INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 3, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Polaris Renewal Services, 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:
|
Plan of Correction
|
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation in two of six client records.
The findings include:
Eight client records were reviewed on February 3, 2014. Six client records were reviewed for the completion of a psychosocial evaluation. The facility did not document a psychosocial evaluation in client records # 5 and 6.
Client # 5 was admitted on October 30, 2013. There was no documentation of a psychosocial evaluation in the record as of February 3, 2014.
Client # 6 was admitted on November 12, 2013. There was no documentation of a psychosocial evaluation in the record as of February 3, 2014.
The Project/Facility Director was interviewed on February 3, 2014 and confirmed the findings.
|
Plan of Correction
The facility failed to document a psychosocial evaluation in two of the six client records reviewed. The counseling staff is responsible to complete the psychosocial evaluation for all patients. Thereafter, the medical director and facility director review and sign-off on the psychosocial evaluation. The counseling staff are responsible for scheduling all appointments with their patients and the receptionist is responsible for requiring patients to meet with their counselors prior to making their way to the dosing window. The facility director will be responsible to monitor compliance on an ongoing basis. |
709.92(a) 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:
|
Observations
Based on the review of client records, the facility failed to document an individual treatment and rehabilitation plan that was developed with the client in two of five client records.
The finding include:
Eight client records were reviewed on February 3, 2014. Five client records were required to have an individual treatment and rehabilitation plan. The facility failed to document an individual treatment and rehabilitation plan in client records # 5 and 6.
Client # 5 was admitted on October 30, 2013. The record did not include documentation of an individual treatment and rehabilitation plan that was developed with the client as of February 3, 2014.
Client # 6 was admitted on November 12, 2013. The record did not include documentation of an individual treatment and rehabilitation plan that was developed with the client as of February 3, 2014.
The Project/Facility Director was interviewed on February 3, 2014 and confirmed the findings.
|
Plan of Correction
The facility failed to document an individual treatment and rehabilitation plan that was developed with the client in two of the five client records reviewed. The counseling staff is responsible to complete the individual treatment and rehabilitation plan with the clients. Thereafter, the medical director and facility director review and sign-off on the individual treatment and rehabilitation plan that the counselor and client have developed. The counseling staff are responsible for scheduling all appointments with their clients and the receptionist is responsible for requiring clients to meet with their counselors prior to making their way to the dosing window. The facility director will be responsible to monitor compliance on an ongoing basis. |
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.
|
Observations
Based on the review of client records, the facility failed to document an individual treatment and rehabilitation plan that was developed with the client that included short and long term goals in two of five client records.
The finding include:
Eight client records were reviewed on February 3, 2014. Five client records were required to have an individual treatment and rehabilitation plan that included short and long term goals. The facility failed to document an individual treatment and rehabilitation plan that included short and long term goals in client records # 5 and 6.
Client # 5 was admitted on October 30, 2013. As of February 3, 2014, the record did not include documentation of an individual treatment and rehabilitation plan that included short and long term goals.
Client # 6 was admitted on November 12, 2013. As of February 3, 2014, the record did not include documentation of an individual treatment and rehabilitation plan that included short and long term goals.
The Project/Facility Director was interviewed on February 3, 2014 and confirmed the findings.
|
Plan of Correction
CORRECTIVE ACTION:
1.The Master/Update Treatment Plan paperwork that is already in chart (and has been to date completed as the Master Treatment Plan/Update within the "goal" of the first 30 days and for every update period thereafter) is now being completed, as of 02/18/2014, "as mandated per Clinical Supervision" within the first 30-days following admission into the program. This change has enabled therapist and patient to greater define short term and long term patient goals, target dates and step level following the initial 30-Day admission period.
SYSTEMIC/PREVENTATIVE CHANGES:
1.Director reviewed Master/Update Treatment Plan paperwork with Therapists and discussed the requirement to complete the paperwork within the first 30 days of treatment. Paperwork will be completed following the initial completion of the Preliminary Treatment Plan, and along with the 30-Day Update Paperwork.
MONITORING/QUALITY ASSURANCE:
1.The Director and therapists will continue to complete quarterly case consults, weekly clinical supervision meetings and chart audits to ensure patient attendance to individual and group sessions, ensuring that all paperwork is completed in a timely manner, and that patient goals are developed with patient insight in the Master/Update Treatment Plan(s).
