INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 27 - 29, 2012 and March 1, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Penn Foundation for Mental Health, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on the review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of nine records reviewed.
Findings:
Sixteen personnel records were reviewed on February 27 - 29, 2012, nine were reviewed to determine counselor qualifications. In personnel record #14, the counselor did not meet the qualifications for the position of counselor because there was no evidence of a minimum of one year clinical experience. A review of the counselor's resume and interviews with staff confirmed the findings.
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Plan of Correction
It was brought to our attention during the site visit that one counselor's experience did not qualify as clinical experience and therefore could not be a counselor. Counselor has already been made a counselor assistant; personnel file has been changed to reflect this change. Inpatient Director has instituted close supervision of this counselor assistant to meet counselor assistant requirements, as spelled out in the regulations. Inpatient Director in coordination with H.R. Director will screen each resume to assure that candidates for employment meet the minimum requirements for the position of counselor before hiring as a counselor. If the successful candidate does not have the education or experience requirements for a counselor, they will be hired as a counselor assistant. Inpatient Director will oversee the implementation of this POC. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records, the facility failed to document a mechanism to collect feedback on completed training in six of nine records.
The findings include:
Sixteen personnel records were reviewed on February 27-28, 2012. Feedback forms were required in nine of sixteen records reviewed, #3, 4, 5, 6, 7, 8, 9, 11 and 15. The training year reviewed was July 1, 2010 through June 30, 2011. Per the facility policy feedback forms are to be completed after every training. The facility failed to document the submission of feedback forms in employee records # 3, 4, 5, 7, 8 and 9. An interview with facility staff on March 1, 2012 confirmed the findings.
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Plan of Correction
During the site visit, it was brought to our attention that training feedback forms are not consistently being completed for trainings that staff are attending. Department supervisors will notify all of their staff of the expectation that training feedback forms are completed following every training. Special Projects Coordinator will work closely with Support Staff Supervisor to track the completion of these forms and no training certificate will be accepted without a training feedback form attached. Special Projects Coordinator will oversee this POC. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of employee training records, that the facility failed to assure that each employee received a written individual training plan.
The findings include:
Sixteen personnel training records were reviewed on February 27-28, 2012. A review of sixteen of sixteen personnel training records, specifically #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16, revealed that the individual training plans were inclusive of generalized topics with no individualized training agendas for specific needs.
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Plan of Correction
It was made clear to us during our site visit, that our individual training plans are too general to meet the standard. The Management Team, which includes all supervisors who are responsible for writing the individual training plans, will discuss individual training plans at our weekly management meeting and discuss what information is expected to be included in the training plan. It will be the expectation that all employee's training plans are individualized for their specific job and level of experience. Executive Director of the Recovery Center will oversee this POC. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, staffing requirements facility summary report, the facility failed to ensure that all staff obtained a minimum of 6 hours of training in HIV/AIDS and at least 4 hours related topics within one year of the date of hire for counselors and counselor assistant and within two years of the date of hire date for all other staff.
The findings include:
Sixteen personnel records were reviewed on February 27-28, 2012. There was no documentation of HIV/AIDS or TB/STD training in one employee record, employee # 16. Employee #16 was required to have HIV/AIDS and TB/STD training within the two years of employment.
Employee #16 was hired September 1, 2001 and was required to have HIV/AIDS & TB/STD training by September 1, 2003. There was no documentation of HIV/AIDS training in the employee's record as of February 28, 2012.
An interview with facility staff on March 1, 2012 confirmed the findings.
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Plan of Correction
During the site visit, it was discovered that our medical doctor was missing the HIV/AIDS training. Our Medical Doctor will complete this training by July 1, 2012. Support Staff Supervisor will track mandatory trainings for all employees, including physicians, to ensure the timely completion of required trainings. Executive Director of the Recovery Center will oversee this POC. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the staffing requirements and the facility summary report form completed by the facility on February 27, 2012 and an interview with the project facility director on February 27, 2012, the facility failed to ensure that staff to client ratios remained at or under 35:1.
The findings included:
Based on the number of hours the employee worked at this facility and the number of clients on each counselors' caseload, all employees who provided counseling exceeded the maximum ratio of 35:1. The counselor represented as employee # 4 had a caseload of 85:1. The counselor represented as employee # 6 had a caseload of 68:1. The counselor represented as employee # 7 had a caseload of 75:1. The counselor represented as employee # 8 had a caseload of 71:1. The counselor represented as employee # 9 had a caseload of 69:1. The counselor represented as employee # 17 had a caseload of 43:1. The counselor represented as employee # 18 had a caseload of 71:1. The counselor represented as employee # 19 had a caseload of 63:1.
