INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the September 15, 2009 licensure renewal inspection. The follow-up inspection was conducted on December 28, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Counseling Alternatives Group, 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 and a plan of correction is due on January 23, 2010.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on and interview with the project director, the facility failed to document an assessment of staff training needs for the November 1, 2008 to October 31, 2009 training year. The findings include:Based on an interview with the project director on December 28, 2009 the project director confirmed that the facility failed to document an assessment of staff training needs for the November 1, 2008 to October 31, 2009 training year, as well as, the staff training needs assessment for the November 1, 2009 to October 31, 2010 training year.
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Plan of Correction
An assessment of staff training needs was made and documented on 1/22/2010 by the project director. The assessment included trainings that several staff members needed for regulation compliance including CPR as well as plans for the entire staff for an in house training on recent developments in the field. The annual staff training plan will be completed by both the project director and the clinical supervisor by the last day of September hereon forward starting with September of 2010. The overall training plan for 2009-2010 will be reviewed with staff this year on 1/28/2010. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on an interview with the project director, the facility failed to document an overall training plan for the November 1, 2009 to October 31, 2010 training year. The findings include:Based on an interview with the project director on December 28, 2009 at 10:30 a.m. it was confirmed that the facility did not document an overall training plan for the November 1, 2009 to October 31, 2010 training year.
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Plan of Correction
An overall training plan for 11/01/09 to 10/31/10 had been written on 1/10/10 by the project director. The needs of the agency (ie- CPR training) were assessed and listed in the agency wide staff training document. Deadlines were created for each agency wide need as well as resource possibilities. Each employee has received a copy of the plan and a signed copy is in each staff member's personnel file.
An evaluation of progress of each staff member will be done quarterly by the end of January, April, July and September when agency's annual goals are reviewed. The project director will be responsible for this and the review has been included in the annual schedule of tasks. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on an interview with the project director, the facility failed to document an annual evaluation of the overall training plan for the November 1, 2008 to October 31, 2009 training year.The findings include:An interview with the project director on December 28, 2009 confirmed that the facility failed to document an evaluation of the overall training plan for the November 1, 2008 to October 31, 2009 training year.
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Plan of Correction
Evaluations of individual training experiences are done by each specific staff member so that at the end of the training year there is a record of the trainings that each staff member attended and an evaluation and description of the trainings. In the past there has not been an evaluation of the overall trainings that comprised the training goals and plans for the entire agency.
This overall evaluation will be done throughout the year by the clinical supervisor and by the end of the year there will be a complete evaluation of all the trainings attended by staff that were part of the overall agency wide plan and a summary of how these trainings influenced the agency as a whole during that training year.This form which will be identical to the individual training feedback form exscept that it will have an agency wide scope and it will be completed by the 31st of each October and will be kept in a folder in the training file drawer located in a file cabinet in the records room. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on the review of facility training documents and personnel records and an interview with the project director, the facility failed to document that the required 6 hours of HIV/ AIDS training was completed within one year of the date of hire for a clinical staff employee in one of five personnel records representing clinical staff.The findings include: The personnel record that was reviewed on September 14, 2009 revealed that employee # 4, a clinical staff person, was hired on 7/1/2007. The facility failed to document that employee #4 had received the required 6 hours of HIV/AIDS training within the first year of employment. This is a repeat citation from the previous licensing inspection as the facility was found in non compliance for this same staff person on August 7, 2008. This issue was to have been corrected by November 15, 2008. An interview with the project director on December 28, 2009 confirmed that the facility had failed to obtain documentation that employee # 4 had completed HIV/AIDS training.
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Plan of Correction
A request of the staff person has been made to either produce documentation of this training which she has had or to retake the training by 2/15/10 by the project director. . If this is not done there will need to be punitive action on the part of the agency (initiated by the project director) and a letter addressing this situation will go into her personnel file. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on an interview with the project director, it was determined that the facility failed to provide a sufficient number of staff persons, so that at least one person with current CPR certification and first aid training is onsite during the project's hours of operation.The findings include:According to an interview with the project director on December 28, 2009 it was noted that the facility failed to have sufficient staff, certified in CPR and first aid training, on duty during the project's hours of operation. Employees # 1, 2, 3, and 4 did not have current CPR certification and first aid training . Employee # 5 was hired on 9/1/2009 but is a part time employee and is only scheduled to work three hours per week at the facility. Employee #6 also had current CPR certification; however, this employee spends the majority of his time at the prison and away from the facility, only spending about 3 hours a week on site. The facility failed to provide CPR and First Aid coverage for 6 hours of the 40 operating hours a week as of December 28, 2009.
