INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 6, 2009 through April 8, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, MinSec Companies LLC 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 May 10, 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 twelve client records.
Findings:
Twelve client records were reviewed on April 7, 2009. Psychosocial evaluations were required in ten client records. The psychosocial evaluations did not include an assessment of client's assets and strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, clients attitude toward treatment and the counselor's impression of the client in client record #1, 2, 3, 5,6, 7, 9 and 10.
|
Plan of Correction
Psychosocial evaluations will include substantially more information and content with regards to client's assets and strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, the client's attitude toward treatment and the counselor's impression of the client.
Responsible Employee:
Program Director
Director of Quality Assurance
Methodology:
A comprehensive training with a focus on Evaluation and Assessment per BDAP Policy 709.91(b)(6) will occur on Wednesday May 20th 2009. During this training, all clinical staff will be instructed on how to provide specific, individualized and comprehensive information with regards to all aspects of assessment including client assets and strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, the client's attitude toward treatment and the counselor's impressions. Program Director and Director of Quality Assurance will monitor the quality and completion of the Psychosocial Assessments monthly on an on-going basis.
Completion Date:
5/20/09
|
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 nine of twelve client records.
Findings:
Twelve client records were reviewed on April 7, 2009. Short and long-term goals were required in ten client records. The facility only documented short and long-term goals without measurable action steps in client records #2, 3, 4, 7, 8, 9 and 10. Also, client records #1 and 6 did not have documentation of short and long-term goals.
|
Plan of Correction
Short term goals will include measurable action steps for each treatment plan
Responsible Employee:
Program Director
Director of Quality Assurance
Methodology:
A comprehensive training session per BDAP Policy 709.92(a)(1) Short/Long Term Treatment Plan Goals will occur with all clinical staff on Wednesday May 20th 2009. During this session, clinical staff will be instructed on how to compose a treatment plan using specific, individualized specific goals for each short term goal that are measurable. Program Director and will monitor the quality and completion of the Short/Long Term Treatment Plan Goals at the time of submission. Director of Quality Assurance will monitor Short/Long Term Treatment Plan Goals and on a monthly basis.
Completion 5/20/09
Status:
|
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 ten of twelve client records.
Findings:
Twelve client records were reviewed on April 7, 2009. Documentation of support services were required in twelve client record. The facility did not document support services in client records #1, 2, 3, 4, 5, 6, 7, 9, 10 and 11.
|
Plan of Correction
Short term goals will include measurable action steps for each treatment plan
Responsible Employee:
Program Director
Director of Quality Assurance
Methodology:
A comprehensive training session per BDAP Policy 709.92(a)(3) Proposed type of support service will occur with all clinical staff on Wednesday May 20th 2009. During this session, clinical staff will be instructed on how to compose a treatment plan identifying specific and individualized support services. This training will also include how to document support services utilized by the client (i.e. GED, Mental Health, Domestic Violence, Anger Management, Job Readiness, Chronic Health Care, HIV Testing, HIV Counseling, Family Counseling, College, Vocational Training, Masjid, Church, Non-Driver's identifcation, Support Groups, etc.) Program Director and Director of Quality Assurance will monitor the documentation of support services in client records on a monthly basis. Completion Date: 5/20/2009 |
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 ten of twelve client records.
Findings:
Twelve client records were reviewed on April 8, 2009. Group progress notes were required in ten client records. The facility did not have documentation of the therapist assessment and or data of the client participation in group notes in client records #1, 2, 3, 4, 5, 6, 7, 9, 10 and 11.
|
Plan of Correction
Group progress notes will include individual response and assessment for each client in each group.
Responsible Employee:
Program Director
Director of Quality Assurance
Methodology:
Group notes will be reformatted to include space for each individual response and participation per BDAP Policy 709.93(a)(5) Progress Notes. A comprehensive training session on the reformatted Group Note will occur with all clinical staff on Wednesday May 20th 2009. Program Director and Director of QA will monitor the quality and completion of the Group Progress Notes at the time of submission and on a monthly basis.
Completion Date: 5/20/2009 |
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.
|
Observations
Based on the review of client records, the facility failed to document aftercare plans in six of six client records.
Findings:
Twelve client records were reviewed on April 7, 2009. Aftercare plans were required in six client records. In accordance with the facility's policy aftercare plans will be completed on all discharged clients. Client records #7, 9 and 10 did not have documentation of aftercare plans. Client record #7 was discharged on 2/13/09 and as of the date of review no aftercare plan had been completed. Client record #9 was discharged on 1/2/09 and as of the date of review no aftercare plan had been completed. Client record #11 was discharged on 3/3/09 and as of the date of review no aftercare plan had completed. Also, client records #8, 10 and 12 did not contain documentation of goals with time frames. Client record #10 did not have documentation of the support services offered to the patient.
|
Plan of Correction
The MinSec Treatment Companies LLC policy on Aftercare Plans shall be revised to state that Aftercare Plans will only be completed on clients who have successfully completed the program.
Responsible Employee:
Director of Quality Assurance
Program Director
Clinical Supervisor
Methodology:
Closed charts will be reviewed by the Program Director and/or Clinical Supervisor prior to the Completion Certificate being signed by the Program Director. The request for the completion certificate must be accompanied by the Aftercare Plan and Discharge Plan. The Program Director and Director of Quality Assurance will monitor Aftercare Plan submissions on a monthly basis.
Completion 5/20/09
|
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 six of six client records.
Findings:
Twelve client records were reviewed on April 8, 2009. Follow-up information was required in six client records. In accordance with the facility's policy that follow-ups will be completed 7 days after discharged, there was no follow-up information was in records #7, 8, 9, 10, 11 and 12. Client #7 was discharged on 2/13/09 and as of the date of review there was no follow-up documented. Client #8 was discharged on 10/27/08 and had no follow-up documented. Client #9 was discharged on 1/2/09 and as of the date of review there was no follow-up documented. Client #10 was discharged on 3/12/09 and as of the date of review there was no follow-up documented. Client #11 was discharged on 3/3/09 and as of the date of the review there was no follow-up documented. Client #12 was discharged on 12/12/08 and had no follow-up documented.
|
Plan of Correction
Follow-up information will be documented for all clients discharged from the facility, regardless of status of discharge.
Responsible Employee:
Program Director; Administrative Assistant
Methodology:
Follow up calls on all discharged clients will be completed by the Administrative Assistant effective Friday, April 24th 2009 per BDAP Policy 709.93(a)(11) Client Records. The Administrative Assistant will keep record of all follow up information in a separate log available to all staff.
Program Director will monitor the completion of all Follow Up Calls in the follow Up Log on a monthly basis.
Completion Date: 4/24/09
|