On February 27, 2012, the Staffing Requirements Facility Summary Report form completed by the facility was reviewed. The form listed each counselor's caseload. The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 40 hours per week.
Based on the total number of hours per week that the facility reported the employees devoted to their clients, the total number of hours in the facility's standard work week (40), and the total number of clients assigned, to the following employees on February 27, 2012, 76 documented to employee #4, 39 to employee #6, 75 documented to employee #7, 58 to employee #8, 65 documented to employee #9, 38 documented to employee #17, 71 to employee #18 and 58 documented to employee #19 exceeded the allowable maximum 35:1 caseload.
The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients' treatment by the facility's standard workweek.
The number of hours per week devoted by Employee # 4 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 36 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 4 had 76 active clients on February 27, 2012.
Employee # 4 (36/40 = 0.9 FTE 76 clients/0.9 FTE = 85:1 caseload)
The number of hours per week devoted by Employee # 6 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 23 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 6 had 39 active clients on February 27, 2012.
Employee # 6 (23/40 = 0.575 FTE 39 clients/0.575 FTE = 68:1 caseload)
The number of hours per week devoted by Employee # 7 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 40 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 7 had 75 active clients on February 27, 2012.
Employee # 7 (40/40 = 1 FTE 75 clients/1 FTE = 75:1 caseload)
The number of hours per week devoted by Employee # 8 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 33 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 8 had 58 active clients on February 27, 2012.
Employee # 8 (33/40 = 0.825 FTE 58 clients/0.825 FTE = 71:1 caseload)
The number of hours per week devoted by Employee # 9 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 38 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 9 had 65 active clients on February 27, 2012.
Employee # 9 (38/40 = 0.95 FTE 65 clients/0.95 FTE = 69:1 caseload)
The number of hours per week devoted by Employee # 17 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 36 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 17 had 38 active clients on February 27, 2012.
Employee # 17 (36/40 = 0.9 FTE 38 clients/0.9 FTE = 43:1 caseload)
The number of hours per week devoted by Employee # 18 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 40 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 18 had 71 active clients on February 27, 2012.
Employee # 18 (40/40 = 1 FTE 71 clients/1 FTE = 71:1 caseload)
The number of hours per week devoted by Employee # 19 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 37 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 19 had 58 active clients on February 27, 2012.
Employee # 19 (37/40 = 0.925 FTE 58 clients/0.925 FTE = 63:1 caseload)
During an interview, facility director confirmed that they had exceeded the allowable maximum caseload of 35:1 for employee's #4, 6, 7, 8, 9, 17, 18 and 19.
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Plan of Correction
The Recovery Center has recently switched over to a new EMR. The new EMR does not have a system in place currently for us to separate out clients who are actively engaged in treatment and those clients who came in only for an assessment or who are in the process of being closed. Upon closer inspection of the initial numbers, we discovered 200 clients who were in the process of being closed or who had not received any services at our facility for many months, some even for years. The Recovery Center has since closed the above clients. Counselors will be given active caseload reports bi-weekly and will be expected to discharge clients in a timely manner and keep caseloads at or below the required 1:35 ratio. Outpatient Coordinator will review caseloads bi-weekly as well to ensure compliance. Penn Foundation Recovery Center will also be applying for an increased license capacity and will hire additional staff as required to maintain regulatory ratios. Executive Director will oversee this POC. |
709.22(e) 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:
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Observations
Based on a review of administrative documentation it was determined that the project failed to make the annual report available to the public by the end of the facility's fiscal year June 30, 2011.
The findings were:
The policy and procedure book was reviewed on February 27 - 28, 2012. The July 1, 2010 - June 30, 2011 annual report was not made available to the public until February 1, 2012. The project's policy stated that the annual report would be made available to the public by the end of the facility's fiscal year June 30, 2011. An interview with facility staff on February 28, 2012 confirmed the findings.
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Plan of Correction
It was brought to our attention during the site visit that the annual report was not made available to the public in a timely fashion. This report is generated by another department at Penn Foundation and that department was not aware of the need to have the report completed by a certain time. The department that generates the annual report will be made aware of the time frame for completion to ensure timely completion in the future. Executive Director will oversee this POC. |
709.24(a)(2) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(2) Treatment models utilized by the project.
