INITIAL COMMENTS
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This report is a result of an initial on-site licensure inspection conducted on June 21-25, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Marworth 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 July 26, 2010.
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Plan of Correction
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709.81(b)(7) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan in two of the three required records.
The findings include:
Three client records were reviewed on June 23-24, 2010 Two of the three client records were from the partial hospitalization activity. Two of those three records were required to have a preliminary treatment plan documented in the client record.
Record # 1 was admitted on 1-26-10 and discharged on 2-17-10. The client record was missing documentation of a preliminary treatment plan.
Record # 2 was admitted on 1-12-10. Discharge was 2-3-10. The client record was missing documentation of a preliminary treatment plan.
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Plan of Correction
The evening partial hospitalization counselor will be instructed by the Outpatient Coordinator (supervisor) on Friday July 16, 2010 about the requirements to develop a preliminary treatment plan as part of the evaluation process and before the end of the initial PHP session. The Outpatient Coordinator will monitor ten (10)records per month for three (3) months (10/12/10) to verify development of the preliminary treatment plan on patients admitted to the PHP. |
709.83(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of one client record, the facility failed to document a discharge summary in one of one record reviewed.
The findings include:
Client record #1 - Client was admitted on 1-26-10 and discharged on 2-17-10. The discharge summary was not documented.
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Plan of Correction
All outpatient counselors will be educated by the Outpatient Coordinator by Friday, July 16, 2010 about the requirement to follow-up with those patients referred to outpatient treatment from the PHP at Marworth.The counselors will be further instructed that should a patient not follow-up with their appointment, contact will be initiated by the counselor and/or a letter sent in an effort to re-engage the patient into treatment.All such attempts will be documented.Should a patient choose not to continue with treatment or if the efforts to contact are not successful,an addendum to the discharge summary will be completed. The outpatient Coordinator will monitor all transfers form PHP to OP for compliance for 30 days from the date of training on July16th ( August17th). |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a record of service which included a chronological listing of all services provided to the client in four of four client records.
The findings include:
Ten outpatient client records were reviewed on June 23-24, 2010. A record of service of the duration of the services provided to the client were required in five client records. The facility did not document a complete record of service in the following client records:
#5 admission date 3-4-10; discharge date 6-2-10.
#6 admission date 5-10-10; discharge date 6-22-10.
# 10 admission date 1-30-07; discharge date 5-26-10.
#11 admission date 5-6-10; discharge date 5-26-10.
#13 admission date 4-15-10; discharge date 5-18-10.
#15 admission 6-2-10; discharge date 6-14-10.
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Plan of Correction
All outpatient counselors will be trained by the Outpatient Coordinator on Friday, July 16th about the requirement to assign a time frame for all patient services rendered.All services will be documented in the Electronic medical record with a "time in" and a "time out" so that the length of service will be captured in the Record of Service. The Outpatient Coordinator will monitor ten (10) records per counselor for one month to insure compliance beginning July 19,2010. |