INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on Friday, November 20, 2020 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Libertae Family House Libertae, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.93(a)(1) 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:
(1) Consent forms.
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Observations
Based on the record provided for review on 11/20/2020, the facility failed to provide documentation of the client's consent forms.
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Plan of Correction
The deficiency will be corrected by taking the following action steps:
1. The facility director, with the manager of admissions, will review, revise and update the intake and admissions policies and procedures as needed.
2. The facility director, with the manager of admissions will develop and implement written standard work procedures for admissions that include obtaining signed consents to treatment upon admission.
3. The manager of admissions will ensure that a signed consent to treatment has been obtained from all clients upon admission.
The correction will be maintained by conducting a rigorous review of client records to ensure that the client's consent to treatment has obtained and included in the client record.
It is the responsibility of the Facility Director with the Director of Social Services and Finance Director to conduct a review of all client records every 30 days for all clients admitted the previous 30 days, to verify that each client record captures the required documentation, including the consent to treatment. |
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.
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Observations
Based on the record provided for review on 11/20/2020, the facility failed to provide documentation of the client's medication records.
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Plan of Correction
The deficiency will be corrected by taking the following action steps:
1. The facility director, with the manager of admissions, will review, revise and update the record keeping policies and procedures as needed, particularly as it pertains to medication records, with all pertinent staff.
2. The facility director, with the operations manager will develop and implement written standard work procedures for medication procedures that include documentation of clients medications in their records.
3. The treatment tech team coordinator will ensure that all medication records have been documented in each client's chart.
The correction will be maintained by conducting a rigorous review of client records to ensure that the client's medication records are up to date and complete.
It is the responsibility of the Facility Director with the Director of Social Services and Finance Director to conduct a review of all client records every 30 days for all clients admitted the previous 30 days, to verify that each client record captures the required documentation, including the consent to treatment. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on the record provided for review on 11/20/2020, the facility failed to provide documentation of the client's record of servies.
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Plan of Correction
The project shall maintain a complete client record on an individual in treatment which includes a record of services provided.
In order to ensure that counseling services are provided in accordance with an individual treatment and rehabilitation plan, a record of service will be provided weekly to the Project Director.
Any gaps in services will be addressed in case conference meetings held each week and in individual supervision meetings with counselors providing treatment services.
The root cause of any failure to provide services will be identified and corrected where needed.
To further ensure that a client is compliant with her individual treatment plan, the client will be issued a weekly schedule of attendance at groups and individual sessions. The group facilitators will check off the client's attendance and the client will turn the attendance in to her respective counselor.
This corrective action will be implemented by the Project Director by December 28, 2020. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on the record provided for review on 11/20/2020, the facility failed to provide documentation of the client's progress notes.
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Plan of Correction
There shall be a progress note after each significant client contact which shall be dated and signed by the individual making the entry.
Progress notes shall include data, assessment and plans relative to treatment.
The data shall include information presented by the client during the counseling session, counselor observations and information about the client from other sources.
The assessment is the interpretative statement(s) based upon both new and previous information and includes the counselor's analysis of and conclusions regarding the client's current situation or status.
The plan, or strategies, shall reflect the counselor's actions to be taken in light of the evaluation and indicate the direction of treatment and include action steps, counselor plan(s) and client assignments or tasks.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records. The Project Director has reviewed the policy and procedures with outpatient agency treatment provider by.
Client records will be reviewed at regularly scheduled supervision meetings with the Clinical Supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records.
Adherence to the requirements regarding client records will be verified and any problems will be reported to the Project Director for corrective action. |
709.93(a)(6) 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:
(6) Individual treatment and rehabilitation plan.
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Observations
Based on the record provided for review on 11/20/2020, the facility failed to provide documentation of the client's individualized treatment and rehabilitation plan.
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Plan of Correction
The treatment provider shall begin to formulate a preliminary treatment and rehabilitation plan upon intake and assessment. At this time a history is taken and psychosocial evaluation is provided. Documentation of the finalized individual treatment and rehabilitation plan that has been developed in collaboration with the client is to be included in the client record within the required timeframe. The treatment plan shall be signed and dated by the individual rendering services. It shall also be documented that the treatment plan was developed with the client.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records.
The Project Director has reviewed the policy and procedures with the outpatient agency treatment provider.
Client records will be reviewed at regularly scheduled supervision meetings with the Clinical Supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records, plus 100% of new admissions per month of the previous month.
Adherence to the requirements regarding client records will be verified and any problems will be reported and reviewed by the Project Director for corrective action. |
709.93(a)(7) 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:
(7) Client-related correspondence.
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Observations
Based on the record provided for review on 11/20/2020, the facility failed to provide documentation of the client's related correspondence.
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Plan of Correction
The facility shall maintain a complete client record for every individual in treatment, including any client-related correspondence.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records. The Project Director has reviewed the policy and procedures with the outpatient agency treatment provider.
Client records will be reviewed at regularly scheduled supervision meetings with the Clinical Supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records, plus 100% of all discharged client records for the previous month.
Adherence to the requirements regarding client records will be verified and any problems will be reported to the Project Director for corrective action. |
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 the record provided for review on 11/20/2020, the facility failed to provide documentation of the client's aftercare plan.
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Plan of Correction
The facility shall maintain a complete client record for every individual in treatment, including an aftercare plan, if applicable.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records. The Project Director has reviewed the policy and procedures with the outpatient agency treatment provider.
Client records will be reviewed at regularly scheduled supervision meetings with the Clinical Supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records, plus 100% of all discharged client records for the previous month.
Adherence to the requirements regarding client records will be verified and any problems will be reported to the Project Director for corrective action. |
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 the record provided for review on 11/20/2020, the facility failed to provide documentation of the client's discharge summary.
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Plan of Correction
Within a week after discharge, the treatment provider shall enter into the client's record a discharge summary describing the reasons for treatment, services offered, response to treatment and client's status or condition upon discharge.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records.
The Project Director has reviewed the policy and procedures with the outpatient agency treatment provider.
Client records will be reviewed at regularly scheduled supervision meetings with the Clinical Supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records, plus 100% of all discharged client records for the previous month.
Adherence to the requirements regarding client records will be verified and any problems will be reported to the Project Director for corrective action. |