INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 20, 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 December 18, 2008.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on the review of personnel records and the facility's policy and procedure manual, the facility failed to document feedback forms in two of four personnel records.
The findings include:
Four personnel records were reviewed on November 20, 2008. The facility's policy states that feedback forms will be completed within 7 days after every training, whether they are internal or external training. Feedback forms were required in four personnel records. The facility did not document feedback forms in personnel records #1 and 3.
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Plan of Correction
The Executive Director revised policy to eliminate the seven(7) day time frame for staff to submit their feedback forms from trainings attended. The Executive Director will review the revised policy at the facility staff meetings at both facilities. At that time the requirement to submit a feedback form for all external trainings along with certification document. The Support person who reviews the training binder on a quarterly basis will confirm that feedback forms are submitted with all internal and external trainings. Upon submitting evidence of a training by a staff member, the support person will make sure that the feedback form is attached; if not, the feedback form will be required to be completed by the staff member while the training experience is still fresh in their minds. This plan of action is the ultimate responsibility of the Executive Director and will be completed in full by December 17th, 2008. |
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 document complete psychosocial evaluations in two of four client records.
Findings:
Eight records were reviewed on November 20, 2008. Psychosocial evaluations were required in four client records. The psychosocial evaluations failed to provide for a clinical assessment of the clients' assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and the clients' attitude toward treatment in client records #1, 2, 3 and 4.
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Plan of Correction
The clinical supervisor will provide training in required documentation of clinical assessment including assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and the clients attitude toward treatment in staff meeting on December 19th,2008. Compliance to this standard 709.8(b)(b) will be assured by routine quality control of client's record at time of initial treatment plan review by the clinical supervisor. |
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 and the facility's policy and procedure manual, the facility failed to document treatment plan updates in one of four client records.
The findings include:
Eight client records were reviewed on November 20, 2008. Treatment plan updates were required in one client record. The policy states that treatment plan updates are to be updated every 30 days. The facility did not document treatment plan updates in client record #3. The client was admitted on 7/1/08 and his last treatment plan update was documented on 8/28/08. His next treatment plan update should have been completed on 9/28/08, but was not documented. Client #3 was discharged on 10/31/08.
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Plan of Correction
The clinical supervisor will provide training in required documentation and required timelines for treatment reviews for Partial Hospitalizaiton level of care at staff meeting on December 19th, 2008. In 709.82(b) compliance to this standard will be assured by routine quality assurance at time of treatment plan review by the clinical supervisor. |
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 four client records.
The findings include:
Eight client records were reviewed on November 20, 2008. Group progress notes were required in four client records. The group progress notes did not have an assessment of the clients' participation in the group and the therapist signatures were copies rather than original signatures in all group notes reviewed in client records #1, 2, 3 and 4.
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Plan of Correction
The clinical supervisor will provide training on documentation of individual assessment in group sessions in staff meeting on December 19th, 2008. The requirement for original signatures on group notes was addressed in a memorandum to all staff on 12/5/08. Compliance to the standard 709.83(a)(9) will be assured by routine review of original signatuares by the administrative staff at time of submission for filing. Compliance to documentation of individual assessment will be assured by routine quality assurance during bi-weekly supervision as required by 709.83(a)(9). |
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 complete psychosocial evaluations in two of four client records.
Findings:
Eight records were reviewed on November 20, 2008. Psychosocial evaluations were required in four client records. The psychosocial evaluations failed to provide for a clinical assessment of the assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and the clients' attitude toward treatment in client records #5 and 6.
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Plan of Correction
The clinical supervisor will provide training in required documentation of clinical assessment including assests/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and the client's attitude toward treatment in staff meeting on December 19th, 2008. Compliance to this standard 709.91(b)(6) will be assured by routine quality control of client's record at time of initial treatment plan review by the clinical supervisor. |
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 four client records.
The findings include:
Eight client records were reviewed on November 20, 2008. Group progress notes were required in four client records. The group progress notes did not have an assessment of the clients' participation in the group and the therapist signatures were copies rather than original signatures in all group notes reviewed in client records #5, 6, 7 and 8.
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Plan of Correction
The clinical supervisor will provide training on documentation of individual assessment in group sessions in staff meeting on December 19th, 2008. The requirement for original signatures was addressed in a memorandum to all staff on 12/5/08. Compliance to this standard 709.93(a)(5) will be assured by routine review of original signatures by administrative staff at time of submission for filing. Compliance to documentation of individual assessment will be assured by routine quality assurance during bi-weekly supervision as required by 709.93(a)(5). |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on the review of client records and the facility's policy and procedure manual, the facility failed to document follow-up information in one of four client records.
Findings:
Eight client records were reviewed on November 20, 2008. Documentation of attempts to follow-up was required in one client record. The facility's policy states that attempts to follow-up on clients be done 30 days from the clients' discharge date. The attempts to follow-up were documented on 11/14/08 in client record # 7. The client was discharged on 10/7/08. The attempt to follow-up on the client was required by 11/17/08.
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Plan of Correction
To ensure that follow up contacts are attempted within 30 days, the facility office manager will review discharged client files every 21 days or on the earliest business day after 21 days. Compliance will be assured by routine quality assurance of discharged client files to meet 709.93(a)(11) standards. This procedure will go into effect on 12/11/2008. |