INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for May 13, 2009 licensing renewal inspection. The follow-up inspection was conducted on November 20, 2009 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 24, 2010.
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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 three of four client records.
The findings include:
Fifteen client records were reviewed on November 20, 2009. Four records were required to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. Client records # 10, 11 and 12 did not have written notification to the client of the decision to terminate the client's treatment.
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Plan of Correction
The program's clinical supervisors will address with the clinical team (i.e. counselors and medical staff) the protocols for involuntary termination during the next scheduled staff meeting. As per the existing procedures, the patient will receive a notice of involuntary termination from his/her counselor. The counselor is responsible for placing a copy in the patient's chart. A progress note is completed by the counselor documenting the meeting with the patient to inform him/her of the involuntary termination. This progress note is also placed in the patient's chart. The Medical Director will verify that there is signed involuntary termination documentationin the patient's file prior to writing the order to initiate the administrative taper. Clinic Director will be notified inadvance of all involuntary terminations and inconjunction with the Clinical Supervisors records audits will be conducted to ensure that protocols are being appropriately followed. |
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 client records, the facility failed to restrict involuntary terminations to those reasons contained in the program's policy and procedure for involuntary terminations in five of six client records.
The findings include:
Fifteen client records were reviewed on November 20, 2009. Six client records were reviewed for documentation of non-compliance discharge information.
Client records # 8 and 9 were listed as being discharged as non-compliant, but there was no documentation in the chart to demonstrate the reasons for discharge, including a discharge summary.
Client records # 10, 11 and 12 were discharged for financial reasons as indicated in the client record documentation.
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Plan of Correction
CTC will continue to utilize all efforts to sustain patients in treatment.
The clinical supervisors will review and reinforce the following protocols with counselors during individual supervision sessions. Additionally, the clinic director will review these protocols with the counselors at the next scheduled staff meeting.
Counselors are responsible for documenting the content of therapy sessions and pertinent conversations with patients, including counseling, education, skill development and problem-solving provided to patients pertaining to noncompliance issues in treatment. Counselors will demonstrate through progressive progress notes and/or treatment plan updates the patient's lack of positive progress and continued noncompliance prior to presenting the patient's case to the clinical team for involuntary termination. Copies of this supporting documentation will be attached to the case consultation sheet when the case is presented to the clinical team.
For patients who become financially non-compliant, the patient will first be notified by the office manager regarding his/her nonpayment status. The office manager will provide the patient with his/her current balance during this conversation. If there continues to be nonpayment, the counselor will be notified and will meet with the patient. The financial situation will be assessed at that time and interventions suggested regarding family involvement, MA eligibility, county funding options, budgeting issues, employment assistance, etc. If appropriate, the treatment plan will be revised with the patient. If appropriate, a realistic financial contract will be developed. If appropriate, take home privileges will be placed on hold. If appropriate, the patient will be referred to the Financial Planning group. Interventions, however, will be established on an individual basis and modified as necessary based on the individual needs of the patient. If appropriate, the patient will be referred to the newly developed Road to Recovery program which is designed for patients who are at-risk of involuntary termination.
When all efforts to sustain the patient in treatment have been utilized and noncompliance with payment and contracts continues, the patient will be tagged to meet with the clinical supervisor and/or clinic director. The clinical supervisor/clinic director will inform the patient that he/she is being placed on scheduled dosing and provided a two week window to work cooperatively and productively with clinic staff to resolve their financial situation with the program. If after this two-week period, noncompliance with payment and contracts continues, an administrative taper will begin. At any point during the administrative taper, 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 and interventions to utilize to address noncompliance concerns. Information from this meeting is shared with counselors. More serious payment issues are discussed during medical team meetings.
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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 the review of client records, the facility failed to execute an evaluative composite picture of the client in relationship to the collected historical data in four of five client records.
The findings include:
Fifteen client records were reviewed on November 20, 2009. Five client records were reviewed for psychosocial evaluations. The content of the evaluations consisted of a repeat of the historical data collected and statements of what the client reported without a clinical impression of the information in client records # 2, 3 and 4. In addition, # 6 was admitted 9-16-09 and there was no psychosocial evaluation in the patient record.
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Plan of Correction
The clinical supervisors will address with their counselors during individual supervision sessions the writing of clinical impressions for the psychosocial evaluations. Examples will be reviewed with counselors as a learning tool. Clinical supervisors will also review completed evaluations after this meeting for ongoing compliance and feedback for skill development. This topic will also be discussed within the coming quarter during a scheduled clinical team meeting. |
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 four of four client records reviewed.
The findings include:
Fifteen client records were reviewed on November 20, 2009. Four client records were reviewed for an individualized treatment plan. Client records # 2 and 6 had documented "1x1" for group and individual counseling. Client records # 3 and 4 stated only "1" for group and individual counseling. This documentation failed to provide frequency of the services.
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Plan of Correction
Counselors will be trained on 2/22 during a scheduled clinical team meeting to use a standard format for listing the type and frequency of treatment and rehabilitation services on patient treatment plans that is clear, concise and universally understood by professionals and patients. Clinical supervisors will review patient treatment plans minimally on a biweekly basis to ensure compliance in this area. |
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 document support services on three of four client records reviewed.
The findings include:
Fifteen client records were reviewed on November 20, 2009. Four client records were reviewed for documentation of proposed support services on the client's treatment plan. Client records # 2, 3 and 4 had no documentation of proposed support services on the comprehensive treatment plan.
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Plan of Correction
The clinical supervisors will review with the counselors during individual supervision sessions as well as during the next scheduled staff meeting, the importance of assessing patient support services and provide counselors of an overview of community resources that can be considered when making recommendations. Clinical supervisors are responsible for reviewing treatment plans and ensuring compliance in this area prior to the filing these documents in the patients' files. |