INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 16 - 18, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Behavioral Health-HA, 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:
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Plan of Correction
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709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based on a review of personnel records, the facility failed to document written job descriptions which included the supervisor's dated signature in two of two personnel records.
The findings include:
Twelve personnel records were reviewed on November 16, 2011. Two personnel records pertained to new employees and were reviewed for documentation of a job description. The facility failed to document a job description which included the supervisor's dated signature in personnel records # 5 and 6.
Employee # 5 is a counselor and was hired on May 12, 2011. There was no documentation of a job description which included the supervisor's dated signature in personnel record # 5.
Employee # 6 is a counselor and was hired on July 11, 2011. There was no documentation of a job description which included the supervisor's dated signature in personnel record # 6.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Job descriptions have been revised to include the supervisor signature. All associates will sign new revised job descriptions by Jan 31, 2012. Director and Clinical Supervisor will be responsibe to get this completed. |
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 on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in nine of eighteen client records.
The findings include:
Twenty-five client records were reviewed on November 16 - 18, 2011. Eighteen client records were reviewed for documentation of informed and voluntary consents from the client. Seven client records contained consents from a timeframe outside of the current licensing inspection. The facility accessed the Internet site of a funding entity to confirm the client's current insurance coverage. Prior to releasing client information to this funding entity, the facility failed to document an informed and voluntary consent from the client in client records # 1, 4, 7, 8, 10, 14, 15, 17 and 25.
The facility director and clinical supervisors were interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
All local medical assistance releases will be updated to include Department of Welfare, Local county medical assistance caseworker and the Promise Website for internet access when checking for eligibility of insurance via website. Training of staff was held on 11/16/011 during staff meeeting. Staff had been instructed to have releases signed by patient. The Clinical Superviors will be responsible for overseeing the completion of releases. |
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 and rehabilitation services, in the individual treatment and rehabilitation plans, in five of seventeen client records.
The findings include:
Twenty-five client records were reviewed on November 16 - 18, 2011. Seventeen client records included an individual treatment and rehabilitation plan and were reviewed for the type and frequency of services. Eight client records contained treatment plans from a timeframe outside of the current licensing inspection. The facility failed to document the type and frequency of treatment and rehabilitation services in client records # 10, 14, 15, 22 and 24.
Client # 10 was admitted into treatment on April 18, 2011. An individual treatment and rehabilitation plan was developed with the client on May 18, 2011. The treatment plan did not specify the type or frequency of treatment and rehabilitation services.
Client # 14 was admitted into treatment on July 21, 2011. An individual treatment and rehabilitation plan was developed with the client on August 11, 2011. The treatment plan did not specify the type or frequency of treatment and rehabilitation services.
Client # 15 was admitted into treatment on March 22, 2011. An individual treatment and rehabilitation plan was developed with the client on April 22, 2011. The treatment plan identified that the client would receive individual and group counseling. The treatment plan did not specify the frequency of these treatment and rehabilitation services.
Client # 22 was admitted into treatment on May 12, 2011 and discharged on September 14, 2011. An individual treatment and rehabilitation plan was developed with the client on June 10, 2011. The treatment plan did not specify the type or frequency of treatment and rehabilitation services.
Client # 24 was admitted into treatment on July 29, 2011. An individual treatment and rehabilitation plan was developed with the client on August 26, 2011. The treatment plan did not specify the type or frequency of treatment and rehabilitation services.
Both clinical supervisors were interviewed throughout the licensing process and confirmed the findings.
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Plan of Correction
Training was conducted during staff meeting on 12/01/2011, treatment plans will specify, however, not limited to, type of frequency of tx and rehabilitation services, 30 days after admission tx plans will include the required time for group and/or individual counseling per month the type frequency will be includd on the tx plan. Clinical supervisors will be responsible for ensuring the type and frequency of services is included on the treatment plans and will conduct chart audits on a monthly basis. |
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 provide written documentation of the proposed type of support service, in the individual treatment and rehabilitation plan, in seven of seventeen client records.
The findings include:
Twenty-five client records were reviewed on November 16 - 18, 2011. The individual treatment and rehabilitation plans were required to include the proposed type of support services in seventeen client records. Eight client records contained treatment plans from a timeframe outside of the current licensing inspection. The facility failed to document the proposed type of support service in client records # 3, 8, 10, 11, 14, 15 and 22.
Client # 3 was admitted into treatment on August 3, 2011 and discharged on September 23, 2011. The individual treatment and rehabilitation plan was completed on September 2, 2011. Support services were not documented in the individual treatment and rehabilitation plan.
Client # 8 was admitted into treatment on July 25, 2011. The individual treatment and rehabilitation plan was completed on August 24, 2011. Support services were not documented in the individual treatment and rehabilitation plan.
Client # 10 was admitted into treatment on April 18, 2011. The individual treatment and rehabilitation plan was completed on May 18, 2011. Support services were not documented in the individual treatment and rehabilitation plan.
Client #11 was admitted into treatment on April 13, 2011. The individual treatment and rehabilitation plan was completed on May 13, 2011. Support services were not documented in the individual treatment and rehabilitation plan.
Client # 14 was admitted into treatment on July 21, 2011. The individual treatment and rehabilitation plan was completed on August 11, 2011. Support services were not documented in the individual treatment and rehabilitation plan.
Client # 15 was admitted into treatment on March 22, 2011. The individual treatment and rehabilitation plan was completed on April 22, 2011. Support services were not documented in the individual treatment and rehabilitation plan.
Client # 22 was admitted into treatment on May 12, 2011 and discharged on September 14, 2011. The individual treatment and rehabilitation plan was completed on June 10, 2011. Support services were not documented in the individual treatment and rehabilitation plan.
Both clinical supervisors were interviewed throughout the licensing process and confirmed the findings.
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Plan of Correction
Training was conducted during staff meeting on 12/01/2011, treatment plans will specify, however, not limited to, type and frequency of tx and rebilitation services, 30 days after admission tx plans will include the required outside support services. the Clinical Supervisor will be responsible and ensure compliance by conducting chart audits monthly to ensure support services are included on the treatment plans. |