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Observations
Based on the review of the facility's policy and procedure manual, the facility failed to document treatment models and definitions in the agency manual.
The findings included :
The policy and procedure manual was reviewed February 27 - 28, 2012. It was noted during the inspection that the treatment models utilized were not documented or defined in the agency manual. Administrative staff were asked to provide the required documentation during the survey. At the time of the exit, March 1, 2012, the required documentation was not provided. The manual must include a listing of the treatment models and their application as defined and implemented at the agency . These were not documented.
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Plan of Correction
It was brought to our attention during the site visit that our policy and procedure manual did not properly document treatment models used at the Recovery Center. Our current document lacked the specifics needed to satisfy this regulation. We will develop a list of treatment models and their descriptions used by Recovery Center staff and add to the policy and procedure manual. Special Projects Coordinator will oversee this POC. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records, the facility failed to document annual staff work performance evaluations in fifteen of sixteen personnel records.
The findings include:
Sixteen personnel records were reviewed on February 27 - 28, 2012. Annual staff work performance evaluations were required in sixteen personnel records. Per the facility's policy, annual staff work performance evaluations are to be documented by the employee's anniversary date. The facility did not document annual staff work performance evaluations on the employee's anniversary date in personnel records # 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16.
Employee # 1 was hired on September 13, 2010. The annual work performance evaluation was due by September 13, 2011. Employee # 1's annual work performance evaluation was not documented and signed until February 27, 2012.
Employee # 3 was hired on September 1, 2010. The annual work performance evaluation was due by September 1, 2011. Employee # 3's annual work performance evaluation was not documented and signed until January 10, 2012.
Employee # 4 was hired on June 1, 2011. The probation work performance evaluation was due by September 1, 2011. Employee # 4's probation work performance evaluation was not documented and signed until January 5, 2012.
Employee # 5 was hired on August 31, 2009. The annual work performance evaluation was due by August 31, 2011. The facility failed to document an annual work performance evaluation.
Employee # 6 was hired on October 23, 2006. The annual work performance evaluation was due by October 23, 2011. The facility failed to document an annual work performance evaluation.
Employee # 7 was hired on October 18, 2010. The annual work performance evaluation was due by October 18, 2011. The facility failed to document an annual work performance evaluation.
Employee # 8 was hired on March 18, 2010. The annual work performance evaluation was due by March 18, 2011. Employee # 8's annual work performance evaluation was not documented and signed until May 26, 2011.
Employee # 9 was hired on November 15, 2010. The annual work performance evaluation was due by November 15, 2011. The facility failed to document an annual work performance evaluation.
Employee # 10 was hired on July 1, 2010. The annual work performance evaluation was due by July 1, 2011. The facility failed to document an annual work performance evaluation.
Employee # 11 was hired on February 15, 2007. The annual work performance evaluation was due by February 15, 2011. Employee # 11's annual work performance evaluation was not documented and signed until February 23, 2012.
Employee # 12 was hired on May 24, 2010. The annual work performance evaluation was due by May 24, 2011. Employee # 12's annual work performance evaluation was not documented and signed until February 23, 2012.
Employee # 13 was hired on November 14, 2011. The probation work performance evaluation was due by February 14, 2012. Employee # 13's probation work performance evaluation was not documented and signed until February 27, 2012.
Employee # 14 was hired on June 15, 2011. The probation work performance evaluation was due by September 15, 2011. Employee # 14's probation work performance evaluation was not documented and signed until January 20, 2012.
Employee # 15 was hired on December 7, 2009. The annual work performance evaluation was due by December 7, 2011. Employee # 15's annual work performance evaluation was not documented and signed until January 31, 2012.
Employee # 16 was hired on September 1, 2001. The annual work performance evaluation was due by September 1, 2011. The facility failed to document an annual work performance evaluation.
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Plan of Correction
It was brought to our attention during the site visit that performance evaluations are not being completed in a timely fashion. We acknowledge the importance of timely completion of performance evaluations and will work to ensure this occurs. We will develop a comprehensive spreadsheet with due dates of all performance evaluations and clinical supervisors will be held accountable for the timely completion of the evaluations. Executive Director of the Recovery Center will oversee this POC. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document the client's psychosocial evaluations in four of four short-term detoxification records reviewed.
The findings include:
Twenty-one client records were reviewed on February 29, 2012 through March 1, 2012. Four short-term detoxification client records for psychosocial evaluations were reviewed, #1, 2, 3 and 4. Per the facility policy, psychosocial evaluations will be completed by the 3rd day of admission. Psychosocial evaluations were not documented in client records, #1 and 2. Additionally, client records # 3 and 4 contained psychosocial evaluations that did not include all required components.
