho-social evaluation, including appropriate clinical assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment and overall impressions/conclusions. Examples of satisfactory psycho-social evaluations and composites will be provided to clinicians and placed in the clinical orientation handbook for future clinicians. The Program Supervisor will randomly review one file at each supervisory session, for each clinician, biweekly to ensure quality and compliance. |
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 the review of client records, the facility failed to update the client's treatment plan with an assessment of the client's progress in relationship to the stated goals in two of four client records.
The findings include:
Fourteen client records were reviewed May 25, 2011. Eight of the fourteen client records were outpatient clients. Eight client records required at least one treatment plan update.
Client # 3 was admitted January 26, 2011. The comprehensive treatment plan was documented February 17, 2011. The treatment plan was updated April 28, 2011, eleven days late. The client's progress was not assessed in relationship to the stated goals of the comprehensive treatment plan.
Client # 4 was admitted January 4, 2011. The comprehensive treatment plan was documented February 2, 2011. The treatment plan was updated April 4, 2011. The client's progress was not assessed in relationship to the stated goals of the comprehensive treatment plan.
Client # 5 was admitted November 16, 2010. The comprehensive treatment plan was documented December 14, 2010. The treatment plan was updated February 8, 2011. The client's progress was not assessed in relationship to the stated goals of the comprehensive treatment plan.
Client # 6 was admitted October 20, 2010. The comprehensive treatment plan was documented November 13, 2010. The treatment plan was updated December 13, 2010. The client's progress was not assessed in relationship to the stated goals of the comprehensive treatment plan. The treatment update included statements that the objectives were either met and deleted or continued and revised. There was no further documentation.
Client # 7 was admitted December 23, 2010. The comprehensive treatment plan was documented January 13, 2011. The treatment plan was updated March 10, 2011. The client's progress was not assessed in relationship to the stated goals of the comprehensive treatment plan. The treatment update included statements that the objectives were either met and deleted or continued and revised. There was no further documentation.
Client # 8 was admitted October 11, 2010. The comprehensive treatment plan was documented October 20, 2010. The treatment plan update for November 26, 2010 demonstrated client's progress was not assessed in relationship to the stated goals of the comprehensive treatment plan. The treatment update included statements that the objectives were either met and deleted or continued and revised. There was no further documentation.
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Plan of Correction
At staff meeting on 6/29/11, the Program Supervisor will provide training to clinical staff on effective treatment plan review to include assessment of progress on stated goals of the comprehensive treatment plan,documentation of completion of goals, reasons for revision of goals and timeline for completion of treatment plan reviews. Examples of satisfactory treatment plan reviews will be provided and placed in the clinical orientation handbook for future clinicians. The Program Supervisor will randomly review one file of each supervisory session, for each clinician, biweekly to ensure quality and compliance. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on the review of client records, the facility failed to document complete progress notes in four of five client records.
The findings include:
Fourteen client records were reviewed May 25, 2011. Eight of the fourteen client records were outpatient client records. Eight records required progress notes. There were progress notes documented after individual and group counseling sessions. The data, assessment and plan (DAP) format was utilized.
Client record # 1 contained group notes written in DAP format. The plan did not reflect actions to be taken by the counselor, action steps or client assignments or tasks. Instead, the topic of the next group was the plan.
Client record # 2 contained group notes written in DAP format. The plan did not reflect actions to be taken by the counselor, action steps or client assignments or tasks. Instead, the topic of the next group was the plan.
Client record # 3 contained group notes written in DAP format. The plan did not reflect actions to be taken by the counselor, action steps or client assignments or tasks. Instead, the topic of the next group was the plan.
Client record # 4 contained group notes written in DAP format. The plan did not reflect actions to be taken by the counselor, action steps or client assignments or tasks. Instead, the topic of the next group was the plan.
Client record # 5 contained group notes written in DAP format. The plan did not reflect actions to be taken by the counselor, action steps or client assignments or tasks. Instead, the topic of the next group was the plan.
Client record # 7 contained group notes written in DAP format. The plan did not reflect actions to be taken by the counselor, action steps or client assignments or tasks. Instead, the topic of the next group was the plan.
Client record # 8 contained group notes written in DAP format. The plan did not reflect actions to be taken by the counselor, action steps or client assignments or tasks. Instead, the topic of the next group was the plan.
In addition, client records # 3 and # 8 were difficult to read to determine compliance.
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Plan of Correction
At staff meeting on 6/29/11, the Program Supervisor will provide training to clinical staff on utilizing DAP format to produce effective group notes, including plans reflecting actions to be taken by counselor and client assignments or tasks where appropriate. Example of satisfactory group notes will be provided and placed in the clinical orientation handbook for future clinicians. The Program Supervisor will randomly review one file at each supervisory session, for each clinician, biweekly to ensure quality and compliance. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document case consultations in four of eight client records as required.
The findings include:
Fourteen client records were reviewed May 25, 2011. Eight of those records were outpatient records. Eight records required at least one quarterly case consultation at the time of the inspection.
Client # 1 was admitted January 6, 2011. There was no quarterly case consultation completed at the time of the inspection.
Client # 2 was admitted January 20, 2011. There was no quarterly case consultation completed at the time of the inspection.
Client # 7 was admitted December 23, 2010. There was no quarterly case consultation completed at the time of the inspection.
Client # 5 was admitted November 16, 2010. The quarterly case consultation completed February 16, 2011 only had one person documented and it could not be considered a consultation.
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Plan of Correction
At staff meeting on 6/29/11, the Program Supervisor will provide training on effective case consultation documentation. Case consults for all client's who are due for quarterly consults will be performed at biweekly supervision sessions and placed in the file at that time. The Program Supervisor will be provided with a list of all active client's admission dates prior to supervisory session to ensure quality and compliance. |