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Plan of Correction
As of 1/26/2010 three staff members have their CPR certification. These individuals are the project director the administrative assisstant both of whom are in the office in the mornings and afternoons and a clinical staff member who works mainly in the evenings. One individual who works with an educational group in the evenings also has his CPR training. At the 1/27/2010 staff meeting all staff members will be reminded by the project director that they need to have a current CPR card by 2/15/2010
CPR credentialing will become an annual item on the agency wide training plan which is devised by the clinical supervisor and the project director in October of each year. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on an interview with the project director, it was determined that employee #1, the project and facility director, did not have the minimum number of training hours for the November 1, 2008 through October 31, 2009 training year. The findings include:According to the interview with the project director on December 28, 2009 it was confirmed that staff did not have the required number of training hours. Employee # 1 was hired on 9/1/1994. This employee was required to have a minimum of 12 hours of training for the November 1, 2008 through October 31, 2009 training year. The facility failed to document the minimum training hours in one of one record where required for the project and facility director positions.
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Plan of Correction
The project director did not satisfy the regulation for a minimum of 12 hours of training for 2008-2009. As this cannot be rectified the only possible action is to plan for the training requirement to be satisfied for 2009-2010. The project director will take advantage of off site, on site and on line opportunities to acquire the required credits. They have already filled out a training plan for this period and the clinical director will review her as well as everyone else's training progress at the 6 month period (April, 2010), At that time anyone not progressing in a timely fashion will need to state when specifically they will accomplish their training goials for that year. |
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 an interview with the project director, the facility failed to limit employee participation on the board of directors to one staff member of the project.The findings include:During an interview with the project director on December 28, 2009 it was disclosed to the licensing specialists that four partners, all clinical employees of the corporation, are current board members. The project director confirmed that all four partners are employees and do sit on the board of directors. This is a repeat citation from the August 6 - 7, 2008 licensing inspection. Following the September 15, 2009 licensing inspection the facility indicated in their plan of correction that they would pursue an exception by December 15, 2009 to permit the four partners to remain as members of the board of directors. The project director confirmed that they did not submit a request for exception as of the date of inspection.
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Plan of Correction
A letter has been written to the Director of the Bureau of Community Program Standards by the project director requesting an exception to this regulation, the reason for the request, the time frame requested and the ction that will be taken if the request is not approved. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on an interview with the project director, it was determined that the facility failed to document an annual audit of financial activities completed by an independent public accountant for the fiscal year ended December 31, 2008.The findings include: During an interview with the project director on December 28, 2009 it was disclosed that the facility did not complete an annual audit of financial activities for the January 1, 2008 through December 31, 2008 fiscal year. The facility failed to produce a copy of annual audit. The facility is an "S" type, small business corporation and was not reviewed for compliance with this standard during the licensing inspection of August 6-7, 2008.
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Plan of Correction
A letter requesting an exception to this regulation has been sent to the Director of the Bureau of Community Program Standards by the project director. The letter requests the exemption, states the reason for the requests, states how the intent of the regulation is fulfilled and outlines further action of the request is denied. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on an interview with the project director, the facility failed to document annual performance evaluations in four out of five personnel records reviewed.The findings include:Five personnel records were reviewed on September 14, 2009. Four out of five personnel records reviewed required annual performance evaluations. The facility failed to document annual performance evaluations in personnel records # 1, 2, 3, and 4. Facility policy and procedure stated that annual performance evaluations would be conducted based on the employees date of hire. Employees # 1, 2, and 3 were hired on 9/1/1994. The facility failed to document performance evaluations that were due on 9/1/2009. Employee #4 was hired on 7/1/2007. The facility failed to document the performance evaluation that was due on 7/1/2009. As of the date of the follow-up inspection on December 28, 2009, the project director confirmed that performance evaluations had not been completed for these personnel records.
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Plan of Correction
All of the staff members of the facility were evaluated by 1/09/2010 by their immediate supervisors or in the case of the preoject director by two peers (the two remaining founding partners) upon the directive of the project director. Each staff member had an opportunity to add comments or agreement or rebutal to the evaluations. They were asked to sign their evaluations and then a copy of the signed evaluation was placed in their personnel files which are held in a locked file cabinet in the administrative assistant's office.