Client #1 was admitted on February 23, 2012 and the psychosocial evaluation was to be completed by February 25, 2012. There was no documentation of client #1's psychosocial evaluations in record reviewed.
Client #2 was admitted on February 20, 2012 and the psychosocial evaluation was to be completed by February 22, 2012. There was no documentation of client #2's psychosocial evaluations in record reviewed.
The facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and the counselor conclusions and/or impressions of the client in client records, # 3 and 4.
A discussion with facility staff on March 1, 2012 confirmed the findings.
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Plan of Correction
It is the expectation that psychosocial evaluations be completed within three days of admission and are completed with all required information. We are in the process of updating our psychosocial evaluation. Areas for written explanation of all required information will be added to the evaluation. Weekly quality control chart audits will be conducted to ensure that evaluations are being completed on time and thoroughly. Inpatient Director will oversee this POC. |
709.63(a)(6) LICENSURE Aftercare plan
709.63. 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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in one of two short-term detoxification client records.
The findings include:
Twenty-one client records were reviewed on February 29, 2012 through March 1, 2012. Per the facility policy, the counselor and client will complete an aftercare plan prior to discharge for successful completions of treatment. An aftercare plan was required in two short-term detoxification discharge client records, #3 and 4. The facility did not document an aftercare plan in client record #3.
Client #3 was admitted on October 3, 2011 and was discharged on October 26, 2011. There was no documentation of an aftercare plan.
An interview with facility staff on March 1, 2012 confirmed the findings.
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Plan of Correction
It was discovered that aftercare plans are not consistently being completed on detox clients. It is the expectation that aftercare plans are completed by clients and discussed with the primary counselor prior to discharge. Clinicians will be expected to begin the collaborative process of the aftercare plan within 72 hours of a tentative discharge date. Penn Foundation Recovery Center will begin quality control chart audits prior to the closing of every file. Charts will not be closed until they have been reviewed for missing documentation and ensured that all required documentation is in chart. Inpatient Director will oversee this POC. |
709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary in one of two short-term detoxification client records.
The findings include:
Twenty-one client records were reviewed on February 29, 2012 through March 1, 2012. Per the facility policy, the counselor will complete the discharge summary 7 days after the clients discharge date. A discharge summary was required in two short-term detoxification discharge client records, #3 and 4. The facility did not document a discharge summary in client record #4.
Client #4 was admitted on November 3, 2011 and was discharged on November 21, 2011. There was no documentation of a discharge summary.
An interview with facility staff on March 1, 2012 confirmed the findings.
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Plan of Correction
It was discovered that discharge summaries are not being consistently completed on discharged detox clients. It is the expectation that a discharge summary is completed on all clients within seven (7) days of discharge. Penn Foundation Recovery Center will begin quality control chart audits prior to the closing of every file. Charts will not be closed until they have been reviewed for missing documentation and ensured that all required documentation is in chart. Inpatient Director will oversee this POC. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in one of two short-term detoxification client records.
The findings include:
Twenty-one client records were reviewed on February 29, 2012 through March 1, 2012. Per the facility policy, the counselor will complete the follow-up documentation with 7 days for referrals and 1 month for all others. Follow-up documentation was required in two short-term detoxification discharge client records, #3 and 4. The facility did not document a follow-up in client record #3.
Client #3 was admitted on October 3, 2011 and was discharged on October 26, 2011. The follow-up was to be done by November 26, 2011. There was no documentation of a follow-up in client record #3 as of March 1, 2012.
An interview with facility staff on March 1, 2012 confirmed the findings.
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Plan of Correction
It is the expectation that a follow-up call be made on every client who is discharged from treatment. Beginning in January, we have begun to track disposition of all clients via follow up calls, on spreadsheet for quality assurance purposes and we report this information quarterly to our SCA. With the implementation of this information as a QA measure, we have started a new system that ensures that follow up calls are made within 7 days. Our aftercare coordinator now makes all follow up calls. We believe this new system, which was not in place during the time period of closed charts that were pulled during the site visit, has resolved this issue. Chart check will be utilized to ensure proper documentation of follow-up calls. Special Projects Coordinator will oversee this POC. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document the client's psychosocial evaluations in five of six residential treatment and rehabilitation records reviewed.
