INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 30 through May 1, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The CARE Center, Inc. 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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709.81(b)(6) LICENSURE Intake and admission
709.81. 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 30 through May 1, 2008, the facility failed to document a complete psychosocial evaluation in two of two records reviewed, #3 and 4. The psychosocial evaluations were client responses and client 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.
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Plan of Correction
The clinical supervisor and facility director will provide a staff training in June 2008 regarding the correct completion of psychosocial evaluations. This will be followed up with each staff person during individual supervision. Compliance will be monitored ongoing through record reviews. |
709.82(a)(1) LICENSURE Treatment and rehabilitation services
709.82. 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 30 through May 1, 2008, the facility failed to document individualized short and long-term goals in the treatment and rehabilitation plan in two of two records reviewed, #3 and 4. The short and long-term goals were not individualized as they were the same.
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Plan of Correction
The clinical supervisor and facility director will conduct a training in July 2008 regarding the development and documenting of individualized short and long term goals. Plans will be reviewed during individual staff supervision to assure compliance. |
709.82(a)(3) LICENSURE Treatment and rehabilitation services
709.82. 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 30 through May 1, 2008, the facility failed to document proposed support services specific to each client in the individual treatment and rehabilitation plan in two of two records reviewed, #3 and 4.
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Plan of Correction
During the regular in-service training of staff regarding treatment plans, the appropriate documentation of support services will be presented by the clinical supervisor. Compliance will be reviewed during regular chart monitoring and via individual staff supervision. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records on April 30 through May 1, 2008, the facility failed to document a complete treatment and rehabilitation plan update at least every 30 days in two of two records, #1 and 3. Treatment plan updates did not include an assessment of the client's progress in relationship to the previously stated goals. In addition, goals not completed were simply dropped from the treatment plan with no explanation.
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Plan of Correction
In-service staff training will be conducted by the clinical supervisor in June 2008. This training will include a comprehensive review of the time frames and procedures for documenting a client's progress in relation to their individualized goals.
Staff will also receive individual supervision and chart review to assure compliance. |
709.83(a)(9) LICENSURE Client records
709.83. 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) Progress notes.
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Observations
Based on a review of client records on April 30 through May 1, 2008, the facility failed to document complete progress notes in three of three records, #1, 3 and 4. Progress notes for group counseling failed to include the clinician's assessment for each client. Individual counseling sessions were missing the clinician's assessment and plan. In addition, there was no continuity between progress notes and how they related to the client's individual treatment and rehabilitation plan.
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Plan of Correction
The clinical supervisor will conduct a staff in-service on documentation of both individual and group treatment progress notes. Emphasis of the training will be on the correct and accurate writing of the clinician's assessment and plan in the documentation. Further, continuity between progress notes and how they relate to the client's individual treatment and rehabilitation plan will be addressed. Quality assurance reviews and individual supervision will be used to monitor compliance.
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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 before December 31st of 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 30 through May 1, 2008, the facility failed to document informed and voluntary consent to release information forms in three of five records reviewed, #2, 6 and 7.
Client records #2, 6 and 7 contained consent to release information forms for the funding source where the purpose of the consent was "other" with no further clarification.
Client information was released without a signed consent form in one record, #6. Copies of letters sent to Adult Probation and The D.U.I. Office were in the client record without a signed consent to release information form signed by the client.
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Plan of Correction
The consent form containing the line "other" has been revised and "other" has been removed. In the client record noted where consents were not in the chart, the clinical supervisor has met with the staff and secured the documents which had been completed but had not been properly filed. The clinical supervisor provided direct supervision to this staff, as well as all clinical and support staff, regarding the correct filing of all documentation prior to filing and/or closing a file.
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 30 through May 1, 2008, the facility failed to document a complete psychosocial evaluation in three of three records reviewed, #2, 6 and 7. The psychosocial evaluations were client responses and client 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.
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Plan of Correction
The clinical supervisor and facility director will provide a staff training in June 2008 regarding the correct completion of psychosocial evaluations. This will be followed up with each staff person during individual supervision. Compliance will be monitored ongoing through record reviews. Emphasis will be given to documenting the 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.
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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 30 through May 1, 2008, the facility failed to document individualized short and long-term goals in the treatment and rehabilitation plan in three of three records reviewed, #2, 6 and 7. The short and long-term goals were not individualized as they were the same. In addition, in record #6 the client was mandated to attend two individual sessions and six group sessions, but an individual treatment and rehabilitation plan was not developed.
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Plan of Correction
The clinical supervisor and facility director will conduct a training in July 2008 regarding the development and documenting of individualized short and long term goals. Plans will be reviewed during individual staff supervision to assure 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 30 through May 1, 2008, the facility failed to document proposed support services specific to each client in the individual treatment and rehabilitation plan in three of three records reviewed, #2, 6 and 7.
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Plan of Correction
During the regular in-service training of staff regarding treatment plans, the appropriate documentation of support services will be presented by the clinical supervisor. Compliance will be reviewed during regular chart monitoring and via individual staff supervision. |
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 30 through May 1, 2008, the facility failed to document a complete treatment and rehabilitation plan update at least every 30 days in three of three records, #1, 2 and 7. The treatment plan update was missing in record #7. Treatment plan updates did not include an assessment of the client's progress in relationship to the previously stated goals in two records, #1 and 2. In addition, goals not completed were simply dropped from the treatment plan with no explanation.
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Plan of Correction
In-service staff training will be conducted by the clinical supervisor in June 2008. This training will include a comprehensive review of the time frames and procedures for documenting a client's progress in relation to their individualized goals. Staff will also receive individual supervision and chart review to assure compliance. |
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 a review of client records on April 30 through May 1, 2008, the facility failed to document complete progress notes in three of three records, #1, 2 and 6. Progress notes for group counseling failed to include the clinician's assessment for each client. Individual counseling sessions were missing the clinician's assessment and plan. In addition, there was no continuity between progress notes and how they related to the client's individual treatment and rehabilitation plan.
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Plan of Correction
The clinical supervisor will conduct a staff in-service on documentation of both individual and group treatment progress notes. Emphasis of the training will be on the correct and accurate writing of the clinician's assessment and plan in the documentation. Further, continuity between progress notes and how they relate to the client's individual treatment and rehabilitation plan will be addressed. Quality assurance reviews and individual supervision will be used to monitor compliance. |