INITIAL COMMENTS
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This report is a result of an on-site plan of correction follow up inspection conducted on February 24, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cen Clear Child Services, Inc. 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 March 19, 2010.
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Plan of Correction
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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 the review of client records during the onsite plan of correction follow up inspection, the facility failed to document an informed, complete client consent for each disclosure of information.
The findings included:
Four client records were reviewed during the inspection . Three client records were applicable for this regulation.
Client record # 2- The client was admitted to treatment on 11/2/09. A consent to release information form, signed by the client and the counselor as a witness, for a release of information to the local courts did not identify the specific information that would be released.
Client record # 3- The client was admitted on 1/21/09. A consent to release information to another treatment provider in the area was filed in the client record . The consent failed to identify the purpose for the release of information. A second consent to release information to a funding entity did not identify the specific information to be released. Both consents were signed by the client and the counselor as a witness.
The findings were reviewed with the Director and he agreed that they were accurate.
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Plan of Correction
The facilily and project will retrain all staff in completion of forms in their entirety. In addition, the project director will discuss deficiencies in regularly scheduled supervisions. In addition, there will documentation of a completed,revised and valid consent to release in the current charts to reflect the deficient areas. |
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 the review of agency policy, an interview with the Director and a review of client records, the facility failed to document treatment plans within the timeframe specified in written agency policy, which required that the comprehensive treatment plan be completed by the fourth session in two of two client records.
The findings included:
Four client records were reviewed on February 24, 2010. Two client records were required to include documentation of treatment plans. The treatment plans were not documented within the time frame stipulated by facility policy and procedure.
Client record # 1 - The client was admitted on 10/13/2009. The treatment plan was completed on 11/24/2009. This was the sixth session for this client.
Client record # 3- The client was admitted on 11/21/2009. The treatment plan was documented on 1/19/2010. This was the sixth session for this client.
The counselor and Director were interviewed and acknowledged that the treatment plans are due at the time of the fourth scheduled session. The findings were reviewed with the Director and he was in agreement that they were accurate.
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Plan of Correction
Our current policy states that treatment plans are to be completed within 6 sessions. We will continue to monitor that timeline of submission occurs by the Project Director |
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 the review of client records during the plan of correction follow up inspection of 2/24/2010, the facility failed to identify the proposed type of support service on each treatment plan .
The findings included:
Four client records were reviewed during the onsite inspection. Two client records were required to include documentation of complete treatment plans by the fourth treatment session.
Client record # 1- The client was admitted on 10/13/2009. The treatment plan was documented on 11/24/09. At the time of the record inspection on 2/24/2010, support services were not documented on the treatment plan as required.
Client record # 3- The client was admitted on 11/21/2009. The treatment plan was documented on 1/19/2010. At the time of the record inspection on 2/24/2010, support services were not documented on the treatment plan as required.
The findings were reviewed with the Director and he agreed that they were accurate.
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Plan of Correction
Project Director will review treatment plans for completeness. Staff have been instructed to idnetify what support services have been identified for each consumer. The treatment plan is being updated to incorporate/added additional support services that are available in the community. |
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 review of client records during the onsite licensing inspection of 2/24/2010, the facility failed to identify support services on each aftercare plan for the client to utilize after discharge in two of two client records.
The findings included:
Four client records were reviewed during the onsite inspection. Two client records were successful discharges and were required to have aftercare plans which included support services.
Client record # 1- The client was admitted on 10/13/09 and discharged on 1/12/10. The aftercare plan was timely but failed to include documentation of the support services the client would utilize after discharge.
Client record # 4- The client was admitted on 9/15/09 and discharged on 12/22/09. The aftercare plan was timely but failed to include documentation of the support services the client would utilize after discharge.
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Plan of Correction
Aftercare/Discharge Planning will be reviewed in supervision with the Project Director for completeness and accuracy. If incomplete therapist will instructed to complete during supervision time. |