INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 5, 2010 through April 6, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Colonial House, 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 April 30, 2010.
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Plan of Correction
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. 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 psychosocial evaluations in nine of ten records reviewed.
The finding includes:
Ten records were reviewed on April 5, 2010. Psychosocial evaluations were required in ten records reviewed.
Client record #1 failed to evaluate the client's support systems and coping mechanisms.
Client record #2 failed to document the client's composite picture and evaluate the client's support systems and coping mechanisms.
Client record #3 failed to evaluate the client's assets and strengths, support systems, coping mechanisms and clients negative factors that might inhibit treatment.
Client record #4 failed to evaluate the client's assets and strengths, support systems and coping mechanisms.
Client record #5 failed to evaluate the client's support systems, coping mechanisms and clients negative factors that might inhibit treatment.
Client record #6 failed to evaluate the client's assets and strengths, support systems, coping mechanisms and clients negative factors that might inhibit treatment.
Client record #7 failed to evaluate the client's assets and strengths, support systems, coping mechanisms, the client's attitude towards treatment and the counselor conclusions/impressions of the client.
Client record #8 failed to evaluate the client's assets and strengths, support systems, coping mechanisms and clients negative factors that might inhibit treatment.
Client record #10 failed to evaluate the client's assets and strengths, support systems, coping mechanisms and clients negative factors that might inhibit treatment.
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Plan of Correction
On 4/22/2010, the Clinical Supervisor met with the entire clinical team to discuss findings from the site inspection. During the meeting, she went over the correct way to complete the counselor's impression. She stressed that the impressions must evaluate the information provided during the interview. For example, it is not correct to just list factors, triggers, or problems. The purpose of the impression is to give a composite assessment of the client strengths and weaknesses which in turn provides the basis for the goals on the treatment plans.
The clinical supervisor advised the treatment that she would be reviewing the impressions weekly during regular staff meetings and individually as needed.
The clinical supervisor will be resposible for insuring compliance with this standard. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 client records, the facility failed to document comprehensive treatment plans after the completion of the clients' assessments in five of ten client records.
The findings include:
Ten client records were reviewed on April 6, 2010. Comprehensive treatment plans can not be documented until the clients' psychosocial and psychosocial evaluations are completed. Treatment plans were required in ten client records. Client records #1, 2, 4, 6 and 10 contained comprehensive treatment plans that were completed before the clients' psychosocial evaluations were completed. Client record #1's comprehensive treatment plan was completed on 3/19/10 and the psychosocial evaluation was completed on 3/20/10. Client record #2's comprehensive treatment plan was completed on 2/3/10 and the psychosocial evaluation was completed on 2/4/10. Client record #4's comprehensive treatment plan was completed on 2/18/10 and their psychosocial evaluation was completed on 2/19/10. Client record #6's comprehensive treatment plan was completed on 1/28/10 and their psychosocial evaluation was completed on 1/29/10. Client record #10's comprehensive treatment plan was completed on 2/16/10 and their psychosocial evaluation was completed on 2/17/10.
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Plan of Correction
On 4/22/2010, the clinical supervisor conducted a staff meeting with clinical team to address the findings from site inspection. She went over the timeline for completion of paperwork. She paid particular attention to when the Biopsych and treatment plans are to be completed. Treatment plans cannot predate biopsychsocials. The team must pay close attention to the dates being documented in the client records. No treatment plans are to be prepared prior to completion of the biopsych and counselor impression.
The clinical supervisor will be responsible for on-going monitoring of compliance of this standard. She will continue to review all treatment plans and check to make sure the treatment is completing paperwork in the correct order and address the clinical team as needed. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document follow-up information in four of five discharge records reviewed.
The findings include:
Ten client records were reviewed on April 6, 2010. Follow-up information was required in five discharge records. Per the facilities policy and procedure all follow-ups will be done within 7 days of clients discharge and 7 days if client is being referred.
Client record #6 was admitted on 1/28/10 and discharged on 2/5/10; there was no documentation of follow-up in the client record.
Client record #8 was admitted on 2/22/10 and discharged on 3/2/10; the follow-up was not completed until 3/15/10.
Client record #9 was admitted on 1/6/10 and discharged on 3/28/10; there was no documentation of follow-up in the client record.
Client record #10 was admitted on 2/16/10 and discharged on 3/8/10; there was no documentation of follow-up in the client record.
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Plan of Correction
On 4/22/2010, the clinical supervisor conducted a staff meeting to address findings from site visit. She spent time discussing follow-up notes. The team was advised that all clients no matter the staus of the discharge must have a follow-up note documente din the chart within 7 days of the discharge. In the event, the counselor is unable to reach anyone personally, they must still document their attempts to conduct the follow-up.
The clinical supervisor will monitor for future compliance during weekly staff meetings and individual supervision meetings. |