INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the April 7, 2010 through April 8, 2010 licensure renewal inspection. The follow-up inspection was conducted on December 1, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Colonial House Outpatient 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 December 23, 2010.
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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
Due to the fact that this cannot be re-evaluated until the next licensing inspection please resubmit the original plan of correction
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Plan of Correction
The director reviewed the policy manual. In the future the director will be responsible to complete the needs assessment training as stated in the policy and porcedures manual which will be completed in March |
704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Due to the fact that this cannot be re-evaluated until the next licensing inspection please resubmit the original plan of correction
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Plan of Correction
A summary will be completed and documneted in the training book by the director of outpatient in the time frame which is stated in the policy book as March |
704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Due to the fact that this cannot be re-evaluated until the next licensing inspection please resubmit the original plan of correction
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Plan of Correction
After completion of every training the staff will make a copy of the certificate of completion and turn it into the director of outpatient. The director will give the counsleor the feedback form to the counselor and have them fill it out and return it. It will then be placed in the training file by the director. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
Due to the fact that this cannot be re-evaluated until the next licensing inspection please resubmit the original plan of correction
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Plan of Correction
The overall training plan for each training year will be completed by the director of outpatient. This will be completed in the time frame that is stated in the policy and procedures manual which is due for March. |
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 psychosocial evaluations in five of five client records reviewed.
The finding includes:
Eight records were reviewed on December 1, 2010. Psychosocial evaluations were required in five records reviewed, #1, 2, 3, 4 and 5.
Client records #1, 2, 3, 4 and 5 failed to include a composite picture of the client and also failed to evaluate the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions/impressions of the client.
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Plan of Correction
An example assessment has been provided by the director of outpatient. This assessment was created using words such as it appears, it presents, in my opinion. The examples presented where focused on the areas of the defciiencies. The director will review the assessments. When they are not completed correctly they will be returned to the writer to complete properly using the examples that were provided. This will be reviewed and presetned by the director in a staff meeting upon approval of the poc and staff will then sign off on the staff meeting minutes stating that they understand what was discussed and agree to comply. The director will be responsible for making sure that this poc is followed through correctly |
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 the review of client records, the facility failed to document treatment plan updates in four of five client records.
The findings include:
Eight client records were reviewed on December 1, 2010. Treatment plan updates were required in five client records reviewed #1, 2, 3, 4 and 5. Treatment plan updates are to be updated every 60 days after the completion of the clients comprehensive treatment plan.
Client #1 was admitted on 8/4/10 and their comprehensive treatment plan was documented on 8/9/10 and their treatment plan update was to be completed by 10/9/10. As of December 1, 2010 documentation of the client's treatment plan update was not available for review.
Client #2 was admitted on 6/14/10 and their comprehensive treatment plan was documented on 6/30/10 and their treatment plan updates was to be completed by 8/30/10 and 10/30/10. As of December 1, 2010 documentation of the client's treatment plan updates was not available in the record for review.
Client #4 was admitted on 7/27/10 and their comprehensive treatment plan was to be documented by 8/27/10 and their treatment plan update was to be completed by 10/27/10. As of December 1, 2010 documentation of the clients comprehensive treatment plan and treatment plan update was not in record for review.
Client #5 was admitted on 8/9/10 and their comprehensive treatment plan was documented on 9/9/10 and their treatment plan update was to be completed by 11/9/10. As of December 1, 2010 documentation of the clients treatment plan update was not in record for review.
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Plan of Correction
Charts will be reviewed weekly by the director and the uncompleted documentation will be returned to the counselor who will have until the end of that business day to complete or document why the document is not completed. This will be reviewed with the clinical staff upon approval of the poc. |
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.
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Observations
Based on a review of client records, the facility failed to document complete case consultations notes in three of five outpatient client record.
Findings:
Eight client records were reviewed on December 1, 2010. Case consultations were required in five client records #1, 2, 3, 4 and 5. Per the facility policy and procedure, case consultations are to be documented every 90 days. Case consultations notes were not documented in client records #1, 2 and 3.
Client record #1 was admitted on 8/4/10 and their case consultation was to be done by 11/4/10. As of the date of the inspection there was no documentation of a case consultation in the records reviewed.
Client record #2 was admitted on 6/14/10 and their case consultation was to be done by 9/14/10. As of the date of inspection there was no documentation of a case consultation in the record reviewed.
Client record #3 was admitted on 7/20/10 and their case consultation was to be done by 10/20/10. As of the date of inspection there was no documentation of case consultation in the record reviewed.
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Plan of Correction
Charts will be reviewed weekly by the director and the uncompleted documentation will be returned to the counselor who will have until the end of that business day to complete or document why the document is not completed. This will be reviewed with the clinical staff upon approval of the poc |
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 the review of client records, the facility failed to document aftercare plans in three of three discharged records reviewed.
The findings include:
Eight client records were reviewed on December 1, 2010. Aftercare plans were required in three discharge records #6, 7 and 8. Per the facility's policy and procedure, aftercare plans are to be completed for all clients successfully discharged from the facility.
Client record #6 was admitted on 9/1/10 and discharged on 11/29/10. A successful discharge, there is no documentation of the client's aftercare plan in client record #6.
Client record #7 was admitted on 7/7/10 and discharged on 10/8/10. A successful discharge, there was no documentation of goals with time frames in client's aftercare plan.
Client record #8 was admitted on 7/12/10 and discharged on 10/19/10. A successful discharge, there was no documentation of goals with time frames in client's aftercare plan.
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Plan of Correction
The following will be presented at the next staff meeting. The counselor will be responsible for meeting with the client in the last session and completing the aftercare plan with the clients input. The director will reivew the policy for completion of the aftercare plan. At that time the direcotr will also discuss the need to document the time frames and goals that will need to be completed.
The director is responsible for ensuring that the corrective action is implemented |