INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 30, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, A Better Today, Inc., 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:
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Plan of Correction
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709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based upon the review of Administrative documentation, the facility failed to make available to the public an annual report which included a financial statement of income and expenses. The findings include:An administrative review, which included a review of the facility's 2011 annual report, was conducted from November 19 - 20, 2012. The facility's 2011 annual report was made available to the public on December 28, 2011, via an ad that was placed in a local newspaper. Page 4 of the 2011 annual report was titled: "A Better Today - 2011 Statistics Income Adverage (sic) for Each Facility." The page included a bar graph with "bars" representing the 5 facilities contained in the project: Scranton, Tunkhannock, Stroudsburg, Hazelton (sic) and Bradford. However, there were no numerical values assigned to any of the bars or to the graph itself. In addition, the report did not contain any reference to expenses for any of the facilities contained in the project. Therefore, the annual report did not include a statement or disclosure of income and expenses as required.The findings were confirmed by the Project Director during the Administrative review.This is a repeat citation from the November 23, 2011, annual inspection.
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Plan of Correction
The Project Director will ensure that the project's annual report will include a statement of income and expenses. The 2011 statement of income and expense was filed in the 2011 corporate manual but was inadvertently not included in the annual report and the 2012 annual report is currently being prepared and will include the 2012 income and expense report. In the future the Project Director will assure that a statement of income and expenses is bound with the annual report to assure it is readily available to the public. All annual reports are also advertised in local newspapers. |
709.26(a)(10) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(10) Work performance evaluations.
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Observations
Based upon the review of the facility's Policy & Procedure (P&P) Manual and personnel records, the facility failed to follow its own policy in regard to the completion of employee work performance evaluations.The findings include:The P&P Manual and employee records were reviewed as part of an Administrative Review which was conducted from November 19 - 20, 2012. The facility's policy titled, "A Better Today Incorporated Work Performance Evaluations," specified the following information: "All employees receive work performance evaluations. The evaluations are filled out by the employee's supervisor. The evaluations are personally shared with the employee and she/he is entitled to make comments as appropriate. Permanent employees will be evaluated on an annual basis in January of each year."Two employee records requiring documentation of employee evaluations were reviewed on November 20, 2012. One of two records, specifically # 1, contained an annual performance evaluation that was not completed as per policy.Employee # 1, the Project Director, was a permanent employee who was hired on October 1, 1987. Therefore, an annual performance evaluation was due no later than January 31, 2012. However, the record contained an evaluation that was late as it was completed and signed by the employee on October 2, 2012. In addition, the evaluation was not completed by the employee's supervisor as specified in the policy. Instead, the evaluation was completed by an employee who was supervised by the Project Director.The findings were confirmed by the Project Director during the exit interview.
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Plan of Correction
Employee #1 will be evaluated on a yearly basis by a member of A Better Today's board of directors. This will begin in January of 2013 and will continue on a yearly basis thereafter.
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based upon observation of the licensing Specialist, the facility failed to protect the confidentiality of client identities.The findings include:Upon arriving at the facility on November 30, 2012, the Licensing Specialist observed four client sign-in sheets situated on top of a counter just inside the main door. Four of four sign-in sheets listed a minimum of 10 clients by using their first and last names. In addition, at least two clients had signed in and had access to all of the other client's names. Therefore, the facility failed to protect the identity of its clients.The findings were confirmed by the Clinical Director.
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Plan of Correction
Beginning December 3, 2012 all client sign in sheets were redesigned to have the client's first name and last initial. The purpose of this change is to become more compliant with client confidentiality rights and requirements.
The clinical director will monitor the sign in sheets from each facility to assure that the change has been made and continues to be updated in the same manner to continue to protect client confidentiality.
