INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 4, 2012 to April 5, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Holcomb Associates, 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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709.28(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.
The findings include:
On April 5, 2012, seven client records requiring documentation of informed and voluntary consent were reviewed. The facility released information without the client's consent in three of seven client records reviewed, specifically, client records # 2, 4 and 6.
Client record # 2 contained one Eligibility Verification System form dated March 30, 2012
in which the facility released information about the client to a government agency, but the facility did not have a signed consent from the client to release the information until April 3, 2012.
Client record # 4 contained one Eligibility Verification System form dated March 7, 2012
in which the facility released information about the client to a government agency, but the facility did not have a signed consent from the client to release the information until April 2, 2012.
Client record # 6 contained one Eligibility Verification System form dated February 27, 2012
in which the facility released information about the client to a government agency, but the facility did not have a signed consent from the client to release the information until February 29, 2012.
The findings were confirmed during an ongoing dialogue with the clinical supervisor on April 5, 2012 from approximately 3:00 P.M. to 3:30 P.M.
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Plan of Correction
The Facility Director will conduct a training with all Clinical Support Staff who utilize the Eligibility Verification System (EVS). Clinical Support Staff will be trained on Confidentiality regulations and instructed to cease use of the EVS until the day of client's admission into the program, and only with proper consent for release of information. Coordinator of Clinical Support Services will be responsible for providing on-going training and Facility Director will be responsible for providing oversight to ensure plan of correction remains in place. |
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 a review of client records, the facility failed to document a psychosocial evaluation in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Biopsychosocial Assessment", states:
"A complete biopsychosocial history/assessment will be conducted and recorded at the client's date of admission to the program .....Biopsychosocial assessment will include, at minimum:
A clear description of the client's presenting and underlying problems; client needs or problems that can or cannot be resolved through treatment or that might inhibit treatment.
The client's assets, strengths or other factors that can contribute to the resolution of identified problems; the potential or available client support systems; obstacles that might effect treatment are documented as well.
The client's preferred coping and defense mechanisms, conclusions regarding the client's appearance, behavior, and reactions during the evaluation will be documented and used to determined course of treatment.
Client's strengths/assets, support systems and preferred coping mechanisms. Potential treatment barriers that may impact the course of treatment. Mental status assessment.
Conclusions and treatment recommendations, including preliminary treatment planning. Recommendations should include treatment modalities and frequency."
On April 5, 2012, four client records requiring documentation of a psychosocial evaluation were reviewed. The facility did not document a psychosocial evaluation according to their policy and procedures in four of four records reviewed, specifically, client records # 1, 2, 3, 4.
Client# 1 was admitted April 2, 2012. The psychosocial evaluation was completed on April 2, 2012; however, the psychosocial evaluation did not include an evaluation of the client's support systems, coping mechanisms, and attitude toward treatment.
Client# 2 was admitted April 3, 2012. The psychosocial evaluation was completed on April 3, 2012; however, the psychosocial evaluation did not include an evaluation of the client's support systems and attitude toward treatment.
Client# 3 was admitted April 2, 2012. The psychosocial evaluation was completed on April 2, 2012; however, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, negative factors, and attitude toward treatment.
Client# 4 was admitted April 2, 2012. The psychosocial evaluation was completed on April 2, 2012; however, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, and attitude toward treatment.
The findings were confirmed during an ongoing dialogue with the clinical supervisor on April 5, 2012 from approximately 3:00 P.M. to 3:30 P.M.
This is a repeat citation. The facility was cited on January 27, 2012; March 23, 2011; and April 23, 2010 for noncompliance with this standard.
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Plan of Correction
The Clinical Supervisor will review all psychosocial evaluations within one business day of the assessment to ensure thorough inclusion of required information including but not limited to client assets, strengths, identified problems, support systems, defense mechanisms, client appearance, behavior and reaction/attitude towards treatment, and coping mechanisms. Facility Director will conduct five random chart reviews per week to support proper completion of psychosocial evaluations, ensuring both clinical elements and administrative content is present. |
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 a review of client records, the facility failed to document an individual treatment and rehabilitation plan.
The findings include:
The facility's policy titled: "Comprehensive Treatment Plans," states:
"A comprehensive treatment plan will be developed within 30 days of the date of admission."
On April 5, 2012, five client records requiring documentation of an individual treatment and rehabilitation plan were reviewed. The facility did not document an individual treatment and rehabilitation plan in two of five records reviewed, specifically, client records # 5 and 7.
Client # 5 was admitted February 27, 2012. The individual treatment and rehabilitation plan was due March 28, 2012; however, client record # 5 did not include documentation of an individual treatment and rehabilitation plan as of April 5, 2012.
Client # 7 was admitted February 29, 2012. The individual treatment and rehabilitation plan was due March 30, 2012; however, client record # 7 did not include documentation of an individual treatment and rehabilitation plan as of April 5, 2012.
The findings were confirmed during an ongoing dialogue with the clinical supervisor on April 5, 2012 from approximately 3:00 P.M. to 3:30 P.M.
This is a repeat citation. The facility was cited on January 27, 2012: March 23, 2011; and April 23, 2010 for noncompliance with this standard.
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Plan of Correction
The facility's policy regarding 30 day completion of comprehensive treatment plans was reviewed with all staff on 4/16/2012. The facility has developed a new system which utilizes the agency's electronic health record to generate a report which calculates the due dates of all comprehensive treatment plans. The report will be generated by the Clinical Supervisor on a weekly basis and reviewed with each clinician during weekly supervision. Clinicians will be responsible for developing treatment plans by the due date, and clinical support will manage data entry. The Facility Director will provide oversight by also running the report to monitor timeliness of treatment plan completion. Furthermore, comprehensive treatment plans for clients #5 and #7 will be completed and logged into the electronic health record by 5/2/12. |
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 an individual treatment and rehabilitation plan update.
The findings include:
The facility's policy titled: " Drug & Alcohol Treatment Activities," states:
"The master treatment plan must be developed within 30 days from the date of admission for both traditional outpatient services and for IOP level of care. It must be reviewed and updated minimally every 30 days thereafter."
On April 5, 2012, one client record requiring documentation of an individual treatment and rehabilitation plan up was reviewed. The facility did not document an individual treatment and rehabilitation plan update in one of one record reviewed, specifically, client record # 10.
Client # 10 was admitted January 30, 2012 and the individual treatment and rehabilitation plan was completed March 2, 2012. The individual treatment and rehabilitation plan update was due April 1, 2012; however, client record # 10 did not include documentation of an individual treatment and rehabilitation plan update as of April 5, 2012.
The findings were confirmed during an ongoing dialogue with the clinical supervisor on April 5, 2012 from approximately 3:00 P.M. to 3:30 P.M.
This is a repeat citation. The facility was cited on January 27, 2012: March 23, 2011; April 23, 2010; and December 22, 2009 for noncompliance with this standard.
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Plan of Correction
The Clinical Supervisor will generate a report using the electronic health record which calculates due dates of treatment plan updates. This report will be used during weekly supervision to communicate with staff on tasks due. Clinical Supervisor will conduct a training with staff on 4/16/2012, informing them that all treatment plan updates require an updated treatment plan and a treatment/progress review of the prior treatment plan objectives. The Facility Director will conduct a random review of 20 charts per month to ensure treatment plan updates are documented in accordance with agency policy. Furthermore, Client #10's treatment plan update will be completed and logged into the electronic health record by 5/2/12. |