INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 29 through 30, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Western Pennsylvania Teen Challenge 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 23, 2010.
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Plan of Correction
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709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of administrative policies and procedures and an interview with the facility director, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24 hour emergency psychiatric coverage.
The findings include:
Based on a review of administrative policies and procedures and an interview with the facility director on March 29, 2010, the facility could not document that they had a current agreement with a licensed hospital or physician for 24 hour emergency psychiatric care.
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Plan of Correction
I, Terry Claesens, have sent a cooperative agrrement to UPMC Western Psychiatric Institute on March 9th 2010 and should be receiving our signed copy within the next few weeks. |
709.52(a)(3) LICENSURE Support service type
709.52. 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records and an interview with the facility director and counselor, the facility failed to document support services in the individual treatment and rehabilitation plan in four of six client records.
The findings include:
Six client records were reviewed on March 29 through March 30, 2010. Support services were required in the individual treatment and rehabilitation plan in six client records. The facility did not document support services in the individual treatment and rehabilitation plan in client records #1, 2, 3, and 6.
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Plan of Correction
Effective 4/19/10, the Counselor and Counselor Assistant will develop a standard "support services" form, to record, on a monthly basis, what support services the client received during their treatment. This form will be completed and placed in the client records each month.
Also, effective as of 4/19/10, the counselor and counselor assistant will be more diligent to document specific support services in the individual treatment plan.
As of 4/30/10 the Director will check the current files of the counselor and counselor assistant to verify they are documenting the supportive services.
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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 a review of the client records and an interview with the facility director and counselor on March 30, 2010 the facility failed to document progress notes which contained a plan documenting strategies, action steps, counselor plans and client assignments or tasks that were specific to the client.
The findings include:
Six client records were reviewed on March 29 through March 30, 2010. Progress notes were required in six of six client records. Client records # 1,2,3,and 6 did not document strategies, action steps, counselor plans and client assignments or tasks. There was no individuality or specificity for the plan portion of the progress notes.
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Plan of Correction
As of 4/23/10, Counselor will meet with Counselor Assistant and explain how the "plan" section of the progress notes must include strategies, action steps, counselor plans and client assignments. The counselor will also explain to the counselor assistant how this section must be individualized on each notation.
As of 4/30/10, the Counselor will check the Counselor Assistant's case files on a monthly basis to be sure that he is in compliance.
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