INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 12, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Brighter Visions Counseling 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:
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
One personnel record was reviewed on December 12, 2016 . The facility failed to provide documentation of a minimum of 6 hours of HIV/AIDS training for employee # 1.
Employee # 1, the Project/Facility Director, started in their position on 3/26/2013. The facility documented that the employee received 5 hours of HIV/AIDS training.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The requirement for all staff to achieve a minimum of 6 hours of HIV/AIDS training will be adhered to in the next training cycle. For Employee #1 this training deficit will be corrected by the end of January, 2017. For new hires it will be achieved within 6 months of hiring. The Director will review training requirements at hiring and monthly after that with all employees. |
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.
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Observations
Nine client records were reviewed on December 12, 2016. The facility exceeded the limitations imposed at 4 Pa. Code 255.5 (b) in client record # 7.
Client # 7 was admitted into treatment on 10/7/16 and was discharged on 11/22/16. Information in the client's record indicated that a letter documenting the client's substance abuse evaluation was forwarded to a county probation office. The letter detailed the client's medication and substance abuse histories, as disclosed by the client. A consent to release information to a county probation office, signed and dated on 10/7/16, was documented in the client's record.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Communication to referral sources is limited to that information permitted by 4 PA Code 255.5. With the client's written consent, a statement of prognosis, including the diagnosis, may be drafted by the counselor reflecting his/her opinion of how treatment will or will not benefit the client based on clinical observations and the information obtained during the intake process. The Counselor may present his/her recommendations for the client's length of stay with the treatment project. No details of the biopsychosocial history can be released to any entity. This Plan of Correction is in effect immediately and will be reviewed by the Director at weekly supervisory meetings. |
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
Nine client records were reviewed on December 12, 2016. The facility failed to document a complete drug and/or alcohol history in client records # 2 and 7.
Client # 2 was admitted into treatment on 9/20/16 and was still active in treatment. The client's Biopsychosocial assessment was completed on 9/20/16. The facility documented that the client had engaged in polysubstance abuse, since early adolescence, and engaged in opioid abuse. The facility failed to specify the substances most frequently abused, the length and patterns of use, and prior treatment episodes, if any.
Client # 7 was admitted into treatment on 10/7/16 and was discharged on 11/22/16. The client's Biopsychosocial assessment was completed on 10/7/16. The facility documented that the client was referred to treatment after an arrest for a DUI of a controlled medication. The facility also documented that the client had prescriptions for Benzodiazepines, from a physician. The facility failed to specify the substances most frequently used, the length and patterns of use, and prior treatment episodes, if any.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.91. Intake and admission. Intake procedures will include documentation of history of drug/alcohol use to include the types of substances used, ages of onset of abuse of each, frequency and patterns of use (both early and recently), prior treatment episodes including levels of care and response to treatment, whether community resources have been used (AA/NA). This historical data will be documented in each biopsychosocial assessment at the initial session and will be reviewed by the Director and Medical Supervisor. This POC is implemented immediately.
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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
Nine client records were reviewed on December 12, 2016. The facility failed to document a treatment plan update at least every 60 days in client records # 1, 3, 4, 8, and 9.
Client # 1 was admitted into treatment on 10/23/15 and was still active in treatment. The comprehensive treatment plan was completed for the client on 10/23/15. Subsequent treatment plan updates were completed for the client on 2/23/16, 5/11/16, 7/25/16, and 10/6/16.
Client # 3 was admitted into treatment on 8/27/15 and was still active in treatment. The comprehensive treatment plan was completed for the client on 11/2/15. Subsequent treatment plan updates were completed for the client on 1/26/16, 6/13/16, 8/22/16, and 11/14/16.
Client # 4 was admitted into treatment on 11/18/15 and was discharged on 3/29/16. The comprehensive treatment plan was completed for the client on 11/18/15. A treatment plan update was due to be completed for the client by 1/18/16 and one was not documented in the client's record.
Client # 8 was admitted into treatment on 8/4/16 and was discharged on 11/16/16. The comprehensive treatment plan was completed for the client on 8/4/16. A subsequent treatment plan update was completed for the client on 10/25/16.
Client # 9 was admitted into treatment on 7/20/15 and was discharged on 3/16/16. A treatment plan update was completed for the client on 9/21/15. A subsequent treatment plan update was then completed for the client on 2/22/16.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A treatment plan update will be completed every 60 days. In a case of non-attendance, a progress note will be documented, noting the client's treatment status and an assessment of the client's progress (in relation to treatment goals). This corrective action will be implemented immediately. |
709.93(a) 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:
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Observations
Nine client records were reviewed on December 12, 2016. The facility failed to document a complete client record in client records # 1, 3, and 8.
Client # 1 was admitted into treatment on 10/23/15 and was still active in treatment. The record of service documented in the client's record indicated that the client attended individual counseling sessions on 11/13/15, 1/18/16, and 4/7/16. Progress notes for these counseling sessions were not documented in the client's record.
Client # 3 was admitted into treatment on 8/27/15 and was still active in treatment. The record of service documented in the client's record indicated that the client attended an individual counseling session on 9/19/16. A progress note for this counseling session was not documented in the client's record. Additionally, progress notes documented in the client's record indicated that the client attended individual counseling sessions on 3/7/16 and 9/20/16. These counseling sessions were not documented on the client's record of service.
Client # 8 was admitted into treatment on 8/4/16 and was discharged on 11/16/16. The record of service documented in the client's record indicated that the client attended an individual counseling session on 8/24/16. A progress note for this counseling session was not documented in the client's record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Treatment records will include progress notes to match each date in the record of service. In order to ensure that this policy is followed meticulously, all records of scheduled clients will be reviewed weekly during staff or supervisory meetings. Each scheduled client's record will be inspected for correct entry in the record of service and a corresponding progress note or case note of absence. This plan of correction will be implemented immediately. |