INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 3 - 5, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, WPIC Center for Psychiatric and Chemical Dependency Services 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 September 3, 2010.
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Plan of Correction
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711.82(f)(1) LICENSURE Ind Counseling - 2X WK
711.82. Treatment and rehabilitation services.
(f) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document that the client was provided individual counseling, at least twice weekly, in two of four partial hospitalization client records.
The findings include:
Nineteen client records were reviewed from August 3 - 5, 2010. Five client records were from the partial hospitalization program. Four client records were required to have documentation of individual counseling at least twice weekly. One client record was from a time frame outside of the current licensing inspection. Per regulation, counseling shall be provided to a client on a regular and scheduled basis to include individual counseling, at least twice weekly. The facility failed to document that individual counseling was provided twice weekly in client records # 15 and 18.
Client # 15 was admitted to the partial hospitalization program on July 6, 2010. For the week of July 6, 2010, no individual counseling sessions were scheduled. For the week of July 12, 2010, no individual counseling sessions were scheduled. For the week of July 19, 2010, only one individual counseling session was scheduled and conducted on July 20. For the week of July 26, 2010, only one counseling session was scheduled and conducted on July 27.
Client # 18 was admitted to the partial hospitalization program on July 6, 2010. For the week of July 6, 2010, only one individual counseling session was scheduled and conducted on July 8. For the week of July 12, 2010, only one individual counseling session was scheduled and conducted on July 15. For the week of July 19, 2010, only one individual counseling session was scheduled and conducted on July 20.
The facility director was interviewed on August 4, 2010 at approximately 9:15 AM. The facility director reviewed client records # 15 and 18 and confirmed that these clients did not receive individual counseling sessions twice weekly, as required. The facility director reported the partial hospitalization program has a new counselor who will conduct the individual sessions to ensure clients receive two individual sessions weekly.
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Plan of Correction
All active clients in the partial hospitalization program will be scheduled for individual counseling sessions 2x/week. The Program Director will be responsible for monitoring the completion and documentation of this activity through supervision and monthly quality assurance chart reviews. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. 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 and an interview with the facility director, the facility failed to document a psychosocial evaluation which included clinical impressions in eight of fourteen client records, as required.
The findings include:
Nineteen client records were reviewed from August 3 - 5, 2010. Fourteen client records were from the outpatient program. Fourteen client records were required to document a psychosocial evaluation including clinical impressions. Per regulation, the evaluation should provided a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation. The facility failed to document the completion of a psychosocial evaluation including clinical impressions in client records # 2, 5, 6, 7, 8, 11, 12, and 14.
Client # 2 was admitted to the outpatient program on December 14, 2009. The psychosocial evaluation was completed on December 1, 2009. The psychosocial evaluation only included client reported historical information and did not include the clinician's impressions or assessment of the client.
Client # 5 was admitted to the outpatient program on July 8, 2010. The psychosocial evaluation was completed on June 14, 2010. The psychosocial evaluation only included client reported historical information and did not include the clinician's impressions or assessment of the client.
Client # 6 was admitted to the outpatient program on June 18, 2010. The psychosocial evaluation was completed on June 16, 2010. The psychosocial evaluation only included client reported historical information and did not include the clinician's impressions or assessment of the client.
Client # 7 was admitted to the outpatient program on September 21, 2009. The psychosocial evaluation was completed on September 10, 2009. The psychosocial evaluation only included client reported historical information and did not include the clinician's impressions or assessment of the client.
Client # 8 was admitted to the outpatient program on November 3, 2009. The psychosocial evaluation was completed on August 19, 2009. The psychosocial evaluation only included client reported historical information and did not include the clinician's impressions or assessment of the client.
Client # 11 was admitted to the outpatient program on July 8, 2010. The psychosocial evaluation was completed on July 1, 2010. The psychosocial evaluation only included client reported historical information and did not include the clinician's impressions or assessment of the client.
Client # 12 was admitted to the outpatient program on May 17, 2010. The psychosocial evaluation was completed on March 3, 2010. The psychosocial evaluation only included client reported historical information and did not include the clinician's impressions or assessment of the client.
