INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 14, 2008 through April 15, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, MinSec Erie 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 and a plan of correction is due on May 19, 2008.
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Plan of Correction
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709.22(e)(3) 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:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
Based on A review of the annual report for 2006/2007, the facility failed to include a statement disclosing the names of officers, directors and principal shareholders.
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Plan of Correction
1. The Project Director will insure that the Annual Plan includes all information required by standard.
2. The Annual Plan shall include a list of principle shareholders and officers.
3. The Correction will be implemented by 1/6/09 when the annual plan is completed for the 2008 calendar year. |
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 client records, the facility failed to document complete psychosocial evaluations in eight of eleven records reviewed, #1, 2, 3, 4, 5, 7, 8 and 12. The psychosocial evaluations were missing in five records, #2, 3, 4, 5 and 7. Evaluations were illegible in two records, #8 and 12. The evaluation was not completed within the time frame identified by the facility in one record, #1.
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Plan of Correction
1. The Project Director will develop a new weekly schedule of documentation submission to ensure timeliness and the completion of all clinical documentation by 6/1/2008
2. The Project Director will update the current policy to ensure that goals for completion of psychosocial evaluations are realistic and corresponding with the standard by 5/30/2008.
3. The Project Director will establish
a training curriculum for clinical staff to explain the new "schedule for documentation" by 6/17,2007.
4. The Program DIrector will monitor and uphold the new documentation system by collecting and acknowledging the submitted documentation on a weekly basis and will insure that monthly file reviews are conducted through the QA system. |
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 facility policy and client records, the facility failed to document preliminary treatment and rehabilitation plans in six of twelve records reviewed, #2, 3, 4, 5, 6 and 7. The policy and procedure stated that preliminary treatment plans were due within seven days of the clients admission date. Preliminary treatment plans were missing in four records, #2, 3, 4 and 5. Preliminary treatment plans were not completed within seven days from admission in two records, #6 and 7.
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Plan of Correction
1. The Project Director will develop a new weekly schedule of documentation submission to ensure timeliness and the completion of all clinical documentation by 6/1/2008
2. The Program Director will monitor and uphold the new documentation system by collecting and acknowledging the timliness of submitted documentation on a weekly basis and will insure that monthly file reviews are conducted through the QA system
3. The Project Director will establish
a training curriculum for clinical staff to explain the new "schedule for documentation" by 6/17,2007.
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709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document a complete treatment plan in ten of eleven records reviewed, #1, 2, 3, 4, 5, 8, 10, 11, 12 and 13. Goals were not stated in terms of measurable criteria in five records reviewed, #1, 8, 10, 11 and 13. Treatment plans were missing in four records, #2, 3, 4 and 5. The treatment plans in one record were illegible, #12.
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Plan of Correction
1. The Project Director will develop a new weekly schedule of documentation submission to ensure timeliness and the completion of all clinical documentation by 6/1/2008
2. The Program Director will monitor and uphold the new documentation system by collecting and acknowledging the timliness of submitted documents on a weekly basis and will insure that monthly file reviews are conducted through the QA system.
3. The Project Director will establish
a training curriculum to instruct clinical staff on "Effective Treatment Planning" to ensure that plaaned goals are realistic and measureable by 7/18,2008.
4. The Program Director will insure that all documentation is legible by requesting typed documentation from counselors whose penmenship is illegible by 6/1/2008 |
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 document the type and frequency of treatment on treatment plans in five of eleven records reviewed, #2, 3, 4, 5 and 12.
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Plan of Correction
1. The Project Director will establish
a training curriculum to instruct clinical staff on "Effective Treatment Planning" to ensure that the type and frequency of services are included in the plan by 6/1/2008.
2. The MinSec Training Institute will conduct a Clinical Inservice Training before 7/18,2008 in order to address inconsistencies and deficiencies in the client documentation practices.
3. The Program Director will monitor consistency in the documentation by collecting and reviewing the timeliness and accuracy of submitted documents on a weekly basis and during monthly file reviews conducted through the QA system.
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709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document support services on treatment plans in five of eleven records reviewed, #2, 3, 4, 5 and 12.
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Plan of Correction
1. The Project Director will establish
a training curriculum to instruct clinical staff on "Effective Treatment Planning" to ensure that an accurate account of client support services are included in the plan by 6/1/2008.
