INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 15, 2009 through January 16, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Aldie Counseling Center 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 14, 2009.
|
Plan of Correction
|
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 complete psychosocial evaluations in eight of eight client records.
Findings:
Sixteen client records were reviewed on January 16, 2009. Psychosocial evaluations were required in eight client records. The psychosocial evaluations failed to document a complete clinical assessment that included a client composite picture, clients problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, clients attitude toward treatment and the counselor's impressions of the client in client records #1, 2, 3, 4, 5, 6, 7 and 8.
|
Plan of Correction
Program Coordinator will provide additional training on how to interpret factual information into a clinical analysis of the patients problems, needs, support systems, negative factors attitude toward treatment and overall impressions. A new document was also introduced which will better support this and staff have been oriented to its use. The psychosocail evaluation/clinical assessment will be reviewed by the Program Coordinator for adherence of a more clinical analysis rather than a historical documentation of client's presentation prior to signature. Peer chart review will be conducted on a monthly basis. A quarterly chart review will be conducted by the Program Coordinator to assure adherence to standards. Compliance officer will similarly randomly review charts for adherence to standards |
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.
|
Observations
Based on the review of client records, the facility failed to document short and long-term goals in five of eight client records.
Findings:
Sixteen client records were reviewed on January 16, 2009. Short and long-term goals were required in eight client records. The facility did not document short and long-term goals with measurable action steps in client records #1, 3, 4, 7 and 14.
|
Plan of Correction
Further training will be provided to all clinicians by the Program Coordinators on writing treatment plans that address both short and long term goals and contain measurable action steps.Treatment plans will be reviewed by the Program Coordinators prior to signature to insure adherence. The Compliance Officer will randomly monitor charts for adherence to this standard |
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.
|
Observations
Based on the review of client records, the facility failed to document support services in four of seven client records.
Findings:
Sixteen client records were reviewed on January 16, 2009. Documentation of support services were required in seven client records. The facility did not document support services in client records #1, 5, 6 and 8.
|
Plan of Correction
Further training will be provided to all clinicians by the Program Coordinators on the proper writing of treatment plans with specific attention to the inclusion and documentation of support services.Treatment Plans will be reviewed by the Program Coordinator prior to signature to insure adherence. The Compliance Officer will randomly monitor charts for adherence tothis standard. |
709.93(a)(5) 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:
(5) Progress notes.
|
Observations
Based on the review of client records, the facility failed to document progress notes in six of eight client records.
Findings:
Sixteen client records were reviewed on January 16, 2009. Group progress notes were required in eight client records. The group progress notes did not have the data of the client's participation in group and the therapist's assessment of the client in records #1, 2, 3, 4, 5 and 7.
|
Plan of Correction
Further training will be provided to all clinicians by the Program Coordinators on the writing of progress notes. Specific attention will focus on both the timely execution of progress notes and the proper writing of a group note in D.A.P. format which is individualized, documents participation in the data section; provides the therapist's assessment within the assessment section; and indicates an individualized action plan in the final section. Also, a check and balance system will be implemented to insure timeliness. All clinicians will utilize a check off system on their daily widgets to identify completion of all notes on a daily basis. Data techs will then monitor that all notes are included in the staff envelopes the next day and the office manager will weekly monitor that all notes are being filed in a timely manner.Quarterly chart reviews will be completed by program Coordinators to ensure compliance to this standard. Similarly the Compliance Officer will randomly monitor charts for adherence to this standard. |
709.93(a)(8) 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:
(8) Case consultation notes.
|
Observations
Based on a review of client records on January 16, 2009, the facility failed to document complete case consultations notes in four of six client records.
Findings:
Sixteen client records were reviewed. Case consultations were required in six client records. Case consultations notes were not documented in client records #3 and 6. Client record #3 was admitted on 7/24/08; to date there has been no documentation of a case consult. Client record # 6 was admitted on 10/14/08; to date there has been no documentation of a case consult. Also, records #4 and 7 were documented late. Client record #4 was admitted on 8/12/08 and case consultation was to be completed by 11/12/08; the case consultation was completed on 11/24/08. Client record #7 was admitted on 6/2/08 the second case consultation was to be completed by 12/2/08; the case consultation was completed on 12/23/08.
|
Plan of Correction
Every client record will include case consultation documentation within the timeframes identified within the standards. Each clinician will now retain a spreadsheet/checklist which will track initial admit/intake date, case consult due dates and other key benchmarks in order to better track documentation due dates. This client spreadsheet and client chart will be reviewed by the Program Coordinator and the clinician in individual supervision on a monthly basis to insure compliance to this standard. Similarly the Compliance Officer will randomly monitor charts for adherence to this standard |
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 eight client records.
Findings:
Sixteen records were reviewed on January 16, 2009. Follow-up information were required in eight client records. In accordance with the facility's policy and procedure manual the facility had 30 days to complete a follow-up when a client is discharged. Client record #9 was discharged on 7/22/09/08 and the follow-up was conducted on 12/1/08. Client record #10 was discharged on 8/14/08 and the follow-up was conducted on 12/2/08. Client record #11 was discharged on 9/10/08 and the follow-up was conducted on 12/2/08. Client record #12 was discharged on 6/30/08 and the follow-up was conducted on 11/14/09. Client record #13 was discharged on 8/26/08 and the follow-up was conducted on 12/1/08. Client record #14 was discharged on 5/9/08 and the follow-up was conducted on 12/1/08. Client record #15 was discharged on 7/29/08 and the follow-up was conducted on 12/1/08. Client record #16 was discharged on 6/23/08 and the follow-up was conducted on 12/1/08.
|
Plan of Correction
The Quality Assurance Officer will provide training to staff responsible for the execution of discharge follow-up with specific attention to the adherence to identified timeframe standards. The Quality Assurance Officer will then conduct a quarterly review of discharged charts to insure that follow up is being completed within 30 days. |