INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on October 31 - November 2, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Center for Behavioral Health - PA 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the clinical supervisor failed to complete a core curriculum in clinical supervision.
The findings include:
Employee # 3 was promoted to clinical supervisor on November 1, 2011. Employee #3 has not functioned for 2 years as a supervisor in the provision of clinical services; therefore, a core curriculum training in clinical supervision is required. The core curriculum training in clinical supervision had not been completed by the clinical supervisor as of November 2, 2012.
An interview with the facility director took place on November 1, 2012 at which time it was confirmed that Employee #3 had not completed the core curriculum in clinical supervision.
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Plan of Correction
In order to comply with this regulation, Clinical Supervisor has been scheduled and registered to attend the required Core Curriculum in clinical supervision training 12/03/12 through 12/07/12.
Program Director will ensure clinical supervisor attends training as scheduled. |
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 an aftercare plan in three of three client records.
The findings include:
Eight discharged client records were reviewed on October 31-November 2, 2012. Three of the discharged clients reviewed was successfully discharged and required an aftercare plan. Client records # 9, 10 and 11 did not include documentation of an aftercare plan.
Client #9 was admitted to treatment on September 15, 2011 and successfully discharged on May 31, 2012. There was no documentation of an aftercare plan in client record #9.
Client #10 was admitted to treatment on October 31, 2002 and successfully discharged on March 9, 2012. There was no documentation of an aftercare plan in client record #10.
Client #11 was admitted to treatment on January 25, 2006 and successfully discharged on August 24, 2012. There was no documentation of an aftercare plan in client record #11.
An interview with the facility director took place on November 2, 2012 at which time it was confirmed that there was no documentation of an aftercare plan in client records # 9, 10 and 11.
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Plan of Correction
In order to comply with this regulation, each patient will be offered a formal plan to follow after he/she leaves treatment. This plan will include future goals with time frames, description of services that can be provided by project after discharge, criteria for re-entry, method and frequency of continuing contact, provision for periodic re-evaluation and signed by the patient.
Clinical Supervisor will monitor for patients leaving treatment successfully and schedule an aftercare plan that aligns with patient's plan for continued care after discharge.
Program Director will monitor to ensure compliance with regulation. |
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 as per agency policy, in two of three client records.
The findings include:
Eight discharged outpatient client records were reviewed on October 31 - November 2, 2012. Three of the discharged clients reviewed were administrative discharges. Per agency policy, follow up contact will be completed within 72 hours for administrative/behavioral clients, 7 days for transferred / referred clients and 14 days and 30 days for all other clients. Follow up was not documented for the administrative discharged clients as per agency policy, in client records # 13 and 14.
Client #13 was admitted to outpatient treatment on August 16, 2006 and terminated from treatment on August 17, 2012. A follow up contact was due to be completed by August 20, 2012. The follow up contact was not completed until August 24, 2012.
Client #14 was admitted to outpatient treatment on August 23, 2010 and terminated from treatment on July 23, 2012. A follow up contact was due to be completed by July 26, 2012. The follow up contact was not completed until August 6, 2012.
An interview with the facility director took place on November 2, 2012, at which time the aforementioned information was confirmed.
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Plan of Correction
In order to comply with agency policy, whenever Medical Director reviews and orders an administrative discharge, Clinical Supervisor will create a computerized prompt to remind the primary clinician to complete the follow up within 72 hours.
Program Director will monitor to ensure policy is followed.
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