INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 18, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, T.W. Ponessa and Associates Counseling Services, Inc. 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 August 15, 2008.
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Plan of Correction
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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on review of six client records on July 18, 2008, two were required to have notification of termination of services. The facility failed to document this notification in one of two required client records. The notification of termination was missing from client record #1.
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Plan of Correction
7/28/08= Group supervision was conducted by the Facility Director and included all clinicians to review said identified charts and findings. Facility Directed announced that group supervision will be replaced by a minimal of an hour of individual supervision at the assigned site of the clinician. An individual supervision schedule was developed and was implemented the week of 8/4/08. A revised "Notice of Termination" letter" was developed and disseminated to the clinicians and all office sites the week of 8/4/08. Copies were placed in the paperwork drawer. A copy was placed in the "example intake chart". Therefore, this letter has now become part of the client chart assembled prior to intake.
A revised individual supervision form was developed by the Facility Director to include "Discharge Charts for Review". As indicated, the clinician and Facility Director will review each discharged client chart to ensure the "Notice of Termination" letter has been sent accordingly. |
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 on July 18, 2008, the facility failed to document a complete biopsychosocial evaluation in five of six client records reviewed, # 1, 2, 3, 4, and 5. Overall clinical impressions were missing in record # 1. The composite picture included only minimal information on the client in records # 1, 2, and 5. The facility failed to provide evaluation of client strengths in record # 3. The strengths were self-identified by the client. The facility failed to provide evaluation of client supports in record #1. Supports were self-identified by the client. The facility failed to provide evaluation of client coping mechanisms in records # 2, 3, and 5. The coping mechanisms identified merely listed drug and/or alcohol use.
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Plan of Correction
7/28/08= Group supervision was conducted by the Facility Director and included all clinicians to review the identified charts and findings. An example of an acceptable summary (identified by the licensing reviewers) was distributed and discussed. Unanimously confirmed that return to the original assessment tool on 7/18/08will be a positive contributing factor. 7/28/08= Group supervision will be replaced by a minimal of an hour of individual supervision at the assigned site of the clinician. An individual supervision schedule was developed and was implemented the week of 8/4/08. A revised individual supervision form was developed to include "Review of Completed Summaries". As indicated, the clinician and Facility Director will review each completed client summary. A clinician who was cited as having a well written summary will provide a copy of the one-page form she uses to assist in the identification of the client's coping mechanisms, possible barriers to treatment,supports, and strengths. Copies were distributed at each individual supervision the week of 8/4/08. Copies were placed in the paperwork drawer. This form will be included in the paperwork documents assembled for the client's intake chart. |
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 on July 18, 2008 of three client records that required an aftercare plan, the facility failed to document measurable and realistic goals with time frames in the aftercare plan in one of three client records reviewed, # 5. Time frames documented included the phrase "ongoing" rather than an actual time frame. Goals documented were generalized, referring to the client's personal future goals rather than more specific recovery-oriented goals. An aftercare plan was missing in client record #6.
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Plan of Correction
7/28/08= Group supervision was conducted by the Facility Director and included all clinicians to review said identified charts and findings. An example of an acceptable discharge summary (identified by the licensing reviewers) was distributed and discussed. 7/28/08= Group supervision will be replaced by a minimal of an hour of individual supervision at the assigned site of the clinician. An individual supervision schedule was developed and was implemented the week of 8/4/08. A revised individual supervision form was developed to include "Upcoming Discharges". As indicated, the clinician and Facility Director will review each client identified as nearing completion of treatment. During each individual supervision the week of 8/4/08, Facility Director and clincian reviewed the identified Aftercare Plans from licensing visit. Identified alternative acceptable responses for: measurable and realistic recovery-oriented goals; and timeframes. Facility Director indicated that the completion of the Aftercare Plan begin prior to the last session.
8/4/08 A user-friendly revised computer version of the Aftercare Plan was developed and reviewed in with each clinician in individual supersion. This form may be printed and handwritten or completed on the computer and then printed. |