INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the March 16, 2012 licensure renewal inspection. The follow-up inspection was conducted on September 24 through 26, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Livengrin Counseling 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.
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Plan of Correction
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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, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in four of eight partial hospitalization activity client records.
The findings include:
Eight client records were reviewed on September 26, 2012. Four client records reviewed were required to have documentation of psychosocial evaluations, #1, 2, 3 and 4. Per the facility policy, psychosocial evaluations will be completed within 7 days of the client ' s admission date. An interview with facility staff on September 26, 2012 confirmed the findings.
The psychosocial evaluations in client records #1, 2, 3 and 4 did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms and negative factors and how they would impact treatment.
Client #3 was admitted on September 4, 2012 and their psychosocial evaluation was to be documented by September 11, 2012. Client #3's psychosocial evaluation was documented on September 14, 2012.
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Plan of Correction
In a meeting on 10/10/12, the Program Manager reminded all counselors that the psychosocial evaluation needs to include evaluation of the patient's assets/strengths, support systems, coping mechanisms and negative factors and how they would impact treatment. The Program Manager will randomly monitor patient charts to ensure compliance. The Quality Assistant will also randomly monitor patient charts to ensure compliance. Oversight will be provided by the Director, Total Quality Management. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to document treatment plans within the facility's time frame in three of eight client records.
The finding includes:
Eight client records were reviewed on September 26, 2012. Treatment plans were reviewed in four client records, #1, 2, 3 and 4. Per the facility's policy, treatment plans will be completed within 7 days of the client's admission date following the completion of the client's biopsychosocial history and evaluation. A discussion with facility staff on September 26, 2012 confirmed the findings.
Client # 1 was admitted on June 21, 2012 and the treatment plan was to be documented by June 28, 2012. Client #1's treatment plan was documented on July 26, 2012.
Client #2 was admitted on July 16, 2012 and the treatment plan was to be documented by July 23, 2012. Client #2's treatment plan was documented on August 12, 2012. The therapist signed the treatment plan on August 12, 2012 and the client signed the treatment plan on September 13, 2012. It could not be determined if the treatment plan was developed with the client.
Client # 4 was admitted on June 19, 2012 and the treatment plan was to be documented by June 26, 2012. Client #4's treatment plan was documented on June 29, 2012.
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Plan of Correction
In a meeting on 10/10/12, the Program Manager reminded all counselors of the need to complete treatment plans within seven days of admission, after the psychosocial assessment has been completed. The Program Manager will randomly monitor patient charts on a monthly basis to ensure compliance. The Quality Assistant will also randomly monitor patient charts on a monthly basis to ensure compliance. Oversight will be provided by the Director, Total Quality Managment. |
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 of client records, the facility failed to document an aftercare plan in two of four discharge records.
The findings include:
Eight client records were reviewed on September 26, 2012. Per the facility policy, the counselor and client will complete an aftercare plan prior to discharge for successful completions. An aftercare plan was required in four client records, #5, 6, 7 and 8. The facility did not document an aftercare plan in client records #5 and 6. Also, client #7's aftercare plan was developed after the clients discharge date, June 12, 2012. Client #7's aftercare plan was developed on June 15, 2012.
Client # 5 was admitted on August 25, 2011 and discharged on May 8, 2012. There was no documentation of an aftercare plan in client record #5.
Client # 6 was admitted on May 15, 2012 and discharged on August 28, 2012. There was no documentation of an aftercare plan in client record #6.
This was discussed and confirmed with the facility director on September 26, 2012.
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Plan of Correction
In a meeting on 10/10/12, the Program Manager reminded all counselors of the need to complete an aftercare plan, if applicable. The Program Manager will randomly monitor patient charts on a monthly basis to ensure compliance. The Quality Assistant will also monitor patient charts on a monthly basis to ensure compliance. Oversight will be provided by the Director, Total Quality Management. |