DATE OF COMPLETION: Ongoing
|
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.
|
Observations
Based on the review of client records, the facility failed to document an individual treatment and rehabilitation plan that was developed with the client that included the type and frequency of treatment and rehabilitation services in two of five client records.
The finding include:
Eight client records were reviewed on February 3, 2014. Five client records were required to have an individual treatment and rehabilitation plan that included the type and frequency of treatment and rehabilitation services . The facility did not document an individual treatment and rehabilitation plan that included the type and frequency of treatment and rehabilitation services in client records # 5 and 6.
Client # 5 was admitted on October 30, 2013. As of February 3, 2014, the record did not contain documentation of an individual treatment and rehabilitation plan that included the type and frequency of treatment and rehabilitation services.
Client # 6 was admitted on November 12, 2013. As of February 3, 2014, the record did not contain documentation of an individual treatment and rehabilitation plan that included the type and frequency of treatment and rehabilitation services.
The Project/Facility Director was interviewed on February 3, 2014 and confirmed the findings.
|
Plan of Correction
The facility failed to document an individual treatment and rehabilitation plan that was developed with the client that included the type and frequency of treatment and rehabilitation services in two of the five client records reviewed. The counseling staff is responsible to complete the individual treatment and rehabilitation plan with the clients that document that type and frequency of treatment and rehabilitation services. Thereafter, the medical director and facility director review and sign-off on the individual treatment and rehabilitation plan that the counselor and client have developed. The counseling staff are responsible for scheduling all appointments with their clients and the receptionist is responsible for requiring clients to meet with their counselors prior to making their way to the dosing window. The facility director conducted an in service review with staff focusing on the areas related to documentation of the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan on 02/05/2014. Ongoing compliance will be the responsibility of the facility director and will be monitored through daily individual record review and weekly clinical supervision. Ongoing in service reviews will occur as needed to ensure ongoing compliance. |
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.
|
Observations
Based on the review of client records, the facility failed to document an individual treatment and rehabilitation plan that was developed with the client that included the proposed type of support services in two of five client records.
The finding include:
Eight client records were reviewed on February 3, 2014. Five client records were required to have an individual treatment and rehabilitation plan that included the proposed type of support services. The facility did not document an individual treatment and rehabilitation plan that included the proposed type of support services in client records # 5 and 6.
Client # 5 was admitted on October 30, 2013. As of February 3, 2014, the record did not contain documentation of an individual treatment and rehabilitation plan that included the proposed type of support services.
Client # 6 was admitted on November 12, 2013. As of February 3, 2014, the record did not contain documentation of an individual treatment and rehabilitation plan that included the proposed type of support services.
The Project/Facility Director was interviewed on February 3, 2014 and confirmed the findings.
|
Plan of Correction
The facility failed to ensure that the proposed type of support services were identified on individualized treatment plans in two of the five client records reviewed. The facility director conducted in service training focusing on the areas of support services on 02/18/2014. Ongoing compliance will be the responsibility of the facility director and will be monitored through daily individual record review and weekly clinical supervision. Ongoing in service trainings will occur as needed to ensure ongoing compliance. |
709.93(a) 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:
|
Observations
Based on the review of client records, the facility failed to document a complete client record that included case consultation notes in three of three client records.
The findings include:
Eight client records were reviewed on February 3, 2014. Three client records required documentation of case consultation notes. The facility failed to document case consultation notes in client records # 1, 2 and 3.
Client # 1 was admitted on June 7, 2013 and a case consultation note was due to be completed by December 31, 2013. The facility failed to document a case consultation note as of February 3, 2014.
Client # 2 was admitted on June 29, 2013 and a case consultation note was due to be completed by December 31, 2013. The facility failed to document a case consultation note as of February 3, 2014.
Client # 3 was admitted on August 1, 2013 and a case consultation note was due to be completed by December 31, 2013. The facility failed to document a case consultation note as of February 3, 2014.
The Project/Facility Director was interviewed on February 3, 2014 and confirmed the findings.
|
Plan of Correction
The facility failed to document case consultation notes in three of three client records. The facility director conducted in service training focusing on the ensuring complete client records that include case consultation on 02/21/14. Ongoing compliance will be the responsibility of the facility director and will be monitored through daily individual record review and weekly clinical supervision. Ongoing in service trainings will occur as needed to ensure ongoing compliance. |