The project director is responsible for having the evaluations done on a yearly basis in October. The task has been placed in the annual agency task schedule. |
709.26(d)(5)(ii) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(ii) The individual shall be informed, by written copy, of their annual evaluation.
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Observations
Based on an interview with the project director, the facility failed to document that individuals were informed, by written copy, of their annual evaluation in four out of five personnel records reviewed.The findings include:Five personnel records were reviewed on September 14, 2009. Four out of five personnel records reviewed required documentation that the employees were informed in writing of their annual performance evaluations. The facility failed to document that the employees were informed of their annual performance evaluations in personnel records # 1, 2, 3, and 4. Facility policy and procedure indicate that the annual written performance evaluations will be based on the employee's date of hire. Employees # 1, 2, and 3 were hired on 9/1/1994. The facility failed to demonstrate that the employees were informed by written copy of their annual performance evaluations that were due on 9/1/2009. Employee #4 was hired on 7/1/2007. The facility failed to demonstrate that the employee was informed by written copy of his/her annual performance evaluation that was due on 7/1/2009. As of the date of the follow-up inspection on December 28, 2009, the project director confirmed that performance evaluations have yet to be completed for these personnel records.
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Plan of Correction
During the first week of January employees were informed verbally at various times by the project director that an evaluation of their work was going to be done by 1/11/2010 and would take place at the convenience of the employee and their immediate supervisor.
In the future, the project director will be responsible for announcing the upcoming evaluations and make certain that evaluations are done before the 31st of October. This task has been placed on the agency's yearly task schedule. |
709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
Based on an interview with the project director the facility failed to document that the employees were informed of their rights. The findings include:Based on an interview with the project director on December 28, 2009 the facility failed to place a copy of the employee rights in each personnel record, a stipulation of the plan of correction submitted following the previous licensing inspection.
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Plan of Correction
After the initial inspection of 9/2009 a copy of the rights of employees was (1) posted in the mail room in a conspicuous location, (2) placed on the bulletin board outside of the mailroom, (3) a copy was placed in each individual's mailbox (4) a copy was placed in each individual's personnel file. It was assumed that no one could possibly miss the message. As of 1/09/2010 a signed copy of the rights were put in everyone's personnel file as well.This was all carried out by the project director.
The deficiency was satisfied for present employees.
For new employees this memo will be included in the packet of documents that they will need to sign as newly hired staff members. The project director will ask the administrative assistant to included this document in the new employee packet in the future and the project director will review the employee folder no later than sven days after the new hire to make certain that it is in the file of the new employee. |
709.26(e)(1) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(1) The employe's right to inspect his own records.
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Observations
Based on an interview with the project director, the facility failed to demonstrate the project's efforts to inform staff of their right to inspect their own records.The findings include:Five personnel files were reviewed on September 14, 2009. There was no documentation in place in personnel records # 4 and 5 that indicated they have been advised of their right to inspect their own record. Based on an interview with the project director on December 28, 2009, it was confirmed that the facility had failed to follow their plan of correction by placing a copy of the client rights in the employee personnel records.
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Plan of Correction
A memo was distributed by the project director on 9/09 that stated that as part of the employee rights everyone has the right to inspect their own personnel record.A signed copy of this memo was placed in everyone's personnel file kept in the locked cabinet in the administraive assistant's office in 1/2010.
The project director has asked the administrative assistant to include this memo amongst the documents that a new staff member needs to read and sign and have in their personnel file. The project director will examine the file within seven days of the new staff member's start of empl;oyment ot make certain that the memo is signed and in their personnel file, |
709.26(e)(2) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(2) The employe's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
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Observations
Based on an interview with the project director, the facility failed to demonstrate the project's efforts toward informing staff of their right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from their personnel records.The findings include:Five personnel records were reviewed on September 14, 2009. There was no documentation in place in personnel records # 4 and 5 that indicated they had been advised of their right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records. An interview with the Project Director on December 28, 2009 confirmed that employees did not have documentation in their personnel records indicating that they have been informed of these rights.
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Plan of Correction
In 9/2009 a memo was displayed and circulated by the project director stating that an employee had the right to request the correction and the removal of inaccurate, irrelevant, outdated or incomplete information from their reords. In 1/2010 a signed copy of the memo which contained that information was placed in everyone's personnel file which is kept in a locked file cabinet in the administrative assistant's office.