The findings include:
Twenty-one client records were reviewed on February 29, 2012 through March 1, 2012. Six client records were reviewed from the residential treatment and rehabilitation records for psychosocial evaluations, #5, 6, 7, 8, 9 and 10. Per the facility policy, psychosocial evaluations will be completed by the 3rd day of admission. A psychosocial evaluation was not documented in client record, #7.
Client #7 was admitted on February 20, 2012 and the psychosocial evaluation was to be completed by February 22, 2012. There was no documentation of client #7's psychosocial evaluation in the client's record.
The facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and the counselor conclusions and/or impressions of the client in four of six residential treatment and rehabilitation client records, #5, 6, 8 and 9.
The psychosocial evaluations in client records #5, 6, 8 and 9 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records #5, 8 and 9 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluations in client records #5, 6, 8 and 9 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records # 8 and 9 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluations in client record # 8 did not include an evaluation of the client's attitude towards treatment and how it would impact treatment.
The psychosocial evaluations in client records # 8 and 9 did not include an evaluation of the counselor conclusions/impression and how they would impact treatment.
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Plan of Correction
During our site visit, it was discovered that our current psychosocial evaluation, was not adequate to meet the entire intent of the regulation. We are in the process of updating our psychosocial evaluation. Areas for written explanation of all required information will be added to the evaluation. Weekly quality control chart audits will be conducted to ensure that evaluations are being completed on time and thoroughly. Inpatient Director will oversee this POC. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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:
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Observations
Based on the review of client records, the facility failed to document an individual treatment and rehabilitation plan in three of six residential treatment and rehabilitation client records.
The findings include:
Twenty-one client records were reviewed on February 29, 2012 through March 1, 2012. Individual treatment and rehabilitation plans were required in five client records, # 5, 6, 7, 8 and 9. The individual treatment and rehabilitation plan is due within three days of the client's admission as stated in the project's policy. An interview with facility staff on March 1, 2012 confirmed the findings.
Client #6 was admitted on January 26, 2012 and the individualized treatment plan was to be completed by January 28, 2012. The individualized treatment plan is to be developed after the completion of the client's biopsychosocial histories and biopsychosocial evaluation. The biopsychosocial history was completed on January 26, 2012 and the biopsychosocial evaluation was completed on February 2, 2012. Client #6's individualized treatment plan was completed on January 26, 2012, 7 days before the completion of the biopsychosocial evaluation.
Client #7 was admitted on February 20, 2012 and the individual treatment and rehabilitation plan was due by February 22, 2012. The individual treatment and rehabilitation plan was not documented as of March 1, 2012.
Client #8 was admitted on November 3, 2011 and the individual treatment and rehabilitation plan was due by November 5, 2011. The individual treatment and rehabilitation plan was not documented as of March 1, 2012.
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Plan of Correction
It was discovered during our site visit that treatment plans are not being developed and placed in charts in a timely manner. It is the responsibility of the counselor to develop a comprehensive treatment plan with the client within three days of admission into the residential program and it is the expectation that this is completed. Weekly quality control chart audits will be conducted to ensure that treatment plans are being completed on time and thoroughly. Inpatient Director will oversee this POC. |
709.53(a)(9) LICENSURE Aftercare plans
709.53. 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 one of three residential treatment and rehabilitation client records.
The findings include:
Twenty-one client records were reviewed on February 29, 2012 through March 1, 2012. Per the facility policy, the counselor and client will complete an aftercare plan prior to discharge for successful completions. An aftercare plan was required in one residential treatment and rehabilitation discharge client record, #10. The facility did not include the following documentation in the aftercare plan in client record #10; time frames, contact person and reentry process.
An interview with facility staff on March 1, 2012 confirmed the findings
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Plan of Correction
It was discovered that aftercare plans are not being completed thoroughly on residential clients. It is the expectation that aftercare plans are completed by clients and discussed with the primary counselor prior to discharge. Clinicians will be expected to begin the collaborative process of the aftercare plan within 72 hours of a tentative discharge date. Penn Foundation Recovery Center will begin quality control chart audits prior to the closing of every file. Charts will not be closed until they have been reviewed for missing documentation and ensured that all required documentation is in chart. Inpatient Director will oversee this POC. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 one of three residential treatment and rehabilitation client records.
The findings include:
Twenty-one client records were reviewed on February 29, 2012 through March 1, 2012. Per the facility policy, the counselor will complete the follow-up documentation within 7 days for referrals and 1 month for all others. Follow-up documentation was required in three residential treatment and rehabilitation discharge client records, #8, 9 and 10. The facility did not document a follow-up in client record #10.
