INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 11, 2006 through July 13, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on August 7, 2006.
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Plan of Correction
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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. The consent shall be in writing and include, but not be limited to:
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Observations
There are multiple consent forms in client records with parental/guardian signature lines, and several records where parents signed these consent forms. Parental consent for treatment or disclosure of information is not mandated by state law and cannot be required.
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Plan of Correction
Consents were developed to include compliance with DPW regulations. The plan is to revise the consents by removing signature line for parent/guaridan. The program Director will re-orient staff to the DOH/BDAP confidentiality regulations and the revised consent forms. Completion date is targeted for 8/31/06. |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. 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
The length and patterns of use, the progression of use, and the client's perception of the effect of their use were not documented in all of the client records reviewed.
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Plan of Correction
Regarding drug and alcohol history and personal history, the documentation is not sufficient in providing a clear assessment. The plan is to implement a recently revised psychosocial assessment that would allow the staff to establish a more thorough client history. The program director will train staff on the usage of the new assessment and the methods used to obtain adequate information. The clinical supervisor will monitor compliance using a monthly chart monitor and provide supervision based on the results. Completion date is targeted for 8/30/2006. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Family history information is minimal or missing in five of five client records reviewed. Personal histories contained very minimal information regarding a client's legal, employment, educational, recreational or sexual history in four of five client records reviewed, #1,2,5 and 6.
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Plan of Correction
Regarding drug and alcohol history and personal history, the documentation is not sufficient in providing a clear assessment. The plan is to implement a recently revised psychosocial assessment that would allow the staff to establish a more thorough client history. The program director will train staff on the usage of the new assessment and the methods used to obtain adequate information. The clinical supervisor will monitor compliance using a monthly chart monitor and provide supervision based on the results. Completion date is targeted for 8/30/2006. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
The physical exam was missing in client record #2. The physical exam was not dated for client #6. The physician's impression of the client was missing in three of four physical exams, #1,3 and 5.
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Plan of Correction
The physician's examinations are completed inconsistently. The plan of action is the program director will review the chart audit procedure with the nurse manager. The nurse manager will complete weekly audits to identify and address deficiencies in the medical record. The nurse manager will provide an inservice to the program's current physician to identify the requirements for a physical examination and provide feedback based on weekly audit reports. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Psychosocial evaluations did not include an assessment of the historical data obtained from the history in five of five client records reviewed.
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Plan of Correction
Clinical staff are currently not utilizing historical data to formulate an evaluation of the client. The plan is the program director will provide a training on formulating a clinical evaluation from the historical data collected throughout the medical record. Compliance of this standard will be ensured by the clinical supervisor through monthly chart monitors. The clinical supervisor will provide supervision to the clinical staff based on the results. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Treatment plan updates do not include a review of progress on previously stated treatment goals in client records reviewed.
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Plan of Correction
The treatment plan reviews have not provided adequate review of progress on treatment goals. The plan of correction is the program director will provide a training to the clinical stff on the proper completion of the treatment plan review. The clnical supervisor will ensure compliance through the monthly chart monitor and provide supervision based on the results. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
The record of services provided was missing or incomplete in four of five client records reviewed, #1, 2, 3 and 5.
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Plan of Correction
The records of service have not been completed properly. The plan of correction began the week of the site visit at which time the clinical supervisor and BHT Supervisor Coordinator implemented a system to accurately document on the client record of service. The clinical supervisor and coordinator provided an inservice on proper documentation techniques. The clinical supervisor and coordinator will ensure compliance using the monthly chart monitor and provide supervision based on the results. |
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
The group notes do not include any group data, assessment or plan in all client records reviewed.
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Plan of Correction
The program was not utilizing a group note that provided information including the data, assessment, and plan. The clinical supervisor has provided training on the proper use of the group note and method of documentation. The new group note is currently in use. The clinical supervisor will ensure compliance using the monthly chart monitor and provide supervison based on the results. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Follow-up information was not documented in three of three client records reviewed.
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Plan of Correction
The staff were not consistently documenting follow-up information. The plan of action is the program director will establish a system to ensure all follow up calls are made and documented properly according to the standard. The program director will orient staff to the proper procedure. The medical director will ensure compliance through closed chart audits. The clinical supervisor will provide supervision based on the audit's results. |