INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 29 through 30, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection Diakon Lutheran Social Ministries 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 November 30, 2007.
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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 document a complete psychosocial evaluation in seven of seven records reviewed, #1, 2, 3, 4, 5, 6 and 7. Psychosocial evaluations did not include a clinical assessment of client's assets and strengths in five of seven records reviewed, #2, 3, 5, 6 and 7. Psychosocial evaluations did not include a clinical assessment of client's problem and needs or the client's attitude towards treatment in four of seven records reviewed, # 2, 3, 6 and 7. Psychosocial evaluations did not include a clinical assessment of negative factors that may inhibit treatment in six of seven records reviewed, #1, 2, 3, 5, 6 and 7. Coping mechanisms were not addressed in four of seven records reviewed, # 3, 5, 6 and 7.
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Plan of Correction
Facility psychosocial evaluation forms include sections to be completed regarding client's assets and strengths, problem and needs, client's attitude towards treatment, negative factors that may inhibit treatment, and coping mechanisms.
Staff were re-educated by the facility compliance officer on November 8, 2007, regarding the requirement that psychosocial evaluations, including the areas of client's assets and strengths, problem and needs, client's attitude towards treatment, negative factors that may inhibit treatment, and coping mechanisms, be documented comprehensively and thoroughly.
Facility Director and compliance officers will perform weekly audits and random chart reviews to monitor completeness of psychosocial evaluations. Any identified deficiencies will be addressed through additional training and/or disciplinary action.
Date: November 8, 2007, and ongoing
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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 the review of client records, the facility failed to review and update treatment plans in two of seven records, #6 and 7.
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Plan of Correction
Staff were re-educated on November 8, 2007, regarding the requirement that treatment and rehabilitation plans be reviewed and updated at least every 60 days.
Facility Director and compliance officers will perform weekly audits and random chart reviews to monitor timely review and updating of treatment and rehabilitation plans. Any identified untimeliness will be addressed through additional training and/or disciplinary action.
Date: November 8, 2007 and ongoing
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a complete discharge summary in six of six records reviewed, # 6, 7, 8, 9, 10 and 11. Discharge summaries did not include the reasons for this treatment experience, services offered, the clients's response to treatment plan goals and the clients's status upon discharge.
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Plan of Correction
A new discharge summary has been developed which includes sections to be completed regarding the reasons for the treatment experience, services offered, client's response to treatment plan goals, and the client's status upon discharge.
Staff will be educated on the new discharge summary form on January 10, 2008. Compliance officers will monitor all discharges to ensure that discharge summaries are being completed within one week after discharge.
Date: January 10, 2008, and ongoing.
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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
Based on a review of the organizational chart, the facility failed to have a project director responsible for the overall management of the project that reports directly to the board.
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Plan of Correction
704.5 (a) Licensure
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Project/Facility Director
The facility has a project director responsible for the overall management of the project and staff as required.
The facility's project director does not report directly to the governing board. Because the facility's organizational structure is not consistent with the Division of Drug and Alcohol Program Licensure Licensing Alert issued in May 2005, which interprets §704.5 to require that the project director report directly to the board, the facility will seek approval from its governing board at the next regularly scheduled meeting of the governing board to request an exception pursuant to 28 Pa. Code §701.11.
Date: February 20, 2008 ? governing board approval of exception request
February 22, 2008 ? submission of exception request to Division of Drug and
Alcohol Program Licensing
Date: April 14,2008- submission being resubmitted per licensing request. Diakon is continuing to address this deficiency through the Sr. VP of Compliance and Legal Affairs to reach an amicable resolution to this regulation.
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