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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 upon the review of treatment plans, the facility failed to document individualized rehabilitation and treatment plans for each client.The findings include:Seven client records requiring documentation of individualized rehabilitation and treatment plans were reviewed on November 30, 2012. The facility failed to document individualized treatment plans in three of seven records, specifically #'s 2, 4, and 7.Client # 2 was admitted on October 23, 2012, and was still an active client on the date of inspection. The record contained a treatment plan that was signed and dated by the client on October 23, 2012. However, the treatment plan was not individualized. Instead, the treatment plan was a standardized form that was the same as the treatment plan found in record # 4.Client # 4 was admitted on November 23, 2012, and was still an active client on the date of inspection. The record contained a treatment plan that was signed and dated by the counselor on November 30, 2012. However, the treatment plan was not individualized. Instead, the treatment plan was a standardized form that was the same as the treatment plan found in record # 2.Client # 7 was admitted on June 26, 2012, and was still an active client on the date of inspection. A treatment plan was due no later than July 6, 2012. However, the record did not include an individual treatment plan as of the date of inspection.The findings were confirmed with the Clinical Director during the exit interview.
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Plan of Correction
Following the Pennsylvania Department of Health services licensure review ending November 30, 2012, training for all A Better Today clinical staff from the Hazleton office was scheduled for December 5, 2012. In this training all pertinent clinical documentation including but not limited to master treatment plans, Treatment plan updates, progress notes, case consultations, and discharge summaries were reformatted and redeveloped. Treatment plan goals will be added in addition to foundation treatment plan strategies from the client's self identified goal preferences. This new treatment plan policy and procedure was implemented on December 5, 2012. Training on all clinical documentation will continuously occur on a weekly basis and will be overseen by the clinical director. The treatment plans will also go through a quality assurance process on an ongoing basis to assure that the changes are made and all future treatment plans have individualized plans to meet each client's goals. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based upon the review of client records, the facility failed to document updated treatment plans that included the client's progress relative to the individual treatment plan.The findings include: Three client records requiring documentation of updated treatment plans were reviewed on November 30, 2012. Two of three records, specifically #'s 7 and 8, either did not include treatment plan updates or contained treatment plan updates that did not include the client's progress relative to their individualized treatment plan.Client # 7 was admitted on June 26, 2012 and was still an active client on the date of inspection. An individualized treatment plan was due no later than July 6, 2012, but was not included in the record. In addition, updated treatment plans documented for August 26, 2012 and November 26, 2012, were included in the record. However, both updates failed to include the client's progress relative to their individual treatment plan. Instead the updated treatment plans were standardized forms that were identical from update to update.Client # 8 was admitted on September 27, 2011, and was discharged on March 22, 2012. The record contained an individual treatment plan that was signed and dated by the client on September 27, 2011. Treatment plan updates were due on or by November 26, 2011, and January 25, 2012. However, the record did not include documentation of either update.The findings were confirmed with the Clinical Director during the record review.
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Plan of Correction
Following the Pennsylvania Department of Health services licensure review ending November 30, 2012, training for all A Better Today clinical staff was scheduled for December 5, 2012. In this training all pertinent clinical documentation including but not limited to master treatment plans, Treatment plan updates, progress notes, case consultations, and discharge summaries were reformatted and redeveloped. In this training treatment plan update goals were reviewed and education was provided to clinical staff on how to better analyze, evaluate, and document client progress relative to their individualized treatment goals. This new procedure was implemented on December 5, 2012. Training on all clinical documentation will continuously occur on a weekly basis and will be overseen by the clinical director. Quality assurance will also be conducted on an ongoing basis to assure the proper procedures continue to be followed. |
709.93(a) 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:
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Observations
Based upon the review of client records and a conversation with the clinical director and project director, it was not possible to determine if the client records were complete or accurate.The findings include:Upon arriving at the facility on November 30, 2012, the clinical director and project director informed the Licensing Specialist that there were issues with the treatment plans and discharge summaries. The project director stated that an employee of the project independently edited and / or corrected clinical documents that they had not created. The project director stated that she then signed the documents as the clinician and dated them as though they were the originals. The project director stated that because of concerns regarding the falsification of records he had instructed the clinical director to remove all treatment plans and discharge summaries from the records.Seven client records requiring documentation of treatment plans were reviewed on November 30, 2012. One of seven records, specifically record # 7, was missing the master treatment plan. However, it was not possible to determine if the treatment plan had not been completed or if it had been removed and not returned. The remaining six client records, #'s 1, 2, 4, 5, 6 and 8 had treatment plans that were put back in the records. However, it was not possible to determine if the treatment plans were the originals or if they had been altered.Five client records requiring documentation of discharge summaries were also reviewed on November 30, 2012. Four of five records reviewed, specifically #'s 8, 9, 11 and 12 were missing discharge summaries. However, it was not possible to determine if the discharge summaries had not been completed or if they had been removed and not returned. The remaining client record, # 10, had a discharge summary that was put back in the record. However, it was not possible to determine if that discharge summary was the original or if it had been altered.The totality of the altered documents is not currently known.
