INITIAL COMMENTS
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This report is a result of a complaint investigation conducted on May 14, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the allegations made against White Deer Run, Inc. were not substantiated, however there was an additional finding.. A plan of correction must be submitted by June 15, 2010.
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Plan of Correction
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709.53(a)(5) LICENSURE Progress Notes
709.53. 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.
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Observations
Based on the review of the client record and an interview with a counselor on 5/14/2010, the facility failed to ensure that a progress note was written after each significant client contact.
The findings included:
During the onsite complaint investigation conducted on May 14, 2010, one client record, the subject of the complaint, was reviewed. The client was admitted on 4/16/10 and discharged administratively on 4/24/10 due to disruptive behaviors exhibited during the treatment episode.
Documentation in the client record indicated that the client received four individual counseling sessions during the treatment episode. One of these sessions (4/16/10) was an introduction to the program expectations as part of the orientation to the treatment regimen. One session (4/19/10) was to review the master treatment plan with this individual and included some observations from the counselor on the client's needs and attitude toward treatment. An individual session was held on 4/21/10 to place the client on a behavior contract. And a final discharge note on 4/24/10 was written to inform the client of an administrative discharge.
No individual progress notes were written between 4/16/10 and 4/24/10 reflecting interventions with the client to deal with the disruptive behaviors presented. The primary counselor was interviewed at approximately 12:00 P.M. on 5/14/10 and questioned about interventions with this individual. She acknowledged that staff were intervening with this individual three or four times per day to address disruptive behavior. None of these interventions were documented in the client record nor were they addressed in any of the existing progress notes. Agency policy and this regulation require documentation of progress notes for each significant client contact.
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Plan of Correction
Clinical Supervisors will provide training by 6/9/10 for their teams regarding "Significant Client Contact" and what types of session(s) as well as content is expected to be reflected in the documentation. Clinical staff will place a copy of the behavioral contract in the patient record; as well as document appropriate interventions utilized to address the behavioral issue with the patient. The clinical supervisors will monitor compliance through the monthly clinical care review process for a period of six months. |