INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 19, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Colonial House Outpatient 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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709.91(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 a psychosocial evaluation in two of ten client records reviewed.
The findings include:
Ten client records requiring documentation of a psychosocial evaluation were reviewed on March 19, 2015. A psychosocial evaluation was not completed in client records #1 and 2.
Client #1 was admitted on 7/11/14 and was still active at the time of the licensing inspection. A psychosocial evaluation was not documented in the client's record.
Client #2 was admitted on 10/14/14 and was still active at the time of the licensing inspection. A psychosocial evaluation was not documented in the client's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Psychosocial assessment will be scheduled by front desk, or another designee, within 24 hours of their Level of Care Assessment or receipt of their Level of Care Assessment. Upon being scheduled, it will be noted in the appointment book by the designee scheduling the appointment that it is a biopsychosocial appointment after which time the counselor will complete the assessment and provide it to the supervisor to sign off on.
In staff meeting, the supervisor will review that a new assessment must accompany all admits and re-admits no matter the number of times in treatment at the same facility. This will be placed in meeting minutes taken by the Executive Assistant and staff will sign off on these minutes to show acknowledgement of this. Continued negligence in this area will result in progressive discipline by the outpatient Director. In order to ensure that this standard is being maintained, at least monthly chart audits will be completed through either the Program Director, Quality Assurance Manager, or through Peer Review to ensure all assessment and impressions are completed for each treatment episode.
For Clients 1and 2, an assessment and impression will be completed for each client by the primary counselor assigned to each respective case and will be provided to the supervisor to sign off on. |
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 a review of client records, the facility failed to specify the type and frequency of treatment and rehabilitation services in six of ten client records.
The findings include:
Ten client records requiring documentation of the type and frequency of treatment services on the individual treatment and rehabilitation plans were reviewed on 3/19/15. The individual treatment and rehabilitation plans contained in client records #1, 2, 3, 6, 7, and 8 lacked documentation of the type and frequency of treatment and rehabilitation services on the client's treatment plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In a staff meeting that was held on 3/23/15, supervisor reviewed how to properly document the type (individual or group session) and how many times per week or month that action step was to occur. This will be followed up in weekly to biweekly suprvision with counselors and the counselor assistant to ensure proper documentation. Supervisor will review treatment plans prior to signing to ensure it is noted if the action step is to occur in an individual and/or group session and how often within the week and/or month. If the treatment plan does not specify individual or group setting, the treatment plan will be kicked back to the counselor for revision.
To ensure this is maintained, at least monthly chart audits will be performed by the Outpatient Director, Quality Assurance Manager, or through peer audits. If staff continue to not place the type and frequency in their treatment plans, progressive discipline will be ensued by the outpatient director.
To address clients 1, 2, 3, 6, 7, and 8 all treatment plan reviews, updates, or any other new treatment plan that will be entered into their respective charts will have the type and frequency noted prior to the supervisor signing off on the document. Those clients that have since been discharged cannot have any alterations made due to the client not being present for the change or the signature. |
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 the review of client records, the facility failed to ensure that a complete record was documented in two of ten client records reviewed.
The findings include:
Ten client records were reviewed for documentation of a complete client record during the renewal inspection on 3/19/15. The facility failed to document a complete record in client records #1 and 4.
Client #1 was admitted on 7/11/14 and was still active at the time of the licensing inspection. The record of service for the client indicated the client received treatment on 11/4/14, 12/4/14, 12/18/14, 12/24/14, 1/15/15, 2/5/15, 2/19/15, 3/2/15, and 3/19/15. The record of service did not document the type of treatment received by the client on these dates.
Client #4 was admitted on 7/2/14 and discharged on 1/29/15. A progress note indicated the client attended a group counseling session on 1/12/15. This group counseling session was not documented on the client's record of service.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Quality Assurance audits will be performed on at least a monthly basis by either the Quality Assurance manager, peer review, and or Director of Outpatient to ensure contact logs, vouchers, and progress notes all coincide. Counselors will be given a deadline of no more than 7 days from date of the quality assurance audit to remedy any inconsistencies. |