INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on December 7-9, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Aldie Foundation 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:
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Plan of Correction
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709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on a physical plant inspection, the facility failed to secure all client records within locked storage containers.
The findings include:
An inspection of the facility's physical plant was conducted on December 8, 2011 between approximately 10:30 AM and 11:30 AM. Client records were stored in boxes in a staff lounge/resource room.
Additionally, the closed records storage room was not dedicated solely for the purpose of record storage. At the time of inspection, the closed records room contained a box of miscellaneous items that were unrelated to client records or record storage.
The findings were confirmed by the Project Director on December 9, 2011.
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Plan of Correction
The client records stored in boxes were all closed charts that have been moved to a secure storage room used only for closed records. All miscellaneous items unrelated to client records were removed from the secure records storage room. The office manager will monitor the storage room to insure that non-record related items are not placed or kept in that room. |
709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
Based on a review of the facility's client census reports, the facility failed develop a data collection and record-keeping system that allows for the efficient retrieval of data needed to measure the project's performance.
The findings include:
The client census reports were reviewed on December 9, 2011. The client census reports did not include the date of admission for clients currently enrolled in the program.
The findings were confirmed by the Project Director on December 9, 2011.
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Plan of Correction
Changes were made to the electronic data system to add a field that specifies the admission date, which may vary according to the criteria of each program. Data entry staff was instructed on how to appropriately complete the admission date field. A client census report can now be generated that lists the applicable admission date for each program. When running this report, the fiscal manager will check to ensure the admission date field is being properly completed by the data entry staff. |
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 the review of client records, the facility failed to document a psychosocial evaluation that included an assessment of the client ' s assets/strengths, support systems, coping mechanisms, negative factors, and/or conclusions regarding the client's appearance, behavior and reactions during the intake process in nine of nine records reviewed.
The findings include:
On December 9, 2011, psychosocial evaluations in nine client records were reviewed, specifically records # 1, 2, 3, 4, 5, 6, 7, 8 and 9. The facility failed to document a psychosocial evaluation that included an assessment of the client's assets/strengths, support systems, coping mechanisms, negative factors, and/or conclusions regarding the client's appearance, behavior and reactions during intake in client records # 1, 2, 3, 4, 5, 6, 7, 8 and 9.
Client # 1 was admitted on 5/4/11. The psychosocial evaluation in client # 1's record did not include an assessment of the client's assets/strengths, support systems, coping mechanisms, negative factors, and conclusions regarding the client ' s appearance, behavior and reactions during the intake process.
Client # 2 was admitted on 8/25/11. The psychosocial evaluation in client # 2's record did not include an assessment of the support systems, coping mechanisms, and conclusions regarding the client's appearance, behavior and reactions during the intake process.
Client # 3 was admitted on 3/28/11. The psychosocial evaluation in client # 3's record did not include an assessment of the client's negative factors and conclusions regarding the client's appearance, behavior and reactions during the intake process.
Client # 4 was admitted on 10/13/11. The psychosocial evaluation in client # 4's record did not include an assessment of the client's assets/strengths, support systems, negative factors, and conclusions regarding the client's appearance, behavior and reactions during the intake process.
Client # 5 was admitted on 7/22/11. The psychosocial evaluation in client # 5's record did not include an assessment of the client's assets/strengths, support systems, coping mechanisms, negative factors, and conclusions regarding the client's appearance, behavior and reactions during the intake process.
Client # 6 was admitted on 8/14/11. The psychosocial evaluation in client # 6's record did not include an assessment of the client's appearance, behavior and reactions during the intake process.
Client # 7 was admitted on 6/8/11. The psychosocial evaluation in client # 7's record did not include an assessment of the client's assets/strengths, support systems, coping mechanisms, negative factors, and conclusions regarding the client's appearance, behavior and reactions during the intake process.
Client # 8 was admitted on 7/22/11. The psychosocial evaluation in client # 8's record did not include an assessment of the client's assets/strengths, coping mechanisms, negative factors, and conclusions regarding the client's appearance, behavior and reactions during the intake process.
Client # 9 was admitted on 8/24/11. The psychosocial evaluation in client # 9's record did not include an assessment of the client ' s assets/strengths, negative factors, and conclusions regarding the client's appearance, behavior and reactions during the intake process.
The findings were confirmed by the Project Director on December 9, 2011.
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Plan of Correction
The clinical director made revisions to the form to include prompts that indicated what types of information should be included in each section of the psychosocial evalutation. The outpatient and NTP program coordinators explained the required elements of the psychosocial evaluation at their respective staff meetings, and will monitor compliance through individual counselor supervision and their quality reviews of client records. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document follow-up information in three of four records reviewed.
The findings include:
On December 9, 2011, four client records requiring follow-up information were reviewed, specifically records # 1, 2, 3 and 10. The facility did not document follow-up information in client records # 2, 3 and 10.
Client # 2 was admitted 8/25/11 and discharged 10/20/11, but client # 2's record did not contain documentation of follow-up information at the time of review.
Client # 3 was admitted 3/28/11 and discharged 10/24/11, but client # 3's record did not contain documentation of follow-up information at the time of review.
Client # 10 was admitted 6/6/11 and discharged 11/17/11, but client # 10's record did not contain documentation of follow-up information at the time of review.
The findings were confirmed by the Project Director on December 9, 2011.
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Plan of Correction
The office manager will ensure that the follow-up information is sent to all clients within the required time frame and that the follow-up documentation is placed into the designated binder in a timely manner. The operations director will periodically inspect the binder to determine if it is kept current. |