INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 9- 10, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Addictive Diseases- Main Line Affiliates 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 November 27, 2007.
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Plan of Correction
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711.91(b)(3(ii) LICENSURE D & A History
711.91. 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
Based on a review of client records conducted on October 9- 10, 2007 the facility failed to document lengths and patterns of substance use/abuse, prior treatment and the client's perception of use related to the drug and alcohol history. This was evident in six of six client records reviewed, specifically #1, 2, 3, 4 and 5.
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Plan of Correction
The fors where clinicians collect data are satisfactory and have required elements related to the lengths and patterns of substance use/abuse. A clinical chart audit will be completed quarterly by the Clinical Director where a random selection of 2 charts per clinician will be reviewed for completeness and attention to this section. First quarterly audit to be completed by 1/15/08 |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. 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 on October 9- 10, 2007 it was determined that the facility failed to document a psychosocial evaluation based on the clinician's analysis of the client's history and present circumstances. A review of six of six client records, specifically #1, 2, 3, 4, 6 and 7, indicated that the psychosocial evaluation was a historical summary that failed to include clinical impressions.
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Plan of Correction
A clinical chart audit will be completed quarterly by the Clinical Director to assure clinical impressions are documented within the psychosocial evaluation. First quarterly audit to be completed by 1/15/08.
Additionally, a staff meeting was held 10/18/07 to review the expectations for clinicians completing the psychosocial evaluation. All clinicians were re-trained on the proper completion of the document.
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711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records on October 9- 10, 2007 it was determined that the facility failed to document treatment plan updates. A review of two of four client records, specifically #3 and 7, the treatment plan updates were missing. In client record #3 the treatment plan update was due on September 30, 2007. The treatment plan update for client record #7 was due on July 2, 2007.
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Plan of Correction
All treatment plan updates are signed by the Clinical Director. The Clinical Director will track, through the assistance of chart audits performed by the Medical Records Tech, to ensure the updates are completed within the timeframes.
Additionally, a staff meeting was held 10/18/07 where the expectations for the treatment plan updates were presented to clinicians and clinicians were re-trained on the completion of updates. |
711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records conducted on October 9- 10, 2007 it was determined that the facility failed to document goals with time frames in the aftercare plan. Three of four client records reviewed, specifically #1, 6 and 7, revealed that the documentation in the aftercare plan failed to include measurable goals with time frames. In addition, in one of four client records, specifically #5, the aftercare plan was missing with no additional documentation in the client record indicating why the aftercare plan was not completed.
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Plan of Correction
The documentation for aftercare plans was reviewed in a staff meeting held 10/18/07 with all clinical staff. Attention to this detail will be given at the time the chart is processed for discharge by the Medical Records Tech. Additionally, this will be included in the new Clinical Chart audit submitted quarterly by the Clinical Director to assure the aftercare plans include measurable goals and time frames. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) 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:
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Observations
Based on a review of client records conducted on October 9- 10, 2007 it was determined that the facility failed to obtain an informed and voluntary consent for the disclosure of information contained in the client record. Of the eight client records reviewed, two client records, specifically #3 and 5, revealed that a "PCPC" was faxed to the county for the purpose of authorizing funding and a discharge summary was mailed to a probation officer, respectively, without an informed written consent to release information form in place. In addition, the information released failed to comply with the regulation 4 Pa. Code Subsection 255.5(b).
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Plan of Correction
255.5 was reviewed in the clinical staff meeting 10/18/07. All consents will be reviewed by both the Medical Records tech during the weekly audit and the Clinical Director during the quarterly clinical chart audit. PCPC's will not be faxed to either the county or the insurance company, unless they do not obtain information that would violate Pa Code 255.5(b) and a valid release of information is obtained. Any issues with insurance company's regarding this will be refered to the State. |