INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 10, 2008 through December 11, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHD Montgomery County Methadone Center 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 January 15, 2009.
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Plan of Correction
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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 complete psychosocial evaluations in seven of seven client records.
Findings:
Ten client records were reviewed on December 11, 2008. Psychosocial evaluations were required in seven client records. The psychosocial evaluations failed to include a clinical assessment of the assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and the counselors impression/impression of the client in client records #1, 2, 3, 4, 5 and 10.
Also, in records #1, 2, 4, 5 and 10 the psychosocial evaluations were completed late. During the review of the facilities policy and procedure manual on December 10, 2008 the policy states that all psychosocial evaluations will be completed at intake. Client #1 was admitted on 10/29/08 and their evaluation was not completed until 12/9/08. Client # 2 was admitted on 6/9/08 and their evaluation was not completed until 7/1/08. Client #4 was admitted on 11/3/08 and their evaluation was not completed until 11/24/08. Client #5 was admitted on 7/1/08 and their evaluation was not completed until 7/21/08. Client #10 was admitted on 8/13/08 and their evaluation was not completed until 9/2/08.
Client #6 was admitted on 7/29/08 and as of to date no psychosocial evaluations was not completed.
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Plan of Correction
MCMC Policy and Procedure Manual has been updated by the program director to revise the policy regarding payschosocial evaluations to state that they will be completed within the first 30 days of intake. A clinical meeting will be held on 1/8/09 by the clinical supervisor to address the appropriate documentation regarding the psychosocial evaluation to include assets/strengths, support systems, coping skills, negative factors that may impact treatment as well as documentation of counselors clinical assessments. The clinical supervisor will monitor charts during chart audits to ensure that these changes are being implemented. Completion Date 1/8/09 |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on the review of client records, the facility failed to document an individualized treatment plan with goals specific to each client's needs in five of seven client records.
Findings:
Ten client records were reviewed on December 11, 2008. Individualized short and long-term goals were required in seven client records. The facility failed to document an individualized treatment plan with goals specific to each client in records #1, 2, 3, 4 and 5.
Records #1, 2, 3, 4 and 5 had the same short and long term goals.
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Plan of Correction
A clinical meeting will be held on 1/7/09 by the clinical supervisor to review the treatment planning process and to ensure that future treatment plans will include and document individualized short and long term goals. Clinical supervisor will monitor the implementation of this via chart audits prior to approving treatment plans. Completion Date: 1/8/2009 |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to ensure that counseling services are provided according to the individual treatment plan in six of seven client records.
Findings:
Ten client records were reviewed on December 11, 2008. Treatment plans were required in seven client records:
Client #1 was required to attend weekly group and individual sessions. Client was admitted on 10/29/08; client only attended one group session dated 11/11/08. There was no documentation that addressed reasons for patient's lack of participation. Client is active in treatment.
Client #2 was required to attend weekly group and individual sessions. Client was admitted on 6/9/08; there was documentation of attendance in three group sessions dated 8/26/08, 9/19/08 and 10/3/08. There was no documentation of individual sessions nor clarification why the client was not attending their required weekly group sessions. Client is active in treatment.
Client #3 was required to attend weekly group and individual sessions. Client was admitted on 8/26/08; the client record contained documentation of attendance in two groups dated 9/16/08 and 10/14/08. There was no documentation of individual sessions nor clarification why the client was not attending their required weekly group sessions. Client is active in treatment.
Client #4 was required to attend weekly group and individual sessions. Client was admitted on 11/13/08 and client had not attended any group sessions. There was no documentation in the client record that addressed why the client was not attending their required weekly group sessions. Client is active in treatment.
Client #5 was required to attend weekly group and individual sessions. Client was admitted on 7/1/08 and client only attended seven group sessions dated 7/22/08, 7/29/08, 8/12/08, 8/28/08, 9/9/08, 10/28/08 and 11/3/08. There was no documentation in the client record that addressed why the client was not attending their required weekly group sessions. Client is active in treatment.
Client #6 was required to attend weekly group and individual sessions. Client was admitted on 7/29/08 and client only attended five group sessions dated 8/1/08, 8/28/08, 9/16/08, 10/14/08 and 11/18/08. There was no documentation in the client record that addressed why the client was not attending their required weekly group sessions. Client is active in treatment.
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Plan of Correction
A clinical meeting will be held on 1/7/09 by the clinical supervisor to review the treatment planning process and to ensure that future treatment plans will include accurate documentation about clients required attendence to counseling sessions as specified in the treatment plan and documentation addressing reasons for client's lack of participation if applicable. Clinical Supervisor will monitor this via chart audits. Completion Dtae 1/8/09 |
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 and the facilities policy and procedure manual, the facility failed to document case consultation notes in two of four client records.
Findings:
Ten client records were reviewed on December 11, 2008. Case consultation notes were required in four client records. The facility's policy stated that case consultations were to be completed every 90 days from the clients admit date. The facility did document case consultation notes in client records #3 and 5 but the case consultations were completed late. Client #3 was admitted on 8/26/08 and their case consultation note should have been completed by 11/26/08; the case consultation note was completed on 12/5/08. Client #5 was admitted on 7/1/08 and their case consultation note should have been completed by 10/01/08; the case consultation note was completed on 10/10/08.
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Plan of Correction
A clinical meeting will be held by the clinical supervisor on 1/7/08 to review case consultations and the time frames for completion of these to be 90 days. This will be monitored by the clinical supervisor via chart audits. Completion Date: 1/8/09 |