INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 11-13, 2009 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 23, 2009.
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on the review of administrative documentation and discussion with administrative staff, the facility failed to demonstrate receipt of Department approval of a clinical supervision training not provided by the Department.
The findings include:
Administrative documentation that included supervision notations and training records was reviewed on May 11 and May 13, 2009. Discussion with the clinic director addressing this training was held on May 13, 2009. The clinic director reported the training attended by the clinical supervisor had been approved by Department staff and it was then requested that the clinic director provide documentation of the approval. The supportive documentation was not provided for review.
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Plan of Correction
The Clinic Director has left 3 messages for BDAP surrounding documentation of approval for 1 clinical supervisor for the Clinical Supervision training completed through CRC Health Group via webinar which was 20 hrs. This was approved verbally via BDAP for this 1 case and documentation has not been received. All information utilized in the training was sent to BDAP via Fed Ex seeking approval. Clinical Supervisors hired from that point on are required to attend the DOH clinical supervision training. The clinical supervisor has been a clinical supervisor since September 2006. Attempts will continue to be made regarding documentation of the in house clinical supervision training previously approved verbally through the end of September. If documentation is not received attempts will be made to schedule the cs for the doh clinica supervision training. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on a physical plant inspection, the facility failed to secure all client records within locked storage containers.
The findings include:
A physical plant inspection was conducted on May 13, 2009 between 11:00 AM and 12:00 noon. There were file cabinets located in the large group room of the counseling building. The file cabinets contained client records and were unlocked, permitting easy access of client records to anyone who accessed the room.
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Plan of Correction
The files will be placed in a locked storage area by 6/23/09. The clinic director and health and safety officer will ensure that this task is completed. Staff have been instructed that no files are to be kept in cabinets that are not locked. The file room will be utlized for storage which is locked. The health and safety officer will monitor file storage for compliance.
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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 one of two client records.
The findings include:
Twelve client records were reviewed on May 11 and 12, 2009. Two 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 record # 2.
In client record # 2, the client was involuntarily terminated from the project on January 20, 2009. There was no documentation of written notification to the client.
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Plan of Correction
The 2 clinical supervisors will address in 1 on 1 supervision with their supervisees the involuntary documentation protocol by 7/3/09. The patient will receive a notice of involuntary termination with a copy placed in the patient's chart. There will also be a progress note completed noted the meeting to inform the patient of the involuntary termination. |
709.91(a)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(4) Involuntary discharge/termination criteria.
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Observations
Based on the review of administrative documentation and client records, the facility failed to restrict involuntary termination to the reasons contained in the facility policy and procedure for involuntary discharges in one of two client records.
The findings include:
Twelve client records and the policy and procedure manual were reviewed on May 11-12, 2009. The policy and procedure manual contained language verbatim to the regulations contained in 715.28 (a)(1)-(10). These do not allow for clients to be discharged for financial reasons. Documentation in client record # 2 indicates that the client was discharged for financial reasons.
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Plan of Correction
CTC will comply with the financial process previously approved.
CTC will utilize all efforts to sustain patients in treatment.
Patients will be notified initially by the office manager re nonapyment. If there continues to be nonpayment the counselor will be notified and will meet with the patient. The financial situation will be accessed at the time and interventions suggested re family involvement, MA eligibility, County funding options, budgeting issues, employment assistance. These issues will be addressed on a treatment plan for the patient.
The interventions will be established on an individual basis, modified as necessary due to individual patient needs.
When all efforts to sustain patients in treatment have been utilized and noncompliance with payment and contracts continues, an administrative taper will begin. If the balance is paid in full the taper will cease.
Patients will be given all appropriate referrals during this time.
A balance meeting is held weekly to review patient balances,interventions to utilize to address concerns.
The counselors, clinical supervisors and clinic director will meet with the more serious payment issues. Financial responsibility issues continue to be reviewed in 1 on 1 supervision bimonthly. |
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 the review of client records, the facility failed to provide an evaluation that contained a clinical analysis of the historical data collected in eight of eight client records.
The findings include:
Twelve client records were reviewed on May 11-12, 2009. Psychosocial evaluations were required in eight client records.
Client # 4 was admitted March 24, 2009. There was no documentation of the psychosocial evaluation as of May 13, 2009.
Client's # 1, 6, 8, 9, 10 and 11 contained documentation of psychosocial evaluations that were not evaluative, instead consisting of client reported statements and data repeated from the client reported history.
Client record # 12 contained documentation that was not legible.
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Plan of Correction
The clinical supervisors will address with their newer supervisees in 1 on 1 supervision writing psychosocial evaluations. They will review examples with them as well as the evaluative nature necessary and the time frames for completion of this evaluation. They will review completed evaluations after this meeting for compliance. This will be addressed with all cousnelors in group supervision in 2 meetings with each supervisor and their supervisees. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to document preliminary treatment and rehabilitation plans based on the individual's initial interview, psychosocial evaluation or other evaluations the individuals may have had in eight of eight client records.
