INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 27, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Habit Opco, Inc. - Pottstown 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 February 25, 2009.
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Plan of Correction
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document complete personal histories in four of four client records.
The findings include:
Four client records were reviewed on January 27, 2009. Personal histories were required in four client records. The facility did not document complete, detailed personal histories in client records #1, 2, 3 and 4. The family history included one word answers in client record #2. The employment history only documented whether the client was currently employed in client records #1, 2, 3 and 4 and failed to document the employment history. The sexual history only identified the client's sexual orientation in client records #1, 2, 3 and 4.
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Plan of Correction
The Clinical Director reviewed the deficiencies in documenting the personal histories with the counselor on 1-28-09. The clinical director provided supervision and guidance on the proper completion of the personal history and the information that is required on 1-28-09. Personal histories will all be reviewed and approved by the clinical director on an ongoing basis. Monthly random audits will be conducted by the Program Director for the next three months then random quarterly audits thereafter.
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709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based on a review of client records, the facility failed to document complete physical exams in four of four client records.
The findings include:
Four client records were reviewed on January 27, 2009. Physical exams were required in four client records. The physical exam was missing documentation of the client's general appearance in client records #1, 2, 3 and 4. The physician's impressions did not include a diagnosis of the client in client records #1, 2, 3 and 4.
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Plan of Correction
Deficiencies in documentation of the physicals were reviewed with the Physician on 2-19-09 by the Program Director. A review of the necessary components for documentation of the physical exam was completed with the Physician by the Program Director on 2-19-09. Physician documentation will be reviewed on a weekly basis for three months by the Program Director to ensure that it meets the criteria set forth in the regulations. Thereafter random reviews of Physician documentation will be done monthly by the Program Director.
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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 document complete psychosocial evaluations in four of four client records.
The findings include:
Four client records were reviewed on January 27, 2009. Psychosocial evaluations were required in four client records. The psychosocial evaluation was not based on clinical impressions, but rather was a repeat of historical information in client records #1, 2, 3 and 4. The client's assets/strengths were missing in client record #4. The client's potential or available support systems were missing in client records #1 and 2. The client's preferred coping mechanisms were missing in client records #1, 2 and 4. Negative factors that might affect treatment were missing in client records #1 and 3. The client's attitude toward treatment was missing in client records #1, 2, 3 and 4.
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Plan of Correction
Deficiencies in the documentation of the psychosocial evaluation were reviewed with the counselor on 1-28-09. The Clinical Director reviewed the necessary components of the psychosocial evaluation with the counselor on 1-28-09. All Psychosocial evaluations will be reviewed and approved by the clinical director on an ongoing basis to ensure that the necessary components are documented. Monthly random audits will be conducted by the Program Director for the next three months then random quarterly audits thereafter. |
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 a review of client records, the facility failed to document proposed types of support services on the treatment plan in three of four client records.
The findings include:
Four client records were reviewed on January 27, 2009. Treatment plans with support services were required in three client records. The facility did not document support services on the treatment plan in client records #1, 2 and 4.
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Plan of Correction
Deficiencies in the documentation of the treatment plan were reviewed with the counselor on 1-28-09 by the Clinical Director. The Clinical Director provided guidance and supervision on treatment planning and the required components of the treatment plan. The Clinical Director will review and approve of all treatment plans on an ongoing basis to ensure that they document all items to include supportive services.
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709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a record of services in four of four client records.
The findings include:
Four client records were reviewed on January 27, 2009. A record of services was required in four client records. A record of services was not documented in client records #1, 2, 3 and 4. The facility director noted a record of services was in the electronic record keeping system, but she was unable to locate it when requested.
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Plan of Correction
The record of service is available in the electronic recordkeeping system. All staff has been trained on how to access the record of services on 1-28-09. The Program Director will ensure that all staff are trained on how to access the record of service report on an ongoing basis. |