INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 4 - 6, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Organization for Women in Early Recovery (POWER) 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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709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to provide counseling to a client on a regular and scheduled basis including individual counseling, at least twice weekly in two of the three records reviewed in the partial hospitalization activity.
The findings include:
Eight client records were reviewed on December 5, 2012. Three of the eight client records were reviewed for the partial hospitalization activity. Three of those three records were required to document individual counseling at least twice weekly. Two of those three did not document individual counseling at least twice weekly.
Client # 1 was admitted on 10-23-2012 and began participating in partial hospitalization services on 11-5-2012. Documentation of two individual sessions per week was not completed for the weeks of 11-12-2012 and 11-19-2012.
Client #6 was admitted on 7-26-2012 and participated in partial hospitalization services from 8-14-2012 to 10-31-2012. Documentation of two individual sessions per week was not completed for the weeks of 8-13-2012, 9-4-2012, 9-10-2012, 9-17-2012, 10-1-2012, 10-8-2012, 10-15-2012, and 10-22-2012.
The findings were reviewed with the facility director and the clinical supervisor and were not disputed.
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Plan of Correction
The Outpatient Program Manager will provide oversight and monitoring to ensure staff are providing counseling to clients on a regular and scheduled basis including individual counseling at least twice weekly. Meeting this requirement has been an ongoing challenge in large part due to clients not showing up for their scheduled appointments. Therefore, the followings strategies will be implemented:
The Intake Therapist will ask clients to sign a "commitment to participate" in Partial Hospitalization that will include attendance expecations, parameters of treatment, and a statement of what behaviors will result in a discharge from partial hospitaliztion.
The Individual Therapists will schedule twice weekly sessions with their clients and closely monitor treatment compliance, and will hold clients accountable to the "commitment to participate". The Program Manager will closely monitor this process including periodic discussion during the weekly team meetings.
The Program Manager will ensure that every client has a "back-up" Therapist to provide coverage in the event the primary Therapist is unavailable to provide an individual session.
The Program Manager will review the clinical record on a regualr basis to enure that clients are receiving two individual counseling sessions per week, and will address non-compliance issues immediately.
Target date for POWER to be in full compliance is 3/5/2013 |
709.93(b) LICENSURE Client records
709.93. Client records.
(b) The project shall develop and maintain client records on standardized project client record forms.
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Observations
Based on a review of client records, the facility failed to document follow-up in three of the four closed client records reviewed in the outpatient activity.
The findings include:
Eight client records were reviewed on December 5, 2012. Five of the eight client records were reviewed for the outpatient activity. Four of the five outpatient records were required to document follow-up. Three of those four did not document follow-up per the facility policy. The policy states follow-up is to be completed within seven days after discharge for clients who are referred and clients who are not referred.
Client # 3 was admitted on 7-3-2012 and was discharged on 8-24-2012. Documentation of follow-up was due by 8-31-2012 and was not completed.
Client # 7 was admitted on 3-2-2012 and was discharged on 8-22-2012. Documentation of follow-up was due by 8-29-2012 and was not completed.
Client # 8 was admitted on 3-7-2012 and was discharged on 7-16-2012. Documentation of follow-up was due by 7-23-2012 and was not completed.
The findings were reviewed with the facility director and the clinical supervisor and were not disputed.
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Plan of Correction
The Outpatient Program Manager will review the facility policy with the Outpatient staff regarding the requirement to document in the medical record follow-up interventions and outcomes with clients within seven days of their discharge.
The Individual Therapists will attempt to follow-up with clients within seven days of their discharge and will document outcome of follow-up interventions in the medical record.
The Program Manager will do periodic chart reviews to ensure follow-ups are done on discharged clients and will address any non-compliance issues immediately.
The target date for POWER to be in full compliance is 3/5/2013 |