INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 23, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Riverside Care, 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 February 25, 2008.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
Based on a review of administrative documents on 1/15/08, the facility failed to document that an assessment of staff training needs was completed and failed to document staff input for the assessment.
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Plan of Correction
Director of Clinical Services will revise policy to reflect specific timeframe for assessment to be completed. Practice Manager will document on site staff feedback to corporate meeting. Practice Manager will document staff feedback in July of each year. Corporate will gather feedback to develop assessment in July of each year. Policy revised 2-5-08. |
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 administrative documents and employee records on 1/15/08, the facility failed to document individualized subject areas for the training plans in three of five employee records reviewed, #2, 4 and 5. Additionally, the individual training plan for employee #1 was not completed within the time frame identified by the facility.
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Plan of Correction
Director of Clinical Services will revise individual training plan form to be completed along with annual evaluation. New form will be more specific and mandatory, due in July with annual evaluation.Practice Manager along with Human Resources will ensure completion. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative documents, the facility failed to document that the annual 2006/2007 Fiscal Year audit was completed within the required timeframe.
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Plan of Correction
The Controller will resolve all issues and have audits finalized by December 31, 2008. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on a physical plant inspection at 9:00 am on 1/23/08, the facility failed to secure all client records within locked storage containers or in a locked room. Two portable files that contained client records sitting in the evening receptionist area at the time of the inspection.
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Plan of Correction
The facility will secure all client records within a locked storage container. The Practice Manager will instruct the Administrative Assistant, Biliing Person and Evening Receptionist of the change of practice. The Practice Manager will monitor storage practices for compliance. |
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 on 1/23/08, the facility failed to document an informed and voluntary consent from the client in one of five client records reviewed, #5. Pay stubs were faxed to the funding source and there was no signed consent from the client.
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Plan of Correction
Chief Compliance Officer in conjunction with Practice Manager will train staff on releasing information in compliance with regulations to prevent future release of inappropriate information. Practice Manager and/or Clinical Supervisor will ensure full implementation of training. Clinical Supervisor will review charts on a random sample, monthly basis so as to be within regulations in the future. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records on 1/23/08, the facility failed to document an informed and voluntary consent for three of five client records reviewed, #2, 3 and 4. Specific information to be released exceeded the limitations imposed by 4 Pa. Code 255.5 to Community Behavioral Health (CBH) and treatment court.
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Plan of Correction
Chief Compliance Officer in conjunction with Practice Manager will train staff on information to be disclosed in compliance with regulations to prevent future release of inappropriate information. Practice Manager and/or Clinical Supervisor will ensure full implementation of training. Clinical Supervisor will review charts on a random sample, monthly basis so as to be within regulations in the future. |
709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records on 1/23/08, the facility failed to document an informed and voluntary consent from the client in two of five client records reviewed, #3 and 4. The purpose section was left blank in consents for CBH and treatment court for #3. The purpose stated in a consent for treatment court was to "provide ongoing treatment" for #4.
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Plan of Correction
Chief Compliance Officer in conjunction with Practice Manager will train staff on purpose related to disclosure of information in compliance with regulations to prevent future release of inappropriate information. Practice Manager and/or Clinical Supervisor will ensure full implementation of training. Clinical Supervisor will review charts on a random sample, monthly basis so as to be within regulations in the future. |
709.28(c)(4) 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:
(4) Dated signature of client or guardian.
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Observations
Based on a review of client records on 1/23/08, the facility failed to document an informed and voluntary consent from the client in three of five client records reviewed, #1, 2 and 3. The client's signatures were not dated on the consent forms.
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Plan of Correction
Chief Compliance Officer in conjunction with Practice Manager will train staff on need to date signatures in compliance with regulations to prevent future release of inappropriate information. Practice Manager and or/Clinical Supervisor will ensure full implementation of training. Clinical Supervisor will review charts on a random sample, monthly basis so as to be within regulations in the future. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records on 1/23/08, the facility failed to document that a copy of a client consent was offered to the client in three of five client records reviewed, #1, 2 and 3.
