INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the December 9, 2008 licensure renewal inspection. The follow-up inspection was conducted on July 16, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, My Sister's Place Thomas Jefferson University 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 28, 2009.
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Plan of Correction
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711.51(b)(6) LICENSURE Psychosocial Evaluation
711.51. 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 a psychosocial evaluation in four of four client records.
The findings include:
Five client records were reviewed on July 16, 2009. Psychosocial evaluations were required in four records. The facility did not document a psychosocial evaluation in client records # 1, 2, 3 and 4.
Client record # 2 did not document a psychosocial evaluation to include the client ' s assets/strengths that can contribute to the resolution of identified problems; the client's preferred coping mechanisms; and the client's potential/available support systems.
Client record # 3 did not document a psychosocial evaluation to include the client's preferred coping mechanisms and the client's potential/available support systems.
Client record # 4 did not document a psychosocial evaluation to include the client's needs/problems that can or cannot be resolved through treatment; the client's assets/strengths that can contribute to the resolution of identified problems; the client's preferred coping mechanisms; and the client's potential/available support systems.
Additionally, client records # 1 and 2 were not dated.
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Plan of Correction
A spreadsheet has been implemented to address specific documents such as treatment plans, case consults, biopsychosocial assessments. The spreadsheet is completed weekly and distributed to the counseling staff.
The Residential Director is responsible to complete and distribute this spreadsheet; monitor any missing documents on a weekly basis and review for timeliness and clinical content during weekly supervision, including dates. All non-compliances will be addressed in weekly supervision.
The Residential Director will be responsible to provide on-going training opportunities for the clinical staff (in-house or off campus) regarding how to assess, capture, and write the clinical elements of the biopsychosocial, such as: coping mechanisms as a tool or possible barrier towards recovery ; what support systems are available to the client, what support systems may be needed to support the client in the recovery process; what identified problems can be addressed while in treatment or need to be addressed as part of the aftercare plan.
Residential Director provided a biopsychosocial assessment writing training on 7/29/09. An additional biopsychosocial training will be provided on 9/15/09 by the Department of Behavorial Health.
Person (s) responsible: Residential Director
Timeframe for completion: Immediate |
711.52(d) LICENSURE Tx Plan Update
711.52. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regimen is less than 30 days, the treatment and rehabilitation plan review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document a treatment plan update in three of four client records.
The findings include:
Five client records were reviewed on July 16, 2009. Treatment plan updates were required in three client records. The did not document a treatment plan update every thirty days as stated in the project's policy manual in client records # 1, 2 and 4.
Client record #1 treatment plan dated 6/1/09, but the treatment plan update was dated 7/14/09.
Client record #2 treatment plan dated 6/8/09, but the treatment plan update was not documented at the time of inspection.
Client record #4 treatment plan dated 4/30/09, but the treatment plan update was dated 6/19/09.
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Plan of Correction
With the implementation of the documentation spreadsheet, all clinical documents will be tracked for timeliness in addition to clinical content. This tracking tool will include specific documents such as treatment plans, case consults, biopsychosocial assessments. The spreadsheet is completed weekly and distributed to the counseling staff.
The Residential Director is responsible to complete and distribute this spreadsheet; monitor timeliness of treatment plans and address the reason for any missing documents, or latenesses with the clinician in weekly supervision and/or upon discovery that the treatment plan is late.
If there is a reason why the treatment plan is late, the Residential Director will explain the need to have that reason reflected in a progress note in the client's chart (hospitalization, incarceration, etc), accompanied by a Disclaimer form, and the expected date for completion of the treatment plan.
If the issue is a time management issue for the clinician, the Residential Director is to provide a plan of correction, including training, to assist the clinician to complete all treatment plans in a timely manner. This POC is to be reviewed in weekly supervision by the Residential Director.
Person (s) responsible: Residential Director Timeframe for completion: Immediate |
711.53(c)(2) LICENSURE Consent to Release Information - Informed/Vol
711.53. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to include within the informed and voluntary consent forms the right for clients to verbally revoke the consent.
Findings:
Five client records were reviewed on July 16, 2009. Informed and voluntary consent forms were required in four client records. The "Consent for Release of Information" forms did not document the client's right to verbally revoke the consent in client records, #1, 2, 3 and 4.
Consent to release information forms to a laboratory and to a government agency did not include the client's right to verbally revoke the consent in records # 1, 2, 3 and 4.
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Plan of Correction
All consents to release information have been reviewed. Any old consents in non-compliance, have been destroyed.
The revised consents clearly state "verbal" revocation of the consent in addition to the "written" revocation.
Person(s) responsible: Residential Director and Administrative Assistant
Timeframe for complete: 7/31/09 |
711.58(a)(2) LICENSURE Drug Storage Area
711.58. Medication control.
When the drug and alcohol project is not physically located within the parent health care facility, it shall have a written policy regarding medications used by clients, which shall include, but not be limited to:
(2) Drug storage areas.
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Observations
Based on a review of administrative documents and a physical plant inspection, the facility failed to store the client's methadone under triple lock as stated in the project policy manual.
Findings:
The policy manual was reviewed on July 16, 2009. The manual required that methadone be stored under triple lock. The physical plant inspection was conducted at approximately 1:30 pm on July 16, 2009. The methadone in individual dose bottles was stored in the locked nurse's office in a single-locked container.
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Plan of Correction
The damaged double lock on the methadone case has been repaired.
Therefore, the triple security is in effect.
The locks will be checked weekly by the nurse when the methadone is brought to the facility. Any breach of security will be immediately reported to the Residential Director and the Program Director for immediate repair and/or replacement.
Person (s) responsible: Residential Director and Nurse
Timeframe for completion: Immediate
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