INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 29, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The CARE Center dba SPHS Care Center 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 June 3, 2008.
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Plan of Correction
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of the policies and procedures manual on April 28, 2008, the project failed to obtain the services of an independent public accountant for an annual audit of financial activities within six months following the end of the project's fiscal year. The annual audit for the project's fiscal year ending June 30, 2007 was not completed until February 25, 2008.
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Plan of Correction
The project did engage an independent public accountant in a timely manner and in accordance with applicable policies and procedures, however, the audit firm did not complete the work on time. Management has met with the audit firm to correct this and has been assured that future audits will be completed by December 31st each year. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on client records reviewed on April 29, 2008, the facility failed to document informed and voluntary consent to release information forms in three of five records reviewed, #2, 3 and 4. Client records #2, 3 and 4 contained consent to release information forms for the funding source where the purpose of the consent was "other" with no further clarification.
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Plan of Correction
The consent form that contained "other" has been revised and "other" has been removed.
The action was implemented by the clinincal supervisor.
Ongoing compliance shall be the joint responsibility of the clinincal supervisor and the facility director and shall be accomplish through regular chart review.
Staff were informed of the change in the form by the clinical supervisor during regular staff supervision meetings. |
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 April 29, 2008, the facility failed to document a complete psychosocial evaluation in five of five records reviewed, #1, 2, 3, 4 and 5. The psychosocial evaluations listed client responses and stated comments rather than a clinical assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, client's attitude toward treatment and overall impressions/conclusions in four records reviewed, #1, 2, 3 and 4. The psychosocial evaluation was missing in one record, #5. The client had a prior admission on April 19, 2007 and was discharged from treatment on June 11, 2007. When the client was re-admitted to treatment on October 29, 2007 a new psychosocial evaluation was not completed.
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Plan of Correction
The clinical supervisor and facility director will provide supervision to staff members with regard to comprehensive documentation in the psychosocial evaluations. One-on-one training will be conducted with each staff member. Additionally, the topic will be thoroughly addressed at an in-service training scheduled for June 2008. At that time, the procedures for re-admissions, especially required documentation, will be reviewed.
Ongoing compliance shall be the joint responsibility of the clinincal supervisor and the facility director and shall be accomplish through regular chart review.
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709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records on April 29, 2008, the facility failed to document individualized short and long-term goals in the treatment and rehabilitation plan in four of five records reviewed, #1, 2, 3 and 4. The short and long-term goals were not individualized or based on each client's needs. Treatment goals were the same for each client.
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Plan of Correction
The clinical supervisor will provide direct education and supervision to staff regarding the appropriate formulation of individualized goals. The supervisor will then conduct quality assurance checks of client records to monitor compliance. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records on April 29, 2008, the facility failed to document proposed support services specific to each client in the individual treatment and rehabilitation plan in three of five records reviewed, #2, 3 and 4.
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Plan of Correction
Supervision and training will be conducted in June 2008 with all staff, by the clinical supervisor, regarding the documentation of support services specific to each client. Charts will be monitored to assure compliance with this corrective action. |
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 on April 29, 2008, the facility failed to document a complete treatment and rehabilitation plan update at least every 60 days in one of two records, #5. The treatment plan update was due January 13, 2008, but was not completed until January 28, 2008. A second treatment plan update was due on March 28, 2008, but was not completed until April 5, 2008.
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Plan of Correction
The clinical supervisor will provide supervision and training to all staff, in June 2008, with regard to treatment planning and time frames. The staff responsible for this client record will immediately receive direct supervision to develop an action plan to assure all documentation is completed within specified time frames.
Ongoing compliance shall be the joint responsibility of the clinincal supervisor and the facility director and shall be accomplish through regular chart review. |