The project director has asked the administrative assistant to include this memo in a packet of documents given to all new employees to read and sign. The signed documents are then placed in the individual's personnel file. The project director will examine the personnel file within seven days of the new staff member's start date to be certain that the document is in their personnel file, signed. |
709.26(e)(3) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(3) The employe's right to submit rebuttal data or memoranda to his own records.
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Observations
Based on an interview with the project director, the facility failed to demonstrate the project's efforts to inform staff of their right to submit rebuttal data or memoranda to their own record.The findings include:Five personnel files were reviewed on September 14, 2009. There was no documentation in place in personnel records # 4 and 5 that indicated the employees had been advised of their right to submit rebuttal data or memoranda to their own record. An interview with the project director on December 28, 2009 confirmed that as of the date of inspection there had been no documentation placed in the personnel records of the employees indicating that they have been informed of these rights.
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Plan of Correction
The project director informed staff members of their right to submit rebutal data in the memos that were posted and in the memos stating employee rights that were then placed in their personnel folders and in their mail boxes.In 1/2010 employees were asked to sign the memo that had been filed in their personnel folders and the administrative assistant who was placed in charge of this task then collected the various memos and filed them in each person's personnel folder. The folders are kept in a locked cabinet in her office.
The project director has asked the administrative asssitant to include this memo in a packet of documents that new hires need to sign at the time of hire. The project director will examine the new staff member's personnel file within seven days of the start of employment to make certain the the document is signed and in the personnel file. |
709.26(f)(3) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
(3) The requisite skills, knowledge and experience.
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Observations
Based on an interview with the project director and the review of personnel records, the facility failed to document the requisite skills, knowledge, and experience on the job descriptions in five of five personnel records reviewed. The findings include:An interview with the project director on December 28, 2009 confirmed that this was not documented in these personnel records as of the date of this inspection. The original citation:Five personnel files were reviewed on September 14, 2009. The job descriptions did not include documentation of the requisite skills, knowledge and experience required for the position in five of five records reviewed. The job description in personnel record # 1, Project Director, did not include documentation of the requisite skills, knowledge and experience required for the project director position. The job description in personnel record 2, Clinical Supervisor, did not include documentation of the requisite skills, knowledge and experience required for the clinical supervisor position.The job descriptions in personnel records # 3, 4, and 5, counselors, did not include documentation of the requisite skills, knowledge and experience required for the counselor position.
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Plan of Correction
All employees have been distributed a document by the project director that states the requisite skills, knowledge, and experience required for their position as of 1/25/2010. By 1/30/2010 every employee will have signed that document and a copy of it will be placed in their personnel file. The administrative assistant is in charge of collecting the signed documents and placing a copy in each individual's personnel file which is located in a locked cabinet in her office. Each employee will also receive a copy of the document for their own personal use.
In the future, for new employees, these documents will be included in a packet of documents that new staff members need to read and sign. The packet is the placed in the individual's personnel file. The administrative assistant is in charge of the packets and supervising the signing ofthe documents. The project director will examine the personnel file to make certain that these documents are included in the folder within seven days of the individual'sof the start of employment. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based upon an interview with the project director on December 28, 2009 the facility was unable to produce any records to be reviewed therefore the original citation remains. The facility failed to document that an informed and voluntary consents to release information were obtained in four of fourteen client records. The findings include:Based on an interview with the Project Director on 12/28/2009 the facility failed to provide a complete record to be reviewed in order to determine compliance of this standard. Fourteen client records were reviewed on September 14 and 15, 2009. Four of fourteen client records reviewed did not have written, informed and voluntary consents signed by the client for the disclosure of information contained in the client record. There was no written consent to release information to a third party payer in client record #2 for the treatment episode that began on 1/15/2008. Client records #6, 12 and 14 did not include documentation of consents to release information forms for releases of information to third party payers.
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Plan of Correction
All clients sign a release found in the front of our client information form for third party payers that (1) allows the agency to bill the third party payer and (2) allows the agency to provide a diagnosis. The client therefore knows (1) who will receive information (their third party payer)(2) that the third party knows that they are in treatment)and (3) that the paying party will receive specific information in this case a diagnosis. The form does not have a start date although it is implied nor an end date. The specificity of the information to be shared with third party payers is pretty clear.