Client # 14 was admitted to the outpatient program on May 17, 2010. The psychosocial evaluation was completed on April 8, 2010. The psychosocial evaluation only included client reported historical information and did not include the clinician's impressions or assessment of the client.
The facility director was interviewed on August 5, 2010. The facility director reviewed these client records and confirmed the psychosocial evaluations included client reported historical information rather than clinical impressions or an assessment of the client.
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Plan of Correction
The Program Director will ensure, through supervision and quality assurance chart review, that the psychosocial evaluation includes clinical impressions that provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation. The necesity of including and documenting this information will be conveyed to all staff by September 30, 2010. Record reviews to begin October 30, 2010 and will occur monthly thereafter.
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711.92(c)(2) LICENSURE Type & Frequency of TX
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document the type and frequency of treatment and rehabilitative services on the individual treatment plan in seven of fourteen client records, as required.
The findings include:
Nineteen client records were reviewed from August 3 - 5, 2010. Fourteen client records were from the outpatient program. Fourteen client records required documentation of the type and frequency of treatment and rehabilitative services on the individual treatment plan. Per regulation, an individual treatment and rehabilitation plan shall be developed with a client; to include the type and frequency of treatment and rehabilitative services. The facility failed to document the type and frequency of treatment and rehabilitative services in client records # 1, 4, 5, 6, 7, 8, and 12.
Client # 1 was admitted to the outpatient program on July 2, 2010, The individual treatment and rehabilitation plan was completed on July 2, 2010. The individual treatment plan did not include the frequency of the individual and family counseling sessions.
Client # 4 was admitted to the outpatient program on February 5, 2010, The individual treatment and rehabilitation plan was completed on February 9, 2010. The individual treatment plan did not include the frequency of the individual counseling sessions.
Client # 5 was admitted to the outpatient program on July 8, 2010, The individual treatment and rehabilitation plan was completed on July 8, 2010. The individual treatment plan indicated IOP (individual outpatient program) every week for 6 weeks. The treatment plan did not indicate each type and frequency of treatment and rehabilitative services provided to the client in the IOP (such as individual and/or family therapy).
Client # 6 was admitted to the outpatient program on June 18, 2010, The individual treatment and rehabilitation plan was completed on June 22, 2010. The individual treatment plan indicated the client would received dual outpatient 3 hours per day, 5 days per week for 6 weeks. The treatment plan did not indicate whether the type of services provided to the client were individual, group and/or family counseling.
Client # 7 was admitted to the outpatient program on September 21, 2009, The individual treatment and rehabilitation plan was completed on July 9, 2010. The individual treatment plan indicated the client would participate in family therapy, as needed. The treatment plan did not indicate the frequency of family therapy. The treatment plan did not indicate the type and frequency of other services provided to the client, such as, individual and group counseling.
Client # 8 was admitted to the outpatient program on November 3, 2009 The individual treatment and rehabilitation plan was completed on November 3, 2009. The individual treatment plan indicated individual counseling, as needed. The individual treatment plan did not include the frequency of the individual counseling.
Client # 12 was admitted to the outpatient program on May 17, 2010, The individual treatment and rehabilitation plan was completed on May 17, 2010. The individual treatment plan indicated IOP (individual outpatient program) every week for 6 weeks. The treatment plan did not indicate each type and frequency of treatment and rehabilitative services provided to the client in the IOP (such as individual and/or family therapy).
The facility director was interviewed on August 5, 2010 at approximately 11:45 AM. The facility director reviewed these client records and confirmed the treatment plans did not clearly indicate the type and frequency of treatment and rehabilitative services being provided to the clients.
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Plan of Correction
The Program Director, thru quality assurance chart reviews will be responsible for reviewing treatment plans to ensure that the type and frequency of treatment and rehabilitative services is documented on the individual treatment plan. All staff will be educated on the necessity of inclusion of the above information by September 30, 2010. Chart reviews will begin October 30, 2010 and will occur montly thereafter. |