INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on November 16, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site complaint investigation, Samara House of CYWA. 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 investigation and a plan of correction is due on December 19, 2009.
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Plan of Correction
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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 a psychosocial evaluation in two of three records reviewed..
The findings include:
Three client records were reviewed on November 16, 2009. Psychosocial evaluations were required in three client records. Psychosocial evaluations must be completed within five days of admission. The facility failed to document a psychosocial evaluation in client records #2 and 3.
In client record #2 the client was admitted on June 10, 2009. The psychosocial evaluation was not dated so there was no way to tell if it was completed within the required timeframe. Additionally, the psychosocial evaluation failed to address the clients assets/strengths, support systems, coping mechanisms, attitude towards treatment and counselor conclusions and impressions.
In client record #3 the client was admitted on October 14, 2009. The facility failed to document a psychosocial evaluation in this client record.
In client record # 1 the facility failed to date the psychosocial evaluation so there was no way to tell if the psychosocial evaluation was completed within the required timeframe.
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Plan of Correction
The facility failed to document a psychosocial evaluation in 2 of 3 records.
-- New Counselor, hired 7/09, is still on a learning curve. She has been given a copy of the State Regulations and the Director has reviewed all psychosocials with this staff, as of hire date and again on 12/7/09. Director to check all biopsychosocials within 5 days to ensure date, clients assets/strengths, support systems, coping mechanisms, attitude toward treatment, Counselor conclusions and impressions.
--New Counselor hired as of 11/30/09. Director will meet weekly with this new staff to train as to State Regulations and timeframes of completion of mandated paperwork, as well as quality of care and services provided. To begin 12/1/09 with individual supervision weekly.
--Counselor of 9 years has been terminated by mutual agreement, as of 11/23/09. She had been on probation several times due to poor and inadequate documentation. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on the review of client records, the facility failed to document progress notes in two of three client records.
The findings include:
Three records were reviewed on November 16, 2009. Progress notes were required in three client records. The facility did not document progress notes in client records #1 and 3. In addition, an interview took place on November 16, 2009 with the Facility Director she acknowledged individual counseling was to consist of a minimum one one individual session per week; she identified staff were not documenting their contacts.
In client record #1 the initial treatment plan dated 10/7/2009 indicates individual sessions are conducted weekly. The facility failed to document individual progress notes for the weeks of 10/19/2009 through 10/25/2009, 10/26/2009 through 11/1/2009, 11/2/2009 through 11/8/2009, and 11/9/2009 through 11/15/2009.
Client # 3 was admitted to the program on 10/14/2009. The facility failed to document individual progress notes in this record for the weeks of 10/19/2009 through 10/25/2009, 10/26/2009 through 11/1/2009, 11/2/2009 through 11/8/2009, and 11/9/2009 through 11/15/2009.
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Plan of Correction
Facility failed to document progress notes in 2 of 3 client records.
-- This Counselor had been on probation for poor and inadequate documentation, along with missing progress notes. It was mutually agreed upon that her employment be terminated.
-- A new Counselor has been hired, as of 11/30/09, who previously worked at Samara House for 9 years. She is also a Certified Clinical Supervisor.
-- Director began individual supervision with this staff as of 12/1/09 and will meet weekly to train on State Regulations, documentation, progress notes, group progress notes and quality of care.
-- Director will check all files weekly and will document any problemmatic charting, as well as ensuring counseling services are given with notes written. |