INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 19, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services - Reading Psychiatric 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 April 14, 2008.
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Plan of Correction
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the facility's policies and procedures, the facility failed to have a written procedure that complied with 4 Pa. Code 255.5. The facility's written procedures for the confidentiality of client identity and records contained a document entitled "Confidentiality Regulations and the Drug and Alcohol Treatment Programs". This procedure included the wording that allowed for the release of client information "with or without the client's consent" to judges and probation/parole.
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Plan of Correction
The Director of Quality Improvement has revised the "Confidentiality Regulations and the Drug and Alcohol Treatment Programs" procedure to state that client information can only be released with the client's consent to judges and probation/parole. |
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 a review of client records, the facility failed to document a complete psychosocial evaluation in six of six client records reviewed, #1, 2, 3, 4, 5 and 6. Psychosocial evaluations did not provide a composite picture of the client. The clinician used one or two word answers with little to no clinical assessment of the client's problems/needs, assets/strengths, potential or available support systems, coping mechanisms, negative factors that may inhibit treatment, and the client's attitude toward treatment.
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Plan of Correction
The Facility Director will oversee that staff are re-educated in staff meeting to provide a composite picture of the client in the psychosocial evaluation. Staff will be reminded to give more clinical insight and to avoid using one or two words answers when assessing the client's needs, strengths, support systems and other factors that may affect treatment. The Quality Improvement Department will also oversee the revision of our psychosocial evaluation to include additional room for staff to document more detailed clinical impressions. The Quality Improvement Department will also monitor the content of our psychosocial evaluations through ongoing chart audits. |
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
Based on a review of client records, the facility failed to document treatment plan updates in three of six records reviewed, #2, 4 and 5. Treatment plan updates were missing in two records reviewed, #2 and 5. The treatment plan update did not include an assessment of the client's progress in relationship to the goals stated on the comprehensive treatment plan in one of six records reviewed, #4.
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Plan of Correction
The Facility Director will remind staff in staff meeting to complete all treatment plan updates in a timely manner. Staff will also be re-educated to include an assessment of the client's progress in relationship to the goals stated on the comprehensive treatment plan. The Project Director and Quality Improvement Department will also oversee an ongoing internal monitoring system by the office administration to ensure the timely completion of treatment plan updates. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document a complete aftercare plan in two of four client records reviewed, #10 and 12. Aftercare plans did not include individualized goals for clients or specific time frames.
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Plan of Correction
The Facility Director will oversee that staff are re-educated through staff meeting to complete Aftercare plans that include individualized goals with specific time frames. The content quality of the Aftercare plan will be monitored through ongoing chart audits by office administration and through random audits by the Quality Improvment Department. |