INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 1-3, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Serento Gardens 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 7, 2009.
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Plan of Correction
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709.22(b) LICENSURE Governing Body
709.22. Governing body.
(b) If a project is publicly funded, not more than one staff member of the project may sit on the governing body at a designated time.
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Observations
Based on a review of board meeting minutes, organizational bylaws, annual report, procedure manual, staffing requirement summary report and interviews with the project director and clinical director the publicly funded facility failed to limit one staff member on the governing body. The findings include: Board meeting minutes and the staffing summary report reviewed on December 03, 2009 provided documentation that the project director and the clinical director were members of the governing body and both the project director and clinical director were governing body officers. This was confirmed by the project director and the clinical director.
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Plan of Correction
The Agency bylaws were amended in the February 22, 2010 meeting of the full board, in accordance with standing procedure. The Vice President was removed from the Board of Directors and the position is no longer noted as an ex-officio member. The sole remaining staff member of the board is the CEO. As the VP/Clinical director was included as a result of a change in the bylaws, board action was necessary to undo the change. The CEO ha no authority to effect bylaws changes.
The bylaws have been returned to their prior version, the one that existed before VP was added as a member. Those bylaws were approved for each of the 29 years prior to the change.
The bylaws need not reference the one staff person limit. Adherance to the regulation will be sufficient demonstration of compliance.
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709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
Based upon a review of the client list and an interview with the clinical director the facility failed to develop and maintain a data collection and record-keeping system that allowed for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives. The findings were:On December 2, 2009 a client list of active and discharged clients was requested. The list that the clinical supervisor provided was for active clients only and did not indicate the date of admission, but only listed the last day of service and the number of sessions attended. It was not possible to determine the admission dates for clients in order to select records for review. When asked if a list could be generated that would provide admission dates and discharge dates the clinical director indicated that she did not think that was possible.
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Plan of Correction
The agency is in the process of purchasing a new collection and record-keeping system. However, until we are able to purchase the system and have it totally intergrated into our data bank the following procedure will occur: The out-patient counselors will indicate on the outside cover of the chart the admission date, date of discharge, re-entry date and subsequent discharge date (when applicable) for each client. In addition, a manual list of active and discharge clients will be generated and maintained by the clinical supervisor until a new system can be purchased. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records on December. 3, 2009 the facility failed to document a consent to treatment in 1 of 5 client records reviewed. The findings were: On December. 3, 2009 five active outpatient client records were reviewed. One of five client records lacked documentation of a consent to treatment. Client #9 was admitted on 9.11.09 and there was no consent to treatment in the client record.
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Plan of Correction
A meeting was held with the out-patient staff on December 11, 2009. Documentation standards and procedures were reviewed, including the need for proper consent to treatment upon admission and re-entry (should the client leave treatment and re-enter). Counselors have been instructed that new consents and releases are required for any client who re-enters treatment within four months after being discharged. If the client returns more than four months after their discharge has been completed a new evaualtion (and chart) will be generated, with the required consents. The clinical supervisor will be responsible for chart reviewing on a monthly basis a sampling of charts for compliance. Unfortunately, the client in question was discharged from treatment before a updated consent could be obtained.
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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 on December. 3, 09 the facility failed to document a psychosocial evaluation in 3 of 5 client records reviewed in accordance with facility policy and procedure. The findings were:Facility policy and procedure stated that the psychosocial evaluation was to be developed at intake. On December. 3, 2009 five active outpatient client records were reviewed. Three of five client records lacked psychosocial evaluations completed in accordance with facility policy and procedure. Client #2 was admitted on 4.2.08; however, there was no date on the psychosocial evaluation or a progress note indicating the date when it was completed. Client #6 was admitted 8.25.09 and the psychosocial evaluation was not completed until 9.8.09.Client #9 was admitted on 9.11.09 and there was no psychosocial evaluation documented on the client record as of 12.3.09.
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Plan of Correction
In most cases the evaluation can be completed during intake (in the first vist), however, there are times when another visit is necessary to complete the intake. The facility policy and procedures manual has been revised to state that a psychosocial evaluation will be developed by the clinician upon completion of the intake process which can take up to two sessions to complete, but shall not go beyond the third session.
In reviewing the chart of Client #9 - this client first entered treatment on 2/17/09. Her intake was completed on that date, as was her psychosocial evaluation. She re-entered treatment on 9/11/09 at which time her intake was reviewed, as was her psychosocial evaluation. Necessary charges were made and the counselor signed off on these changes on 9/11/09.
The client is no longer in treatment. However, we will review other charts to assure compliance on this issue. |
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 a review of client records on December. 3, 2009 the facility failed to document a preliminary treatment plan in 2 of 5 client records reviewed in accordance with facility policy and procedure. The findings were:Facility policy and procedure stated that preliminary treatment plans were to be developed at intake. On December. 3, 2009 five active outpatient client records were reviewed. Two of five client records contained preliminary treatment plans that were completed late. Client #5 was admitted on 7.20.09 and the preliminary treatment plan was not completed until 8.3.09. Client #6 was admitted 8.25.09 and preliminary treatment plan was not completed until 9.8.09.
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Plan of Correction
The facility and procedures manual has been revised to state that a preliminary treatment plan will be developed by the clinician upon completion of the evaluation. In most cases the evaluation is completed during the intake (or intitial) session, but in some cases it is necessary to complete the evalaution in two sessions. The saff was instructed on December 11, 2009, during a documentation training session, that the preliminary treatment plan needs to be generated upon competion of the intake process. The counselors were told that the intake process can take up to two sessions to complete but must not exceed three sessions. The clinical supervisor will review random charts on a monthy basis to ensure compliance. |
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 on a review of client records for five discharged clients the facility failed to document a discharge summary within seven days of discharge.The findings were:On 12.3.09 five client records, #4, #7, #10, #11, #12 were reviewed for discharge summaries. Two of five records reviewed lacked documentation of the discharge date to verify that the discharge summaries were completed within seven days of discharge, specifically client records #10 and #12.
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Plan of Correction
A meeting was held with the outpatient clinicians on December 11, 2009 to discuss ducumentation standards and procedures. The clinicians were reminded that all discharge summaries need to be completed within seven days of discharge. The date that the discharge summary is completed will be inluded with the signature of the clinician completing the discharge. The clinical supervisor will be responsible for reviewing randomly chosen charts for compliance on a monthly basis. |