INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 9 through 11, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Persad Center, 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 and a plan of correction is due on November 6, 2007.
|
Plan of Correction
|
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on a review of client records, the facility failed to document a notification of termination in one of one record, #8.
|
Plan of Correction
The Clinical Director will review licensing standards for notification of termination and the agency policy reflecting the licensing standards with all drug & alcohol therapists in Group Supervision on December 3, 2007. The Clinical Supervisor will review all terminations with therapists in individual clinical supervision beginning December 1, 2007 to ensure all client's are notified of discharge. The Clinical Director will add notice of termination to the quarterly chart audit form by December 3, 2007 to ensure that there is a double check for completion of notification letters. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
|
Observations
Based on a review of client records, the facility failed to document that the client had an opportunity to request reconsideration of the decision to terminate treatment in one of one record, #8.
|
Plan of Correction
The Clinical Director will review licensing standards for notification of termination and the agency policy reflecting the licensing standards with all drug & alcohol therapists in Group Supervision on December 3, 2007. The Clinical Director will review all discharges in individual Clinical Supervision with therapists to ensure that all clients are notified of termination and that they are aware of their rights to appeal discharges. The Clinical Director will add notice of termination to the quarterly chart audit form by December 3, 2007 to ensure that there is a quality check on all standards including the right of the client to be notified of termination and of their right to appeal. |
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 a review of client records, the facility failed to document a complete psychosocial evaluation in seven of eight client records reviewed, #1, 2, 3, 4, 6, 7 and 8. Psychosocial evaluations were historical and did not include a clinical assessment of clients.
|
Plan of Correction
The Clinical Director will review the licensing standards around documentation of the psychosocial evaluation with all drug & alcohol therapists / intake therapists in group supervision on December 3, 2007. Review of the psychosocial assessment will be added to the initial review of the case / case documentation on December 3, 2007. Chart reviews will be completed quarterly and reports reviewed by the clinical director to ensure that all psychosocial evaluations meet the standards established by the Bureau of Drug & Alcohol Program Licensure. |
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.
|
Observations
Based on a review of client records, the facility failed to document follow up information in one of three records reviewed, #8.
|
Plan of Correction
The Clinical Director will review licensing standards for follow up, documentation of follow up, and the agency policy reflecting the licensing standards with all drug & alcohol therapists in Group Supervision on December 3, 2007. All discharges will be reviewed by the Clinical Director in individual clinical supervision to ensure that an appropriate plan for follow up has been established. This will begin on December 3, 2007. At the beginning of each month, the Adminstrative Assistant will inform the Clinical Director of clients scheduled for/ requiring follow up that month. Clients scheduled for follow up will be reviewed in individual clinical supervision to ensure that follow ups are completed and that attempted contacts are documented. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
|
Observations
The facility failed to provide a copy of the agreement at the time of the inspection.
|
Plan of Correction
The Executive Director will request a copy of a current signed provider agreement from the Department of Public Welfare by December 31, 2007. |