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Plan of Correction
Chief Compliance Officer in conjunction with Practice Manager will train staff on need to document that a copy of consent was offered to consumer in compliance with regulations to prevent future release of inappropriate information. Practice Manager and/or Clinical Supervisor will ensure full implementation of training. Clinical Supervisor will review charts on a random sample, monthly basis so as to be witihin regulations in the future. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records on 1/23/08, the facility failed to document complete drug and alcohol histories in five of five client records reviewed, #1, 2, 3, 4 and 5. The histories did not include length and patterns and the client's perception of use.
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Plan of Correction
The implementaion of new electronic chart system will include lengths and patterns of use and the client's perception of use in Biopsychosocial history. Director of Clinical Services will ensure full implementation. Practice Manager and/or Clinical Supervisor will review all intake documentation on a weekly basis so as to be within regulations in the future. |
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 on 1/23/08, the facility failed to document complete psychosocial evaluations for five of five client records reviewed, #1, 2, 3, 4 and 5. Support systems and a clinical assessment of how assets/strengths, negative factors and support systems would impact the potential for treatment were not included.
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Plan of Correction
The implementation of new electronic chart system will include clinical assessment of how assets, strengths, support systems and negative factors would impact the potential for treatment in the Biopsychosocial. Director of Clinical Services will ensure full implementation by training, or assigning training, of all staff in new system and forms. Practice Manager and/or Clinical Supervisor will review all intake documentation on a weekly basis so as to be within regulations in the future. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records on 1/23/08, the facility failed to document goals stated in terms of measurable criteria in four of six client records reviewed, #2, 3, 5 and 6.
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Plan of Correction
The implementaion of new electronic chart system will include training of staff to develop measurable goals. Practice Manager and/or Clinical Supervisor will ensure full implementation of training. Clinical Supervisor will review treatment plans and sign them, so as to be within regulations in the future. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records on 1/23/08, the facility failed to document the proposed type of support service in four of six client records reviewed, #1, 2, 3 and 6.
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Plan of Correction
The implementation of new electronic chart system will include new treatment plan form with support services. Director of Clinical Services will develop form in new system. Practice Manage and/or Clinical Supervisor will ensure full implementation of training on new form. Clinical Supervisor will review treatment plans and sign them, so as to be within regulations in the future. |
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 on 1/23/08, the facility failed to document an assessment of the client's progress in relationship to the previously stated goals in three of four client records reviewed, #1, 4 and 5.
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Plan of Correction
The implementaion of new electronic chart system will include new updated treatment plan format. The format will include previous treatment plan goals on top of updated treatment developed with an assessment of previous goals as a mandatory field. Therefore, all staff must document progress of previous goals on all updated treatment plans. Practice Manager and/or Clinical Supervisor will ensure full implementation of training. Clinical Supervisor will review treatment plans and sign them, so as to be within regulations in the future. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of client records on 1/23/08, the facility failed to document a complete record of services in two of five client records reviewed, #1 and 2.
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Plan of Correction
The implementaion of new electronic chart system will include regular reports of client attendance or absenteeism in relation to scheduled appointments. These reports will be produced automatically and be given to assigned therapist on a monthly basis. Practice Manager and or/ Clinical Supervisor to ensure full implementation of training. Clinical Supervisor will review charts on a random sample, monthly basis so as to be within regulations in the future. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records on 1/23/08, the facility failed to document complete aftercare plans in three of three client records reviewed, #4, 5 and 7. An aftercare plan was not completed for client record #7. Goals with timeframes, support services and the re-entry process were missing client records #4 and 5.
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Plan of Correction
The implementaion of new electronic chart system will include new aftercare plan format, which will include goals with time frames,support services and re-entry process as a mandatory field. Practice Manager will train staff on importance of documentation. Director of Clinical Services will ensure full implementation by reviewing discharge documentation on a weekly basis. |
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 on 1/23/08, the facility failed to document follow-up information in two of four client records reviewed, #6 and 7.
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Plan of Correction
Policy will be revised by Director of Clinical Services to reflect the following changes; a log will be developed for support staff to document follow-up calls of all discharged consumers, unless no phone number available, then letter to be mailed. Practice Managers will train support staff regarding importance of follow-up and insure implementation of follow-up. Practice Manager and/or Clinical Supervisor will review all follow-up documentation on a monthly basis so as to be within regulations in the future. |