INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 31 & August 01, 2008 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 and a plan of correction is due on August 29, 2008.
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Plan of Correction
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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 upon a review of nine client records on July 31 & August 1, 2008, four records reviewed were for the Partial Hospitalization program. Of those four records, four required that a psychosocial evaluation be completed based upon the client's date of admission and the facility's policy of completion within 15 days from the date of admission.
Findings:
The facility failed to properly document when the psychosocial evaluation had been completed in one of four records reviewed, specifically #9.
Client #9 had been admitted on 5/27/08; however there was no date on the psychosocial evaluation to indicate when it had been completed and if it had been completed within 15 days of admission in accordance with facility policy.
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Plan of Correction
The clinical supervisor will review with the clinical staff at the staff meeting on 10/8/08 that the master treatment plan can not be affectively developed until the bio-psycho-social evaluation is completed. At the time that each of the clinical staff has the clinical supervisor sign off on the master treatment plan, the clinical supervisor will review the clinical chart to confirm that the bio-psycho-social evaluation has been fully completed. |
709.83(a)(5) 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:
(5) Medication records.
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Observations
Based upon a review of nine client records on July 31 & August 1, 2008, four records reviewed were for the Partial Hospitalization program. Of those four records, four required documentation for medications as identified in the medical history portion of the client records.
Findings:
The facility failed to properly document medications listing the name of the medication, dosage and/or frequency of use in one of the four records reviewed, specifically record #8.
Client record #8 lacked the dosage for the medication Lisinopril and the dosage for Soma was listed as "350?". The medical history had been completed on April 17, 2008 and as of the ending date of the inspection, August 1, 2008, the facility had not documented the actual dosages.
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Plan of Correction
The clinical supervisor will review with the clinical staff and front office staff, at the staff meeting on 10/22/08 that a complete and accurate medication list is required for all clients being admitted into treatment. The front office staff will review the medical history form after completion by the client, at the time of the initial assessment. If medication names, doses, or frequency of use is not completed, the front office staff will ask the client to bring in the additional information by the second session. The clinician will also review the medical history form at the time of the initial assessment and will question the client if there is incomplete medication information and ask for the remaining medication information to be brought in by the next session. The clinical supervisor will randomly review one chart from each clinician at the time of clinical supervision every 2 weeks to monitor for compliance. |
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based upon a review of four personnel records on July 29, 2008 the facility failed to maintain written job descriptions for all project positions.
Findings:
One of four records reviewed, #1, lacked a written job description for the position of Project Director.
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Plan of Correction
The overall list of regular duties and responsibilities will be outlined for the Project Director (Executive Director). This outline will then be converted to a formal job description. This task is the responsibility of the Executive Director and will be completed by September 30, 2008. |
709.93(a)(2) 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:
(2) Medication records.
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Observations
Based upon a review of nine client records on July 31 & August 1, 2008, seven records reviewed were for the Outpatient program. Of those seven records, four required documentation for medications as identified in the medical history portion of the client records.
Findings:
The facility failed to properly document medications listing the name of the medication, dosage and/or frequency of use in two of the four records reviewed, specifically records #6 & 8.
Client record #6 lacked the dosage for Nexium and client record #8 lacked the dosage for the medication Lisinopril and the dosage for Soma was listed as "350?".
The medical history for client record #6 had been completed on June 11, 2008 and the medical history for client record #8 had been completed on April 17, 2008. As of the ending date of the inspection, August 1, 2008, the facility had not documented the actual dosages in either client record.
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Plan of Correction
The clinical supervisor will review with the clinical staff and front office staff, at the staff meeting on 10/22/08 that a complete and accurate medication list is required for all clients being admitted into treatment. The front office staff will review the medical history form after completion by the client, at the time of the initial assessment. If medication names, doses, or frequency of use is not completed, the front office staff will ask the client to bring in the additional information by the second session. The clinician will also review the medical history form at the timie of the initial assessment and will question the client if there is incomplete medication information and ask for the remaining medication information to be brought in by the next session. The clinical supervisor will randomly review one chart from each clinician at the time of clinical supervision every 2 weeks to monitor for compliance. |