INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 1, 2010 through June 3, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Coatesville Treatment 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 June 27, 2010.
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Plan of Correction
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill logs for the past year were reviewed on June 1, 2010. The facility did not document any alternate exit used during fire drills. The front door was the exit route used during every fire drill.
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Plan of Correction
Fire drills are conducted on a monthly basis on varying days and times. The Health & Safety Officer is responsible for coordinating and documenting drills. The Health & Safety Officer will prepare and conduct a minimum of 6 drills during the calendar year that specifically require staff and patients to choose and use alternative exits in the buildings. The use of alternative exits will be clearly documented on the fire drill logs. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client in writing of a decision to involuntarily terminate the client's treatment at the project, in two of four client records.
The findings include:
Sixteen client records were reviewed on June 2, 2010 through June 3, 2010. Four records were required to include documentation of the notification to the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The facility failed to document that it notified the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client records #11 and 14.
Client record #11 was involuntarily terminated from the project on April 16, 2010. There was no documentation of written notification to the client.
Client record #14 was involuntarily terminated from the project on January 12, 2010. There was no documentation of written notification to the client.
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Plan of Correction
Following the survey, #11 and #14 records were reviewed by the Clinic Director. The Notification of Involuntary Termination form was found in #14's record. It had been inadvertently stapled to the Case Consultation in which the team concurred with the recommendation to involuntarily discharge this patient. The Notification of Involuntary Termination form was not present in #11's record.
Following the clinical team meeting, in which the decision to involuntary terminate a client's treatment was made, the assigned Counselor will complete the Notification of Involuntary Termination form and present it to the client. The client will be asked to initial and date the form. A copy of the form will be provided to the client. The Counselor will write a progress note detailing the content of the meeting with the patient. A copy of the Termination form and progress note will be given to the Clinical Director and the original documents filed in the client's record. The Clinical Director will maintain a binder of copied of this documentation on all patients who have been notified of the decision to involuntarily terminate. |
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 completely document psychosocial evaluations in eleven of sixteen client records reviewed.
The finding includes:
Sixteen records were reviewed on June 2, 2010 through June 3, 2010. Psychosocial evaluations were required in twelve records reviewed.
Client records #2, 3, 4, 5, 6, 7, 8, 9, 11, 12 and 13 failed to include documentation of the client's assets and strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
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Plan of Correction
Clinical Supervisors provided Counselors with a SNAP "cheat sheet" on 6/16/10 to assist them in compiling all of the necessary information to completely document all required content areas of the psychosocial evaluation.
Clinical Supervisors meet with Counselors once a month to provide training, resources and feedback to assist the Counselors in improving their clinical skills. Once a quarter, a meeting will be devoted to developing the Counselors' assessment, interviewing and writing skills as it pertains to the intent and requirements of the psychosocial evaluation.
On a monthly basis, Clinical Supervisors will audit a sample of new admission records, including the reading and review of the psychosocial evaluation. The applicable counselors will be provided direct feedback and recommendations regarding the content of the psychosocial evaluation during individual supervision the following month. |
709.92(a) 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:
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Observations
Based on the review of the facilities policy and procedure manual and client records, the facility failed to document comprehensive treatment plans timely per their policy and procedure in five of twelve records reviewed.
The findings include:
Sixteen client records were reviewed on June 2, 2010 through June 3 2010. Comprehensive treatment plans were required in twelve client records. In accordance with the facility's policy and procedure, personal histories are to be completed within 30 days of the client's admit date.
Client record #1 was admitted on 9/14/09 and their comprehensive treatment plan was completed on 10/19/09.
Client record #5 was admitted on 12/22/09 and their comprehensive treatment plan was completed on 2/5/10.
Client record #6 was admitted on 11/9/09 and their comprehensive treatment plan was completed on 12/29/09.
Client record #9 was admitted on 11/19/09 and their comprehensive treatment plan was completed on 12/21/09.
Client record #12 was admitted on 12/9/09 and their comprehensive treatment plan was completed on 1/22/09.
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Plan of Correction
The 5 records in which the Comprehensive Treatment Plan were completed outside of the required timeframe occurred as a result of a Counselor vacancy when manpower was limited to cover these cases. Additionally, the project struggles with adhering to the time requirement for the Comprehensive Treatment Plan due to chronicity of cancelled or missed appointments by clients.