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Plan of Correction
All Hazleton clinical records are currently undergoing quality assurance and quality control procedures beginning December 5, 2012 to ensure all client records are complete and meet Pennsylvania Department of Health services licensure regulations. Beginning December 5, 2012 all A Better Today Hazleton office client clinical records were audited and evaluated for Pennsylvania Department of Health services licensure requirements by our internal quality assurance team. This audit is complete in scale, and should be completed by January 7, 2013.
To specifically break down A Better Today's audit and training procedures, the following processes are occurring:
Following the Pennsylvania Department of Health services licensure review ending November 30, 2012, training for all A Better Today clinical staff in the Hazleton office was scheduled for December 5, 2012. In this training all pertinent clinical documentation including but not limited to master treatment plans, Treatment plan updates, progress notes, case consultations, and discharge summaries were reformatted and redeveloped. In this training all components of the clinical record were reviewed and education was provided to clinical staff on how to better complete the clinical record in it's entirety. This new procedure was implemented on December 5, 2012. Training on all clinical documentation will continuously occur on a weekly basis and will be overseen by the clinical director. Quality assurance will also be conducted on an ongoing basis to assure the proper procedures continue to be followed. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based upon the review of client records, the facility failed to document progress notes relative to the client's involvement with the project.The findings include:The facility documents progress notes by utilizing the Data Assessment Plan (DAP) format. The Plan section of the progress note is to be used to identify the counselor's and / or client's actions to be taken and the direction of treatment.Seven client records requiring documentation of progress notes were reviewed on November 30, 2012. Five of seven records, specifically #'s 1, 2, 5, 6 and 7 contained progress notes that failed to document the client's involvement with the project as they included standardized Plans.Client # 1 was admitted on November 8, 2012, and was still an active client on the date of inspection. The record included progress notes for counseling sessions conducted on the following dates: November 12, 16, 19, and 28, 2012. However, the Plan sections were not individualized as each progress note contained a standardized Plan. Client # 2 was admitted on October 23, 2012, and was still an active client on the date of inspection. The record included progress notes for counseling sessions conducted on the following dates: October 25, 2012; and November 2, 5, 14, 19, and 29, 2012. However, the Plan sections were not individualized as each progress note contained a standardized Plan. Client # 5 was admitted on September 26, 2012, and was still an active client on the date of inspection. The record included progress notes for counseling sessions conducted on the following dates: October 2, 9, 11, 16, 23, and 25, 2012; and November 7, 8, 9, 13, 15, 19, 28 and 29, 2012. However, the Plan sections were not individualized as each progress note contained a standardized Plan. Client # 6 was admitted on November 21, 2012, and was still an active client on the date of inspection. The record included progress notes for counseling sessions conducted on the following dates: November 26 and 28, 2012. However, the Plan sections were not individualized as each progress note contained a standardized Plan. Client # 7 was admitted on June 26, 2012, and was still an active client on the date of inspection. The record included progress notes for counseling sessions conducted on the following dates: November 7, 8, 12, 13, 14, 19, 21, 26 and 28, 2012. However, the Plan sections were not individualized as each progress note contained a standardized Plan. The findings were confirmed by the Clinical Director during the record review.