The findings include:
Twelve client records were reviewed on May 11-12, 2009. Eight client records were reviewed for preliminary treatment plans. Client records # 1, 4, 6, 8, 9, 10, 11 and 12 all contained identical preliminary treatment plans addressing the same two goals. The first goal addressed the client being opiate dependent and the second goal addressed the client paying for his or her services. The second of the two goals was not an area identified in any of the client interviews or evaluations in the client records reviewed. The treatment plans were not individualized and were not client specific.
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Plan of Correction
The preliminary treatment plan has been modified to include more individualized goals upon admission. If financial responsibility is not identified it will not be addressed on a treatment plan. The clinical supervisors will ensure that this is implemented. The clinical supervisors will monitor for compliance in bimonthly one on one supervision when completing random chart reviews. |
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 measurable, individualized treatment goals in eight of eight client records.
The findings include:
Twelve client records were reviewed May 11-12, 2009. Individualized treatment goals were required in eight client records. The goals were not individualized in client records # 1, 11 and 12. The goals were not written in terms of measurable criteria in client records # 6, 7, 8 and 9. A treatment plan was developed for client record # 4 without benefit of a psychosocial history or evaluation being completed. Client record # 11 contained language of the client being a male and female interchangeably. The client was actually a male, but the treatment plan addressed his "pregnancy."
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Plan of Correction
Individualized treatment plans will be reviewed by the clinical supervisors in 1 on 1 supervision with the counselors by 6/26/09. They will address how to develop a treatment plan and how to individualize treatment plans as well as treatment plan update writing. The clinical supervisors will sign treatment plans on a weekly basis. If revisions are necessary the counselors will receive a chart correction notification form. They wil have 48 hours to make the revisions and will review the plans with their supervisor within the time frame. If the treatment plan is in compliance the clinical supervisor will sign the plan. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to provide individualized treatment plans in eight of nine client records.
The findings include:
Twelve client records were reviewed on May 11-12, 2009. Eight client records were reviewed for individualized treatment plans. Client records # 1, 6, 7, 8, 9, 10, 11 and 12 all contained the same services, one individual and one group per month regardless the length of time in treatment or what issues were being addressed.
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Plan of Correction
The clinical supervisors will review evaluating service frequency based on the therapeutic need of the patient and noting this on the treatment plans. This will be addressed in 2 group supervision sessions with the clinical supervisors supervisees. The clinical supervisors after reviewing treatment plans weekily will address individual service recommendations on the plans in 1 on 1 supervision and when reviewing charts on a random basis. Chart correction notfication forms will be utilized and corrections will be completed within 48 hours of notification. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to provide individualized treatment plans with support services in four of six client records.
The findings include:
Twelve client records were reviewed on May 11-12, 2009. Six client records were reviewed for individualized support services on the established treatment plans. Client records # 4, 6, 8 and 12 did not contain any proposed type of support services.
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Plan of Correction
The clinical supervisors will review in 1 on 1 supervision with the counselors the importance of assessing patient support services. The counselors will also be referred to the community resources binder in the clinic directors office for additional assistance with support services. They will conduct random chart reviews in the next 90 days to review compliance in this area and will continue to utilize chart correction notification forms for corrections that are needed with a 48 hour due date for corrections. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records, the facility failed to document a complete aftercare plan in one of one client records.
The findings include:
Twelve client records were reviewed on May 11-12, 2009. A completed aftercare plan was required in one client record. Client record # 3 contained an aftercare plan with missing components. The plan contained generalized goals with no time frames. There was no description of available support services after discharge. The plan was a generalized document that did not contain a plan for the client to follow after leaving treatment for his or her ongoing recovery efforts.
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Plan of Correction
The clinical supervisors will review the discharge after care plan process with the counselors in 1 on 1 supervision by 7/3/09. The will ask their supervisees in each meeting the patients that are going to be discharged and patients that are tapering off of Methadone. The supervisors will follow up monthly with their supervisees regarding the discharge after care plans they are working on with their patients.They will review the list of patients that are in need of an aftercare plan and will review plans prior to review with the patient for compliance. Chart reviews will be completed in the next 90 days to review for ongoing compliance. |
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 administrative documentation and client records, the facility failed to document any follow up attempts in three of three client records.
The findings include:
Twelve client records were reviewed on May 11-12, 2009. Follow up attempts were required in three client records. There was no documentation of any follow up attempts in client records # 1, 2 and 3. The administrative documentation included consents for follow up and the policy manual. The policy manual contained procedures to follow up with a referred client within 7 days of the appointment. All other discharged clients were to have at least one attempted follow up contact at 30 and then at 90 days post discharge. The consents for follow up signed by the client and witnessed by the staff person varied from 90 days to 12 months, most saying only at 12 months.
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Plan of Correction
The discharge follow up release has been amended to have patients contacted 30 days after discharge. If the counselor is able to speak with the former patient the discharge treatment evaluation form will be completed at that time. This will then be forwarded to the clinic director. The CRC policy has been amended to reflect these adjustments. Patients referred to another facility will be contacted by their primary counselor for follow up within 1 week. This will be reviewed with the counselors in 2 group supervision sessions with the clinical supervisors. They will montior for compliance when reviewing discharge charts on a weekly basis. |