INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 6-7, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Trehab 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 January 29, 2010.
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Plan of Correction
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704.6(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
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Observations
Based on the review of personnel records, the facility failed to ensure that the clinical supervisor met one of the requirement for 2 years of clinical treatment experience.
The findings included:
The facility employs one full time clinical supervisor . Employee # 4 does not meet the requirement for 2 years of clinical treatment experience which includes 1 year of working directly with the chemically dependent.
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Plan of Correction
Immediately following the onsite inspection on 1/6 and 1/7 the status of individual holding the title of clinical director was changed to lead counselor to reflect current supervisory qualifications. Further, staff indicated as lead counselor at the time of inspection has since changed to counselor. All treatment staff have been appraised of this change. Based on staff size (less than 8 full-time counselors, counselor assistants, or both), Trehab's outpatient facility as indicated by BDAP, does not require a clinical supervisor. Effective 1/8, Trehab's Drug and Alcohol Outpatient Facility will be supervised by a lead counselor. Trehab's drug and alcohol department's policy manual will reflect this change as will all other pertinent treatment paperwork. Lead counselor will oversee paperwork change and Executive Director will audit these changes for thoroughness. |
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, the facility failed to ensure that disclosures of client identifying information to third party payers, health and hospital plans, criminal justice entities and government officials did not exceed the limitations imposed at 4 Pa. Code subsection 255.5(b).
The findings included:
Six client records were reviewed between January 6 and 7, 2010. Documentation of releases of client identifying information in 3 of 6 clients records demonstrated that information released to third party payers exceeded the limitations imposed at 4 Pa. Code subsection 255.5(b).
Client record # 1 included documentation of releases of information to a third party payer which included information of his/her drugs of choice, sexual and physical abuse and tendency toward violent/aggressive behavior. The specificity of this information exceeded the limitations imposed at 4 Pa. Code subsection 255.5(b).
Client record # 3 included documentation of releases of information to a third party payer which included information about the client's incarceration. The specificity of this information exceeded the limitations imposed at 4 Pa. Code subsection 255.5(b).
Client record # 6 included documentation of releases of information to a third party payer which included information about the client's incarceration. The specificity of this information exceeded the limitations imposed at 4 Pa. Code subsection 255.5(b).
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Plan of Correction
Lead counselor met with counseling staff following the onsite inspection and reviewed the regulation pertaining to confidentiality, specifically what information can be disclosed to third party payers, health and hospital plans, criminal justice entities and government officials to ensure that information did not exceed regulatory limitations. Forms from 3rd party payers were reviewed and counseling staff were instructed they were not to complete specific sections of the forms that exceed 4 Pa. Code subsection 255.5 (b) even though this information was requested by payer. Lead counselor reiterated the importance of following all rules of confidentiality. Lead counselor will audit all charts that disclose information to 3rd party payers on an ongoing basis to ensure 100% compliance. |
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 the review of client records, the facility failed to document psychosocial evaluations which provided a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation.
The findings included:
Six client records were reviewed during the January 6 and 7, 2010 inspection. Complete psychosocial evaluations were required in 6 of 6 of the client records reviewed. The psychosocial evaluations in 6 of 6 client records were incomplete and were not evaluative.
Client record # 1- The client was admitted on 6/11/09 and discharged on 8/27/09. Most of the psychosocial evaluation consisted of the client's history as reported by the client. The portion of the document written by the counselor was not evaluative and failed to document possible relationships, conditions and causes leading to the client's current situation.
Client record # 2- The client was admitted on 5/4/09 discharged on 9/24/09. Most of the psychosocial evaluation consisted of the client's history as reported by the client. The portion of the document written by the counselor was not evaluative and failed to document possible relationships, conditions and causes leading to the client's current situation.
The evaluation failed to document the client's coping mechanisms.
Client record # 3- The client was admitted on 9/21/09 discharged 12/10/09. Most of the psychosocial evaluation consisted of the client's history as reported by the client. The portion of the document written by the counselor was not evaluative and failed to document possible relationships, conditions and causes leading to the client's current situation.
The evaluation failed to identify the client's strengths and coping mechanisms as observed by the clinician writing the evaluation.
Client record # 4- The client was admitted on 10/22/09. Most of the psychosocial evaluation consisted of the client's history as reported by the client. The portion of the document written by the counselor was not evaluative and failed to document possible relationships, conditions and causes leading to the client's current situation. The evaluation failed to identify the client's strengths and coping mechanisms as observed by the clinician writing the evaluation.
Client record # 5- The client was admitted on 12/22/09. Most of the psychosocial evaluation consisted of the client's history as reported by the client. The portion of the document written by the counselor was not evaluative and failed to document possible relationships, conditions and causes leading to the client's current situation. The evaluation failed to identify the client's coping mechanisms as observed by the clinician writing the evaluation.
Client record # 6- The client was admitted on 12/15/09. Most of the psychosocial evaluation consisted of the client's history as reported by the client. The portion of the document written by the counselor was not evaluative and failed to document possible relationships, conditions and causes leading to the client's current situation. The evaluation failed to identify the client's coping mechanisms as observed by the clinician writing the evaluation.
The psychosocial evaluations, as a whole, were generic in content and lacked appropriate individualization in the area of treatment recommendations. The deficiencies in the psychosocial evaluations were discussed during ongoing interviews with the Clinical Supervisor throughout the inspection.