However, as this does not meet regulations for all third party payers the regulation was reviewed in the staff meeting of 9/16/09 and clinical staff are now required to have the client sign a release form for all and any third party payers. In addition the twice monthly chart review that is being done by the project director and the clinical director should provide a safety net to make certain that these releases are signed. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on an interview with the project director and the inability for the facility to provide any records to review the original citation remains. The original citation, based on the review of client records, identified that the facility failed to document that the client was offered a copy of each consent to release information form in five of fourteen client records.The findings include:Based on an interview with the Project Director on 12/28/2009 the facility failed to provide a complete record to be reviewed in order to determine compliance of this standard. Fourteen client records were reviewed on September 14 and 15, 2009. In five out of fourteen client records reviewed, there was no documentation that clients were offered a copy of each consent to release information. The facility included a check off on the consent to release information forms to document whether the client accepted or refused a copy of the consent to release information form they had just signed. This check off was left blank on the consent to release information forms documented in client records # 3, 9,11,12, and 13.
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Plan of Correction
Clients are offered the opportunity to accept or reject copies of release, consents, HIPPA etc. The clinician at times forgets to check the appropriate box.
The regulation was reviewed at the staff meeting held on 9/16/2009. The twice monthly review of randomly selected files by the project director and the clinical supervisor helps bring clinician behavior in line with this requirement. If an acceptance or denial to get a copy of a release is not checked in the approprite place the clinician is asked to remedy the situation with the client if possible and they are agin reminded of the regulation. |
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 on an interview with the project director the facility failed to have an record keeping system that allows for the efficient retrieval of data needed to measure the projects performance.The findings include:Based on an interview with the project director on December 28, 2009, the facility was unable to produce a current list of clients for the licensing inspector to be able to conduct open and closed chart audits. The facility failed to provide a complete record to be reviewed.
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Plan of Correction
The project director and the administrative assistant worked on a computer entry that would identify clients by opening date and type of client (DUI, codependent, drug and alcohol, SAP assessment) in 1/2010. The major difficulty occurs when an individual comes to the agency and is open under one category and then qualifies or another. This problem is currrently being worked on and should be resolved by a change in the billing form starting 2/2010. An evaluation of the effectiveness of the change will take place after the first week in February, 2010 and will be evaluated by the administrative assistant and the project director. The administrative assistant is in chartge of keeping the list up to date. The list will be reviewed by the project director and the administrative assitant the first week of each month. |
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 an interview with the project director and the inability to provide a client record to review the original citation remains. The original citation, based on a review of the facility's policy and procedure manual and a review of client records, identified that the facility failed to document preliminary treatment and rehabilitation plans in three out of eleven client records reviewed. The findings include:Based on an interview with the Project Director on 12/28/2009 the facility failed to provide a complete record to be reviewed in order to determine compliance of this standard. On September 14 and 15, 2009, during the review of client records, the facility failed to document preliminary treatment and rehabilitation plans in three out of eleven client records reviewed. The policy and procedure regarding preliminary treatment plans was then reviewed on September 14, 2009. The policy for completion of the preliminary treatment plan stated that it will be based on the first interview and documented at the end of the psychosocial evaluations. A preliminary treatment plan was not documented in client records # 5, 10, and 14. Client record # 5 was admitted on 4/14/2009. A psychosocial evaluation was completed on 4/14/2009; however, the facility failed to document a preliminary treatment plan in the client record. Client record # 10 was admitted on 3/31/2009. A psychosocial evaluation was completed in the client record; however, the facility failed to document a preliminary treatment plan in the client record. Client record #14 was admitted on 12/10/2008. The facility failed to document a preliminary treatment plan in this client record as of September 15, 2009.
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Plan of Correction
The last part of the psychosocial deals with preliminary plans for the client. This part lie all of the other parts of the form is to be completed by the clinician or the individual who does the initial intake.
The regulation of both the Bureau and the agency was reviewed at a staff meeting on 9/16. The once staff person who was not present was told of this in a phone conversation that evening.