Client #10 was admitted on December 15, 2011 and was discharged on January 11, 2012. The follow-up was to be done by February 11, 2012. There was no documentation of a follow-up in client record #10 as of March 1, 2012.
An interview with facility staff on March 1, 2012 confirmed the findings.
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Plan of Correction
It was discovered that follow-ups are not being completed consistently as required. It is the expectation that a follow-up call be completed on every client discharged from the residential program. Beginning in January, we have begun to track disposition of all clients via follow up calls, on a spreadsheet for quality assurance purposes and we report this information quarterly to our SCA. With the implementation of this information as a QA measure, we have started a new system that ensures that follow up calls are made within 7 days. Our aftercare coordinator now makes all follow up calls. We believe this new system, which was not in place during the time period of closed charts that were pulled during the site visit, has resolved this issue. Chart check will be utilized to ensure proper documentation of follow-up calls. Special Projects Coordinator |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document medical histories in four of eight outpatient client records.
The findings include:
Twenty-one client records were reviewed on February 29, 2012 through March 1, 2012. Eight client records were reviewed in the outpatient activities department, #14, 15, 16, 17, 18, 19, 20 and 21. Of the eight, four did not have the required documentation for the client's family medical history, #15, 16, 18 and 19. An interview with facility staff confirmed the findings.
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Plan of Correction
It was discovered that family medical history is not being consistently documented in outpatient clinical records. In conjunction with our switch to a new EMR, the Recovery Center has developed a new assessment tool, what we call our Biopsychosocial Evaluation. As part of this new document, which has now been implemented for all new clients, family medical history is included in the tool on the first page. We believe this new assessment tool will ensure documentation on client's family medical history on all clients. Weekly quality control chart audits will be used to ensure the assessment tool is being completed to include the family medical history. Outpatient Coordinator will oversee this POC. |
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 the review of client records, the facility failed to document the client ' s psychosocial evaluations in eight of eight outpatient records reviewed.
The findings include:
Twenty-one client records were reviewed on February 29, 2012 through March 1, 2012. Eight client records were reviewed from the outpatient records for psychosocial evaluations, #14, 15, 16, 17, 18, 19, 20 and 21. Per the facility policy, psychosocial evaluations will be completed within one month after admission. The facility failed to provide a psychosocial evaluation in the eight records that included assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and the counselor conclusions and/or impressions of the client in the eight outpatient records. A discussion with facility staff on March 1, 2012 confirmed the findings
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Plan of Correction
During our site visit, it was discovered that our current psychosocial evaluation, was not adequate to meet the entire intent of the regulation. We are in the process of updating our psychosocial evaluation. Areas for written explanation of all required information will be added to the evaluation. Weekly quality control chart audits will be conducted to ensure that evaluations are being completed on time and thoroughly. Outpatient Coordinator will oversee this POC. |
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:
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Observations
Based on the review of client records, the facility failed to document an individual treatment and rehabilitation plan in seven of eight outpatient client records.
The findings include:
Twenty-one client records were reviewed on February 29, 2012 through March 1, 2012. Individual treatment and rehabilitation plans were required in eight client records, #14, 15, 16, 17, 18, 19, 20 and 21. The individual treatment and rehabilitation plan is due within one month of the client's admission date and the completion of the client's biopsychosocial history and biopsychosocial evaluation per the facility's policy. An interview with facility staff on March 1, 2012 confirmed the findings.
Client #14 was admitted on December 21, 2011 and the individual treatment and rehabilitation plan was to be completed by January 21, 2012. The individualized treatment plan is to be developed after the completion of the client's biopsychosocial histories and biopsychosocial evaluation. The biopsychosocial history and biopsychosocial evaluation were completed but the date they were completed could not be determined. Client #14's individualized treatment plan was completed on December 28, 2011 and due to the lack of dates, the time of completion could not be determined.
Client #15 was admitted on November 22, 2011 and the individual treatment and rehabilitation plan was due by December 22, 2011. The individual treatment and rehabilitation plan was not documented as of March 1, 2012.
Client #17 was admitted on September 12, 2011 and the individual treatment and rehabilitation plan was due by October 12, 2011. The individual treatment and rehabilitation plan was documented on November 11, 2011, almost 30 days late.
Client #18 was admitted on July 28, 2011 and the individual treatment and rehabilitation plan was due by August 28, 2011. The individual treatment and rehabilitation plan was not documented as of March 1, 2012.
