INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the June 1, 2010 through June 3, 2010 licensure renewal inspection. The follow-up inspection was conducted on December 6, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 January 1, 2011.
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Plan of Correction
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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 nine of eighteen client records.
The findings include:
Eighteen client records were reviewed on December 6, 2010. Nine 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 #9, 10, 11, 13, 14, 15,16,17 and 18.
Per the facility policy and procedure titled Notification of Termination states:
Involuntary discharge from the outpatient programs may occur as a result of but not limited to, the following behaviors:
i. The patient has committed or threatened to commit acts of physical violence in our around the treatment premises.
ii. The patient possessed a controlled substance without prescription or sold or distributed a controlled substance, in or around the treatment program premises.
iii. The patient has been absent from the narcotic treatment program for three (3) consecutive days or longer without cause.
iv. The patient has failed to follow treatment plan objectives.
Client record #9 was involuntarily terminated, hospital stay, from the project on November 2, 2010. There was no documentation of written notification to the client.
Client record #10 was involuntarily terminated, attendance failure, from the project on November 30, 2010. There was no documentation of written notification to the client.
Client record #11 was involuntarily terminated, never returned, from the project on November 4, 2010. There was no documentation of written notification to the client.
Client record #13 was involuntarily terminated, against medical advice, from the project on October 15, 2010. There was no documentation of written notification to the client.
Client record #14 was involuntarily terminated, against medical advice, from the project on October 8, 2010. There was no documentation of written notification to the client.
Client record #15 was involuntarily terminated, behavior, from the project on October 6, 2010. There was no documentation of written notification to the client.
Client record #16 was involuntarily terminated, against medical advice, from the project on September 21, 2010. There was no documentation of written notification to the client.
Client record #17 was involuntarily terminated, against medical advice, from the project on October 27, 2010. There was no documentation of written notification to the client.
Client record #18 was involuntarily terminated, against medical advice, from the project on October 9, 2010. There was no documentation of written notification to the client.
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Plan of Correction
Previously, we did not send out written notification of termination to patients that left the program against medical advice. After 14 days of no response to phone calls placed by the patient's assigned counselor, patients are discharged from the program as this is viewed as the patients decision not to return to treatment. Patients were contacted by their assigned Counselor after missing two days of being medicated.
Starting on 1/17/2011, after missing two days of being medicated, the assigned counselor will be responsible for contacting the patient's residence. On the third day of missing dosing, the counselor will be responsible for sending out a letter to the patients inquiring about their whereabouts. The letter will also notify the patient that they will be at risk of having their treatment terminated after 14 days of no contact with the facility; and prior to the 14th day, they have a right to a fair hearing. If a patient requests a fair hearing prior to the 14 day, their discharge will be placed on hold until after the fair hearing is conducted by staff members selected to be a part of the fair hearing process. The counselor will also be responsible for documenting in a progress note that will be kept in the patient's chart that displays the time and date the call was made and the letter was sent. The counselor will also submit a copy of the letter to the Clinical Supervisor to ensure that the letter was completed. Staff will receive training on the new process listed above on 1/13/2011 so that the process can began on 1/17/2011.
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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 completely document psychosocial evaluations in eight of eighteen client records reviewed.
The finding includes:
Eighteen records were reviewed on December 6, 2010. Psychosocial evaluations were required in eight records reviewed, #1, 2, 3, 4, 5, 6, 7 and 8.
Client records # #1, 2, 3, 4, 5, 6, 7 and 8 failed to include documentation of the client's assets and strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, client attitude towards treatment and the counselor conclusions/impressions of the client.
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Plan of Correction
Beginning on 1/7/2011, Counselors will submit all psychosocial assessments completed for new patients within the first 30 days of treatment to the Clinical Supervisors for review prior to being filed in patient charts to ensure that it clearly documents the patients assets and strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, patients attitude towards treatment and the counselor conclusions/impressions of the patient. The Clinical Supervisors will sign off on the psychosocial assessments to verify that it has been reviewed. |
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 ten discharged records reviewed.
The findings include:
Eighteen client records were reviewed on December 6, 2010. Follow-up information was required in five of ten discharge records # 9, 15, 16, 17 and 18. 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 # 9 was admitted on 10/15/07 and discharged on 11/2/10. There was no documentation of follow-up information.
Client # 15 was admitted on 2/22/07 and discharged on 10/6/10. There was no documentation of follow-up information.
Client record #16 was admitted on 6/24/10 and discharged on 9/21/10. There was no documentation of follow-up information.
Client # 17 was admitted on 7/13/10 and discharged on 10/27/10. There was no documentation of follow-up information.
Client # 18 was admitted on 1/17/08 and discharged on 10/9/10. There was no documentation of follow-up information.
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Plan of Correction
Beginning 1/3/2011, the Clinical Supervisors will utilize a Post Evaluation Discharge Form when contacting patients that have been discharged from treatment. Previously, the Clinical Supervisors would document on the Discharge Summary that follow-up had been made with the patient within 30 days of the discharge. The Post Evaluation Form will be utilized to ensure there is clear and concise documentation regarding follow-ups within 30 days of the discharge. The Post Evaluation Discharge Form will be maintained in a Discharge Follow-Up binder along with a tracking sheet that will highlight that the follow-up has been completed within 30 days of the discharge. All discharge follow-ups will be maintained and managed by the Clinical Supervisors. |