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Plan of Correction
Following the Pennsylvania Department of Health services licensure review ending November 30, 2012, training for all A Better Today clinical staff was scheduled for December 5, 2012. In this training all pertinent clinical documentation including but not limited to master treatment plans, Treatment plan updates, progress notes, case consultations, and discharge summaries were reformatted and redeveloped. In this training client progress notes were reevaluated for integrity and staff was trained on the process of individualized problem/goal analysis, evaluation, and documentation. Specifically individualizing each progress note's plan of goals; to represent both current acute client problem goals, and internal consistency with the client's treatment plans. This new procedure was implemented on December 5, 2012. Training on all clinical documentation will continuously occur on a weekly basis and will be overseen by the clinical director. Quality assurance will also be conducted on an ongoing basis to assure the proper procedures continue to be followed. |
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 upon the review of client records, the facility failed to document aftercare plans for clients who were successfully discharged from the program.The findings include:Four client records requiring documentation of an aftercare plan were reviewed on November 30, 2012. Two of four records, specifically #'s 8 and 9, did not include client aftercare plans.Client # 8 was admitted on September 27, 2011, and was successfully discharged on March 22, 2012. Therefore, an aftercare plan was due no later than March 22, 2012. However, as of the date of inspection, the record did not include an aftercare plan.Client # 9 was admitted on May 29, 2012, and was successfully discharged on October 11, 2012. Therefore, an aftercare plan was due no later than October 11, 2012. However, as of the date of inspection, the record did not include an aftercare plan.The findings were confirmed by the Clinical Director during the record review.
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Plan of Correction
Following the Pennsylvania Department of Health services licensure review ending November 30, 2012, training for all A Better Today clinical staff was scheduled for December 5, 2012. In this training all pertinent clinical documentation including but not limited to master treatment plans, Treatment plan updates, progress notes, case consultations, and discharge summaries were reformatted and redeveloped. In this training discharge summaries were reviewed and education was provided to clinical staff on how to better analyze, evaluate, and document client progress relative to their individualized treatment and discharge status. This new procedure was implemented on December 5, 2012. Training on all clinical documentation will continuously occur on a weekly basis and will be overseen by the clinical director. Quality assurance will also be conducted on an ongoing basis to assure the proper procedures continue to be followed. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based upon the review of client records, the facility failed to document discharge summaries.The findings include:Five client records requiring documentation of discharge summaries were reviewed on November 30, 2012. Four of five records, specifically #'s 8, 9, 11 and 12, did not include discharge summaries.Client # 8 was admitted on September 27, 2011, and was discharged on March 22, 2012. Therefore, a discharge summary was due no later than March 29, 2012. However, the record did not include a discharge summary as of the date of inspection.Client # 9 was admitted on October 17, 2011, and was discharged on January 29, 2012. Therefore, a discharge summary was due no later than February 5, 2012. However, the record did not include a discharge summary as of the date of inspection.Client # 11 was admitted on August 27, 2012, and was discharged on September 25, 2012. Therefore, a discharge summary was due no later than October 2, 2012. However, the record did not include a discharge summary as of the date of inspection.Client # 12 was admitted on May 29, 2012, and was discharged on October 11, 2012. Therefore, a discharge summary was due no later than October 18, 2012. However, the record did not include a discharge summary as of the date of inspection.The findings were confirmed by the Clinical Director during the record review.
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Plan of Correction
Following the Pennsylvania Department of Health services licensure review ending November 30, 2012, training for all A Better Today clinical staff was scheduled for December 5, 2012. In this training all pertinent clinical documentation including but not limited to master treatment plans, Treatment plan updates, progress notes, case consultations, and discharge summaries were reformatted and redeveloped. In this training discharge summaries were reviewed and education was provided to clinical staff on how to better analyze, evaluate, and document client progress relative to their individualized treatment and discharge status. This new procedure was implemented on December 5, 2012. Training on all clinical documentation will continuously occur on a weekly basis and will be overseen by the clinical director. Quality assurance will also be conducted on an ongoing basis to assure the proper procedures continue to be followed.
The charts that were previously missing discharge summaries have been updated to include the discharge summaries with the appropriate information for each client. The quality assurance team will monitor charts to assure that all discharge summaries are completed in a timely manner. The clinical director will oversee this review.
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