Client #19 was admitted on June 16, 2011 and the individual treatment and rehabilitation plan was due by July 16, 2011. The individual treatment and rehabilitation plan was not documented as of March 1, 2012.
Client #20 was admitted on July 21, 2011 and the individual treatment and rehabilitation plan was due by August 21, 2011. The individual treatment and rehabilitation plan was not documented as of March 1, 2012.
Client #21 was admitted on June 28, 2011 and the individual treatment and rehabilitation plan was due by July 28, 2011. The individual treatment and rehabilitation plan was documented on September 28, 2011, over 30 days late.
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Plan of Correction
It was discovered during our site visit that treatment plans are not consistently being completed in a timely manner. It is the expectation that treatment plans are to be completed within 30 days of admission into outpatient treatment. Penn Foundation Recovery Center is now utilizing a new EMR. With the new EMR, clinicians are given a notice on their desktop for all paperwork that is due. The notification will remain there until the paperwork has been completed. The notice is also displayed on the clinical supervisor's computer, allowing for supervisor to monitor completion of paperwork. We believe this will aid the counselors in more timely completion of paperwork. In addition, weekly quality control chart audits will be conducted to ensure that treatment plans are being completed on time and thoroughly Outpatient Coordinator will oversee this POC. |
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 a treatment plan update in three of three outpatient client records.
The findings include:
Twenty-one client records were reviewed on February 29, 2012 through March 1, 2012. Three client records were required to have documentation of treatment plan updates. Per the facility policy, treatment plan updates are required to be completed within 60 days of the comprehensive treatment plan. The facility failed to document a treatment plan update in client records # 14 and 17. Also, one treatment plan update was documented late in record #16.
Client #14 was admitted on December 21, 2011 and the comprehensive treatment plan was completed on December 28, 2011. A treatment plan update was due by February 28, 2012. The treatment plan update was not documented in record #14 as of March 1, 2012.
Client #16 was admitted on October 13, 2011 and the comprehensive treatment plan was completed on October 25, 2011 A treatment plan update was due by December 25, 2011; the treatment plan was not updated until February 14, 2012.
Client #17 was admitted on September 12, 2011 and the comprehensive treatment plan was completed on November 11, 2011, which was late. A treatment plan update was due by January 11, 2012. The first treatment plan update was documented on December 1, 2011 and the second, due on February 1, 2011, was not documented in record #17 as of March 1, 2012.
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Plan of Correction
During our site visit, we were made aware that treatment plan updates are not consistently being completed and in a timely manner. It is the expectation that a treatment plan update is completed on every open outpatient client every 60 days. Penn Foundation Recovery Center is now utilizing a new EMR. With our new EMR, clinicians are given a notice on their desktop for all paperwork that is due. The notification will remain there until the paperwork has been completed. The notice is also displayed on the clinical supervisor's computer, allowing for supervisor to monitor completion of paperwork. We believe this will aid the counselors in more timely completion of paperwork. In addition, weekly quality control chart audits will be conducted to ensure that treatment plans are being completed on time and thoroughly Outpatient Coordinator will oversee this POC. |
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 complete case consultations notes in five of eight outpatient client records.
Findings:
Twenty-one client records were reviewed on February 29, 2012 through March 1, 2012. Case consultations were required in five outpatient client records, #15, 16, 17, 19 and 21. Per the facility's policy, case consultations are to be documented every 90 days. An interview with facility staff on March 1, 2012 confirmed the findings.
Client #15 was admitted on November 22, 2011 and a case consultation was to be documented by February 22, 2012. As of the date of review. there was no documentation of client #15's case consultation.
Client #16 was admitted on October 13, 2011 and a case consultation was to be documented by January 13, 2012. As of the date of review, there was no documentation of client #16's case consultation.
Client #17 was admitted on September 12, 2011 and a case consultation was to be documented by December 12, 2011. Client #17's case consultation was documented January 9, 2012 almost one month after the required date.
Client #19 was admitted on June 16, 2011 and discharged on September 29, 2011. A case consultation was to be documented by September 16, 2011. As of the date of discharge on September 29, 2011, there was no documentation of client #19's case consultation.
Client #21 was admitted on June 28, 2011 and discharged on October 2, 2011. A case consultation was to be documented by September 28, 2011. As of the date of discharge on October 2, 2011, there was no documentation of client #21's case consultation.