The twice a month review of randomly selcted files by the clinical supervisor and the project director should eliminate this problem. If this omission is found the clinician will be told to rectify the situation. |
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 an interview with the project director and the inability for the facility to provide any records to review the original citation remains. The original citation identified that based on a review of client of records, the facility failed to document complete and current records of services in six out of ten client records reviewed.The findings include:Based on an interview with the Project Director on 12/28/2009 the facility failed to provide a complete record to be reviewed in order to determine compliance of this standard. On September 14 and 15, 2009 ten client records were reviewed. In client records # 2, 3, 6. and 7, there were no documentation of records of services provided. In client records # 1 and 4 the records of services were not current. Client # 2 was admitted on 1/15/08 and was last seen on 9/8/09. There was no documentation of a record of services.Client # 3 was admitted on 2/18/09 and was last seen on 9/10/09. There was no documentation of a record of services.Client # 6 was admitted on 4/2/09 and was last seen on 8/26/09. There was no documentation of a record of services.Client # 7 was admitted on 5/10/07 and was last seen on 9/4/09. There was no documentation of a record of services.Client # 1 was admitted on 4/24/09. The record of services listed only the date of admission and did not list the session for 9/3/09 for which a progress note had been recorded.Client # 4 was admitted on 7/28/08. The last documented service for client # 4 on the record of services was 8/31/09. The record of services did not list the session for 9/14/09 for which a progress note had been recorded.
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Plan of Correction
This regulation was reviewed at a staff meeting on 9/16/2009. The one staff person who was not there was told of it over the telephone that night.
The project director and the clinical supervisor are now examining randomly pulled files twice a month. If threr is an issue with a noncompliant service recird form the clinician is made aware of it and then told to bring the form up to date. |
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 on an interview with the project director and the inability for the facility to provide any records to review the original citation remains. The original citation identified that the facility failed to document progress notes in five out of ten client records reviewed.The findings include:Based on an interview with the Project Director on 12/28/2009 the facility failed to provide a complete record to be reviewed in order to determine compliance of this standard. On September 14 and 15, 2009 a review of ten client records revealed that in five out of ten client records reviewed, the plan portion of the progress note was not specific to the individual client's treatment plan.In client record #3 progress notes did not include a plan that was consistent with the treatment plan on the following dates: 2/18/2009, 2/25/2009, 3/4/2009, 3/17/2009, 3/27/2009, 4/1/2009, 4/7/2009, 4/15/2009, 4/22/2009, 4/29/2009, 6/2/2009, 6/11/2009, and 6/17/2009. In client record # 5 the progress notes did not include a plan that was consistent with the treatment plan on the following dates: 7/14/2009, 7/21/2009, 8/25/2009, 9/1/2009, and 9/8/2009. In client record # 7 the progress notes did not include a plan that was consistent with the treatment plan. In client record # 9 the progress notes did not include a plan that was consistent with the treatment planIn client record # 10 the progress notes did not include a plan that was consistent with the treatment plan
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Plan of Correction
In the clinical meeting held on 9/16/09 the project director reviewed the standard that stated that the plan portion of a progress note needs to be specific to the individual's treatment plan with all clinical staff members. The one individual who could not attend was informed that night by phone.
The project director and the clinical director now check randomly picked files twice a month in order to monitor for compliance with regulations. If progress notes do not include plans that are specific to the client's treatment plans the clinician is notified by the project director and told to follow the standard.
If a clinician would consistently refuse to do so they would get a note placed in their personnel file to that effect written by the project director. |
709.93(a)(7) 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:
(7) Client-related correspondence.
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Observations
Based on an interview with the project director and the inability for the facility to provide any records to review the original citation remains. The original citation specified that, based on the review of client records, the facility failed to maintain copies of all client related correspondence within the client record. The regulation at 4 Pa. Code subsection 255.5 (a)(10) states that the "Project shall keep and maintain a written record of all information which is disclosed under this section." The client identifying information released to third party payers and criminal justice entities, as identified at 4 Pa. Code Subsection 255.5, was not documented in seven of fourteen client records.The findings include:Based on an interview with the Project Director on 12/28/2009 the facility failed to provide a complete record to be reviewed in order to determine compliance of this standard.The facility failed to document correspondence to funding entities in seven out of 14 client records reviewed on September 14 and 15, 2009. The facility failed to document correspondence to funding entities in client records # 6, 7, 8, 9,10, 12, and 14 .
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Plan of Correction
In the staff meeting of 9/16/09 this regulation was reviewed to all staff present. The one staff member that was not present was told about this in a telephone conversation that evening. As there is a newly establishe review of records action b y both the project director and the clinical supervisor this issue will be monitored on a regular basis. If there is an issue with a particular folder or counselor it will be addressed by first speaking to that individual and also providing a written reminder of this regulation and a plan of action to correct the problem. |