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Plan of Correction
Following the onsite inspection, lead counselor met with counseling staff to compare/contrast current psychosocial evaluation summary format used by Trehab with different recommended format examples provided by cite inspector. Counseling staff have been instructed to include more clinical impressions based on observable client behavior such as coping mechanisms and affect/change in affect during initial intake evaluation. Further, to ensure an individualized, composite picture of the client for comprehensive treatment planning is obtained, more detail will be reflected in the summary regarding specific relationships, conditions and causes leading to client's current life situation. Further counseling staff will ensure client's current coping mechanisms and strengths will be consistently addressed within the summary. Counseling staff were given examples to reference. Lead counselor will audit 3-5 random charts on a monthly basis to ensure this is being accomplished. |
709.92(a) 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:
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Observations
Based on the review of client records at the time of the annual licensing inspection and an interview with the Clinical Supervisor, the facility failed to document individualized treatment plans in 6 of 6 client records.
The findings included:
Six client records were reviewed onsite during the annual inspection conducted from January 6 to January 7, 2010. Treatment plan were not individualized, but generalized in 6 of 6 client records reviewed. A template format is used to document the treatment plans. The format lists generic short and long term goals at the top of the form. A checklist of objectives is listed further down on the form. The counselor chooses from the generic lists of goals, while the client is expected to work from the second checklist of objectives. The clients check off on the objectives as they proceed through the treatment process. The facility does not complete individualized treatment plans based on the psychosocial evaluations.
Client record # 1- The client was admitted on 6/11/09. The treatment plan was formulated on the date of admission. Treatment goals documented on the client's treatment plan were generic and included treatment goals for: regular attendance, 12 step attendance, obtain a sponsor and provide clean urines.
Client record # 2- The client was admitted on 5/14/09. The treatment plan was formulated on the date of admission. Treatment goals documented on the client's treatment plan were generic and included treatment goals for: regular attendance, 12 step attendance, obtain a sponsor and provide clean urines.
Client record # 3- The client was admitted on 9/21/09. The treatment plan was formulated on the date of admission. Treatment goals documented on the client's treatment plan were generic and included treatment goals for: regular attendance, 12 step attendance, learn about addiction, meet probation requirements and change people, places and things.
Client record # 4- The client was admitted on 10/22/09. The treatment plan was formulated on the date of admission. Treatment goals documented on the client's treatment plan were generic and included treatment goals for: regular attendance, support group attendance, meet probation requirements and learn about addiction.
Client record # 5- The client was admitted on 12/22/09. The treatment plan was formulated on the date of admission. Treatment goals documented on the client's treatment plan were generic and included treatment goals for: regular attendance, 12 step attendance and recovery skills.
Client record # 6- The client was admitted on 12/15/09. The treatment plan was formulated on the date of admission. Treatment goals documented on the client's treatment plan were generic in nature and included such goals as: regular attendance, 12 step attendance, and change people, places and things.
During a discussion on 1/7/09 at approximately 10:15 A.M.. The topic of individualized treatment plans was discussed and the Supervisor was queried as to how the treatment plans were individualized. The clinical supervisor stated that the individualized portions would be in the possession of the clients and not documented in the client record.
Copies of these documents were not filed in the client records.
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Plan of Correction
Following the onsite inspection, lead counselor revamped the existing treatment plan format to ensure greater individualization. Checklists have been eliminated. Counseling staff will provide problem statements from specific data captured during the evaluation process in different, primary life domains (e.g. drug/alcohol use, physical/medical, psychiatric, family/social, functioning/employment, spiritual/need for affiliation). To ensure this is being accomplished effectively, a treatment planning worksheet that lists domains is completed by counselor during the initial evaluation and reviewed/clarified with client as a problem area. Corresponding goals, objectives and interventions by counselor are described under each problem statement as an action plan during treatment. Further, target dates and resolution dates are required after each objective; a box next to the objectives clearly indicates if objectives are required or optional before discharge. Lead counselor has reviewed the new format with counseling staff and it is being implemented. Lead counselor will audit 3-5 random charts monthly to ensure this new method of treatment planning is being followed consistently. The statement regarding a discussion with department supervisor on 1/7/09 at 10:15 a.m. included in the citation findings represents a misinterpretation by cite inspector. To clarify, clinical supervisor reviewed with inspector the current practice of how treatment plans were being individualized and that a specific area on the treatment plan was designated as the responsibility of the client to check off (on their own copy) as they completed sessions. This practice was established to encourage client accountability and keep them active in the treatment process. Additionally, it was explained that when goals were addressed and/or completed this would be reflected/documented by staff in the client log and progress note, both of which are part of the client record. |
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 the review of the client records, the facility failed to document attempts to follow up on clients in accordance with facility policy which stated that follow up will occur within 7 days for clients who are referred elsewhere and within 60 days for clients who are not referred. The facility failed to document an attempt to follow up on a client within 60 days in one of one client record.
The findings included:
Six client records were reviewed during the annual licensing inspection . Three of these were closed client records. One record had a discharge date of 12/10/09 and the follow up was not yet due.
Two closed client records were required to include documentation of an attempt to follow up on the client. One of the two client records included documentation of an attempt to follow up on the client that was more than 60 days beyond the discharge date.
Client record # 1- The client was admitted on 6/11/09 and discharged on 8/27/09. The follow up date documented in the client record was 1/8/2010, more than 130 days after the discharge date.
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Plan of Correction
Following the onsite inspection, lead counselor clearly indicated on the facility's aftercare plan worksheet that follow-up information will be requested from clients within 60 days of discharge. Counseling staff have been instructed to provide the office manager, in writing, names of clients upon discharge to be placed on a follow-up mailer tracking sheet. The office manager will be responsible for ensuring follow-up letters are mailed within the 60 day time-frame based on information provided by counseling staff. Lead counselor has reviewed this follow-up procedure with all staff involved. Lead counselor will audit the tracking sheet 1 x monthly to ensure this procedure is being followed with consistency. |