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Plan of Correction
Case consultations are not being completed consistently and when they are being completed, they are being completed late. It is the expectation that every open client has a case consultation every 90 days, per the regulation and our policy and procedure. Penn Foundation Recovery Center is now utilizing a new EMR. With our new EMR, clinicians are given a notice on their desktop for all paperwork that is due. The notification will remain there until the paperwork has been completed. The notice is also displayed on the clinical supervisor's computer, allowing for supervisor to monitor completion of paperwork. We believe this will aid the counselors in more timely completion of paperwork. In addition, weekly quality control chart audits will be conducted to ensure that treatment plans are being completed on time and thoroughly Outpatient Coordinator will oversee this POC. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary within 7 days of discharge in three of four outpatient discharge client records.
The findings include:
Twenty-one client records were reviewed on February 29, 2012 through March 1, 2012. Per the facility policy, the counselor will complete the discharge summary seven days after the client's discharge date. A discharge summary was required in four outpatient discharge client records, #18, 19, 20 and 21. The facility did not document a discharge summary within the required 7 days following the client's discharge date in client records #18, 20 and 21.
Client #18 was admitted on July 28, 2011 and was discharged on September 25, 2011. The discharge summary was documented on December 14, 2011, over two months following client #18's discharge date of September 25, 2011.
Client #20 was admitted on July 21, 2011 and was discharged on October 5, 2011. The discharge summary was documented on December 14, 2011, over two months following client #20's discharge on October 5, 2011.
Client #21 was admitted on June 28, 2011 and was discharged on October 2, 2011. The discharge summary was documented on November 10, 2011, over one month following client #20's discharge on October 2, 2011.
An interview with facility staff on March 1, 2012 confirmed the findings.
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Plan of Correction
It was discovered that discharge summaries are not being done in a timely manner. Penn Foundation Recovery Center will begin quality control chart audits prior to the closing of every file. Charts will not be closed until they have been reviewed for missing documentation and ensured that all required documentation is in chart. Outpatient Coordinator will oversee this POC. |
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 two of four outpatient discharge client records.
The findings include:
Twenty-one client records were reviewed on February 29, 2012 through March 1, 2012. Per the facility policy, the counselor will complete the follow-up documentation within 7 days for referrals and 1 month for all others. Follow-up documentation was required in four outpatient discharge client records, #18, 19, 20 and 21. The facility did not document a follow-up in client records #19 and 20.
Client #19 was admitted on June 16, 2011 and was discharged on September 29, 2011. The follow-up was to be completed by October 29, 2011. There was no documentation of a follow-up in client record #19 as of March 1, 2012.
Client #20 was admitted on July 21, 2011 and was discharged on October 5, 2011. The follow-up was to be completed by November 5, 2011. There was no documentation of a follow-up in client record #20 as of March 1, 2012.
An interview with facility staff on March 1, 2012 confirmed the findings.
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Plan of Correction
It was discovered during the site visit that follow-ups are not consistently being completed and documented. We will revise our current policy and procedure to include documentation of the sent letter and also including returned letters into the clinical record. Penn Foundation Recovery Center will begin quality control chart audits prior to the closing of every file. Charts will not be closed until they have been reviewed for missing documentation and ensured that all required documentation is in chart. Outpatient Coordinator will oversee this POC. |
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 the review of the staffing requirements facility summary report, the facility failed to maintain the authorized maximum capacity of 275.
The findings include:
The staffing requirements facility summary report, completed by the facility, was reviewed on February 27, 2012. The staffing requirements facility summary listed 496. The number of current active clients and the maximum number of clients that the facility is allotted is 275. The facility is currently over maximum capacity by 221. An interview with the facility director on February 27, 2012 confirmed the findings.
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Plan of Correction
The Recovery Center has recently switched over to a new EMR. The new EMR does not have a system in place currently for us to separate out clients who are actively engaged in treatment and those clients who came in only for an assessment or who are in the process of being closed. Upon closer inspection of the initial numbers, we discovered 200 clients who were in the process of being closed or who had not received any services at our facility for many months, some even for years. The Recovery Center has since closed the above clients. Counselors will be given active caseload reports bi-weekly and will be expected to discharge clients in a timely manner and keep outpatient cases at or below the 275 capacity limit. Outpatient Coordinator will review caseloads bi-weekly as well to ensure compliance. Penn Foundation Recovery Center will also be applying for an increased license capacity and will hire additional staff as required to maintain regulatory ratios. Executive Director will oversee this POC. |