During the new patient orientation, the expectations during the first 30 days of treatment will be reviewed and stressed with clients, including the completion of the Psychosocial Evaluation and Comprehensive Treatment Plan.
During the first 30 days of treatment, if a client chronically cancels or does not show for scheduled appointments, the Counselor will utilize hard holds to ensure that the client meets with the Counselor as needed to stay within the required timeframes for documentation completion.
Clinical Supervisors will maintain a tracking sheet of the dates that new cases are assigned and the dates of completion for the Psychosocial Evaluation and Comprehensive Treatment Plan. Clinical Supervisors will monitor for time lapses and provide Counselors with reminders of the impending deadlines. |
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, the facility failed to conduct a case consultation with two or more people in four of twelve client records.
The findings include:
Sixteen client records were reviewed on June 2, 2010 through June 3, 2010. Case consultations were required in twelve client records. Client records #1, 5, 7 and 8 had documentation that revealed that the therapist and the medical director signed case consultation documentation on different days, indicating that the case consultations were not conducted in accordance with regulatory requirement.
A review of client record #1 revealed that the therapist signed the first case conflagration on 12/14/09 and the medical director signed it on 1/6/10. The second case consultation was signed by the therapist on 1/5/10 and by the medical director on 1/6/10.
A review of client record #5 revealed that the therapist signed the case consultation on 3/15/10 and the medical director signed it on 3/17/10.
A review of client record #7 revealed that the therapist signed the case consultation on 4/21/10 and the medical director signed it on 5/12/10.
Client record #8 showed that the therapist signed the first consultation on 2/12/10 and the medical director signed it on 5/26/10. For the second consultation, the therapist deigned the case consultation on 5/5/10, while and the medical director signed it 5/12/10.
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Plan of Correction
The time difference between the signature of the Counselor and signature of the Medical Director is reflective of: 1)the part time schedule of the project's Medical Director and 2)adherence to the feedback provided by a Licensing Specialist during a previous survey in which the Licensing Specialist communicated that the Medical Director was required to review and sign every case consultation. Case consultations pertaining to quarterly or annual reviews or reviews of behavior issues routinely have been scheduled on days that the Medical Director is not present at the project and thus, have had only the counseling staff present. On these consultations, the date of the signature of the counselor represents the date in which the team consultation took place with the members present listed and checked off at the top of the form. The date of the signature of the Medical Director represents when the Counselor subsequently reviewed the content and outcome of the case consultation with the Medical Director to obtain his signature.
The case consultation form has been revised and split into two separate forms, a Medical Case Consultation and Clinical Case Confrontation form. The new forms reflect the need for all team members present at the consultation to either sign or initial their participation in the meeting. These revised forms have been presented to staff and are being piloted between 6/16/10 and 6/30/10. A finalized form and protocols will be developed and implemented by the Clinical Director and Clinical Supervisors. The Medical Director will participate in and sign all Medical Case Consultations. |
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, the facility failed to document timely follow-up information in five of eight discharged records reviewed.
The findings include:
Sixteen client records were reviewed on June 2, 2010 through June 3, 2010. Follow-up information was required in six of eight discharge records # 9, 10, 11, 14, 15 and 16. In accordance with the facility's policy and procedure, all follow-ups are to be completed within 30 days of client's discharge if not being referred.
Client # 10 was admitted on 9/8/08 and discharged on 4/24/10. There was no documentation of follow-up information.
Client # 11 was admitted on 1/15/10 and discharged on 1/19/10. There was no documentation of follow-up information.
Client record #14 was admitted on 8/9/07 and discharged on 1/21/10. There was no documentation of follow-up information.
Client # 15 was admitted on 6/26/08 and discharged on 2/12/10. There was no documentation of follow-up information.
Client # 16 was admitted on 7/13/09 and discharged on 4/1/10. There was no documentation of follow-up information.
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Plan of Correction
Follow up on discharged clients had been the responsibility of the assigned Counselor. This responsibility will be moved to the Clinical Supervisor. Following discharge, the Counselor will complete the necessary documentation to close the record. The record will then be given to the Clinical Supervisor who will audit the record and complete the follow-up call(s). The Clinical Supervisor will generate a case note detailing the follow-up conversation with the client &/or the attempts to successfully contact the discharged client to conduct follow-up. |