2. The MinSec Training Institute will conduct a Clinical Inservice Training before 7/18,2008 in order to address inconsistencies and deficiencies in the client documentation practices.
3. The Program Director will monitor consistency in the documentation by collecting and reviewing the timeliness and accuracy of submitted documents on a weekly basis and during monthly file reviews conducted through the QA system.
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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 on a review of client records, the facility failed to document complete treatment plan updates in seven of eleven records reviewed, #1, 3, 4, 8, 10, 11 and 13. Treatment plan updates did not include an assessment of the client's progress in relationship to the stated goals of the treatment plan in three records, #8, 10 and 11. Treatment plan updates were missing in four records reviewed, #1, 3, 4 and 13.
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Plan of Correction
1. The Project Director will develop a new weekly schedule of documentation submission to ensure timeliness and the completion of all clinical documentation by 6/1/2008.
2. The Program Director will monitor and uphold the new documentation system by collecting and acknowledging the timeliness of submitted documents on a weekly basis and will insure that monthly file reviews are conducted through the QA system.
3. The Project Director will establish
a training curriculum to instruct clinical staff on "Effective Treatment Planning" to insure that a consistent and accurate assessment of the client's progress is included in the plan updates by 6/1/2008.
4. The MinSec Training Institute will conduct a Clinical Inservice Training before 7/18,2008 in order to address inconsistencies and deficiencies in the client documentation practices.
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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 a review of client records, the facility failed to document complete progress notes in thirteen of thirteen records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13. Progress notes did not include the plan portion of the note.
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Plan of Correction
1. The Project Director will develop a training curriculum to instruct clinical staff on "Effective Clinical Documentation" to insure that group progress notes are presented in the DAP format by 6/1/2008.
2. The MinSec Training Institute will conduct a Clinical Inservice Training before 7/18,2008 in order to address inconsistencies and deficiencies in the client documentation practices.
3. The Program Director will monitor and uphold the new documentation system by collecting and acknowledging the accuracy and timeliness of submitted documents on a weekly basis and will insure that monthly file reviews are conducted through the QA system.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations in twelve of thirteen records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, and 13. Case consultations were missing in six records, #2, 3, 4, 5, 7 and 13. Case consultations were not documented within the time frame identified by the facility in two records, #11 and 12. Case consultations did not include the disposition in two records, #6 and 8. The case consultation in record #1 did not include documentation of the summary of the discussion or disposition.
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Plan of Correction
1. The Project Director will develop a training curriculum to instruct clinical staff on "Effective Clinical Documentation" to insure that case consultations are accurate in their content and timely by 6/1/2008.
2. The Project Director will update the current policy to ensure that MinSec's policy for completing case consultations are realistic and corresponding with the standard by 5/30/2008.
3. The MinSec Training Institute will conduct a Clinical Inservice Training before 7/18,2008 in order to address inconsistencies and deficiencies in the client documentation practices.
4. The Program Director will monitor and uphold the new documentation system by collecting and acknowledging the accuracy and timeliness of submitted documents on a weekly basis and will insure that monthly file reviews are conducted through the QA system.
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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 on a review of client records, the facility failed to document aftercare plans in three of five records reviewed, #10, 11 and 13.
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Plan of Correction
1. The Project Director will develop a new weekly schedule of documentation submission to ensure timeliness and the completion of all clinical documentation by 6/1/2008.
2. The Program Director will monitor and uphold the new documentation system by collecting and acknowledging the timeliness of submitted documents on a weekly basis and will insure that monthly file reviews are conducted through the QA system.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in three of five records reviewed, #9, 12 and 13.
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Plan of Correction
1. The Project Director will develop a new weekly schedule of documentation submission to ensure timeliness and the completion of all clinical documentation by 6/1/2008.
2. The Program Director will monitor and uphold the new documentation system by collecting and acknowledging the timeliness of submitted documents on a weekly basis and will insure that monthly file reviews are conducted through the QA system.
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709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a review of the facility's census report, the facility failed to maintain the authorized maximum capacity of 150. The census report completed by the Project Director indicated a census of 161 clients.
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Plan of Correction
1. The Project Director shall be responsible for adherence to the standard by notifying the DOH, of any changes in the Program within the appropriate timeframe.
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