INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 2, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Carbon Monroe Pike Drug and Alcohol Commission, 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 April 29, 2008.
|
Plan of Correction
|
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a April 2, 2008 review of client records, the facility failed to document a complete psychosocial evaluation in eight of eight client records reviewed, #1, 2, 3, 4, 5, 6, 7 and 8. Client records #1, 2 and 5 were missing an assessment of the client's coping mechanisms. The psychosocial evaluations contained historical data rather than and evaluation of the client's assets/strengths, coping mechanisms and negative factors that may inhibit treatment in client record #3. Client record #4 was missing support systems. Client record #6 was missing a composite picture of the client that included an assessment of the client's problems/needs, client's attitude towards treatment and the counselor's conclusions/impressions. Psychosocial evaluations were missing a composite picture of the client that included an assessment of the client's problems/needs, assets/strengths, supports systems, negative factors that may inhibit treatment, client's attitude towards treatment and the counselor's conclusions/impressions in two records, #7 and 8.
|
Plan of Correction
The facility director, Lead Outpatient Counselor, and Outpatient Supervisor will provide training to the Primary Counselors on April 30, 2008. At this time we will review the deficiencies found using files which repeated data rather than providing a composite picture of an assessment of the client, and provide examples of how to properly complete the psychosocial evaluation. We will provide handouts on coping skills and defense mechanisms, support systems, and strenghts/weaknesses to be utilized by the primary counselor when completing the psychosocial. The facility director will also provide examples of problems/needs and barriers to treatment using example files. The primary counselors will practice completing the psychosocial summary in all the above areas. The Outpatient Supervisor and Facility Director will review and provide feedback. The Lead Counselor and Oupatient Supervisor will conduct weekly chart reviews for the next month to observe all areas are properly assessed and provided additional individual training if needed. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. 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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a April 2, 2008 review of client records, the facility failed to document the frequency of treatment sessions on treatment plans in five of eight records reviewed, # 1, 3, 4, 6 and 8. Client records # 1, 3, 4, 6 and 8 documented the type of treatment,0 but did not include the frequency of that treatment on the respective individual treatment plans.
|
Plan of Correction
The Facility Director, Outpatient Supervisor, and Lead Counselor will provide a training session on April 30, 2008 to review defiencies in this area with the primary counselor. A sample treatment plan will be provided denoting examples of frequency of treatment modalities. The Outpatient Supervisor and Lead Counselor will check files weekly for the next month to note that frequency of services is included in the treatment plan and provide additional individual training if necessary. |
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.
|
Observations
Based on a April 2, 2008 review of client records, the facility failed to document treatment plan updates in within the sixty day time frame in two of seven client records reviewed, # 6 and 7, The treatment plan update was missing in client record # 6 and was late in client record # 7.
|
Plan of Correction
In review of the files it was noted that both files were from the same primary counselor who is still on probationary status. The primary counselor was met with on April 25, 2008 and his probation was extended for three months. The facility director has increased his supervision time to include review timeliness of treatment plan updates by the facility director reviewing files and creating a tracking system to ensure treatment plan updates are done on time. The Outpatient Supervisor will also be checking charts weekly for the next three months during his extended probation. The facility director will review at the April 30, 2008 training session with all primary counselors due dates for treatment plan updates. |
709.93(a)(2) 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:
(2) Medication records.
|
Observations
Based on a April 2, 2008 review of client records, the facility failed to document a complete medication record in three of four records reviewed, # 2, 5, 6 and 7, The medication record including the dose, frequency and prescribing physician was missing in client record #2. The client's medication was only mentioned in the psychosocial evaluation. The dose of the medication was missing in two records, #5 and 7. The dose and frequency of the medication was missing in client record #6.
|
Plan of Correction
The facility director and Outpatient Supervisor will hold a training day with all primary counselors on April 30, 2008. We will review new policy and procedure which provides direction on how to obtain this information. The policy states that from the screening call the client will be advised by staff at the Referral Center to bring in a copy of the pharmacy printout for all medication currently taking. The assessor will ask for the copy when the client shows for the face to face assessment. If the client does not produce the copy the assessor will advise the client to bring it to the psychosocial appointment with the primary counselor. If the client does not produce the printout to the counselor a release for the pharmacy will be obtained and the counselor will contact the pharmacy for a printout. If the client is not on any medication it will be noted in the psychosocial assessment. |