INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 15 through 17, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House-CU, 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.
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in three of six records reviewed.
Findings:
Twelve personnel records were reviewed on November 15, 2011. Six personnel records were reviewed for counselor qualifications. Three records were promoted from counselor assistant to counselor prior to meeting the required experience to be a counselor.
Employee # 6 was hired as a counselor assistant on February 11, 2010. Employee # 6 had a qualified Bachelor's Degree; however, after review of their work history they needed to gain one year of clinical experience in a health or human service agency, preferably in a drug an alcohol setting before being promoted to counselor. On November 29, 2010, after eight months of employment, this staff member was promoted to counselor prior to having a year's clinical experience. This employee was not eligible to be a counselor until February 11, 2011.
Employee # 7 was hired as a counselor assistant on November 3, 2010. Employee # 7 had a qualified Bachelor's Degree; however, after review of their work history they needed to gain one year of clinical experience in a health or human service agency, preferably in a drug an alcohol setting before being promoted to counselor. On May 6, 2011, after six months of employment, this staff member was promoted to counselor prior to having a year's clinical experience. This employee was not eligible to be a counselor until November 3, 2011.
Employee # 8 was hired as a counselor assistant on July 19, 2010. Employee # 8 had a qualified Associates Degree, however, after review of their work history they needed to gain two years of clinical experience in a health or human service agency, preferably in a drug an alcohol setting before being promoted to counselor. On May 12, 2011, after ten months of employment, this staff member was promoted to counselor prior to having a year's clinical experience. This employee was not eligible to be a counselor until July 19, 2012.
This was discussed with the facility director on November 15, 2011 and she acknowledged that the staff were promoted to counselor status prior to obtaining the required experience according to the staffing regulations.
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Plan of Correction
Employee #8 has an associates degree and was promoted to a counselor on May 12th. Effective 11/17/11 this counselor went back to being a counselor assistant until he receives 2 year experience and a posistve evaluation to be promoted. The Program Directoe will monitor the staffing qualification and make sure all clinical staff meet the qualifications for their positions prior to hire and promotion. The Program director will be responsible for following the regulations. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on the review of employee training records, the facility failed to document a training plan that was developed with the employee and their supervisor in ten of ten records. .
The findings include:
The facility's training year runs from January to December each year. The training plans are to be completed by the end of January each year. On November 15, 2011, training plans were reviewed for 2011 training year. The facility documented a training plan in all ten records reviewed, however, the facility failed to provide documentation that authenticated that the plan was developed with the employee and their supervisor in record # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
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Plan of Correction
Effective 2/1/12, All new training plans will be completed and authenticated by each employee and their supervisor. The Program Director will monitor for compliance. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, staffing requirements facility summary report, the facility failed to ensure that all staff obtained at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum within one year of the date of hire for counselors and counselor assistant and within two years of the date of hire date for all other staff.
The findings include:
Twelve personnel records were reviewed on November 15, 2011. There was no documentation of TB/STD training in one employee record. They were required to have TB/STD training within the one year of employment. An interview with the Facility Director on November 15, 2011 confirmed this finding.
Employee #8 was hired July 19, 2010 and was required to have TB/STD training by July 19, 2011. There was no documentation of TB/STD training in the employee's record as of November 15, 2011.
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Plan of Correction
Effective 12/7/11, A training will be held between the Clinical Supervisor and the Program Director regarding the importance of having the required training within the first year of employment. Any new employee will have the required training within one year of employment. The Clinical Supervisor will monitor all employees to make sure they are scheduled to receive the required trainings. The Program Director will monitor for compliance.Employee #8 has been scheduled for Feb 7th TB/STD, and Feb 16th HIV/AIDS. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the staffing requirements facility summary report form completed by the facility on November 15, 2011 and the patient list with counselor assignments, the facility failed to ensure that staff to client ratios remained at or under 35:1.
The findings included:
Nine counselors caseloads were reviewed on November 17, 2011. Based on the number of hours the employee worked at this facility, and the number of clients on the counselors' caseload, one counselor exceeded the caseload of 35:1. . The counselor represented by personnel record #5 had a caseload of 36:1, which exceeds the maximum of 35:1.
Employee # 5 had an assigned caseload of 37 patients according to the patient list with counselor assignments. There were 26 patients who were justified as a reduced caseload. However, according the the exception that the facility has with the Department, no more than 50% of the counselor's caseload can be reduced. Therefore, the counselor could only have 19 clients with reduced counseling hours on their caseload. A review of the caseload concluded the findings.
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Plan of Correction
The Program Director and the clinical supervisor have been reviewing each counselor caseload.
Effective 1/31/12, counselors that have not worked at the facility long enough will have a ratio of no more than 35.1 We have been reviewing the caseload and have corrected th deficiency. The Clinical Supervisor and the Program Director will be responsible to monitor compliance with each counselor caseload.
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on observation during the physical plant inspection the facility failed to ensure privacy so that counseling sessions cannot be seen outside the counseling room.
The findings include:
A physical plant inspection was conducted on November 15, 2011. During the tour between 3:30 p.m. and 4:00 p.m. four counselor offices, the clinical supervisor's office, the facility directors office, and the window in the lobby did not have window coverings in place. On November 17, 2011 the licensing specialists walked the perimeter of the facility and observed clients in the lobby and a client in a counseling office. The facility director confirmed that window coverings were not in place.
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Plan of Correction
Effective 12/31/2011, four counselor offices, the facility directors office, and the window in the lobby will have window coverings placed on them to prevent any persons who may walk around the perimeter from observing inside the facility. Compliance will be the responsibility of the facility Director. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill logs, the facility failed to activate a fire alarm or smoke detector during each fire drill.
The findings include:
The fire drill logs were reviewed on November 15, 2011. Per regulation, the nonresidential facility shall set off a fire alarm or smoke detector during each fire drill. The fire drill log was reviewed for documentation of fire drills from the time period of October 2010 to October 2011. The facility failed to documented on the fire drill logs that a smoke detector or fire alarm had been activated for the monthly fire drills documented during this period.
The facility director was interviewed on November 15, 2011 and confirmed the fire alarm or smoke detector was not activated each month.
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Plan of Correction
As of 11/15/11, we are no longer able to use the exception for the use of the cow bell in place of sounding the fire alarm. Effective 12/7/11, we will be activating the fire alarm or the smoke detector during each monthly fire drill. The Health and Safety Captain will be responsible to ensuring this is done monthly. The Program Director will monitor for compliance. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the 2010 annual report during the onsite licensing inspection of November 15, 2011 through November 17, 2011, the facility failed to document a financial statement of income and expenses in the body of the report.
The findings include:
The annual report was reviewed during the licensing inspection on November 15, 2011. No financial statement of income and expenses was included in the provided published report.
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Plan of Correction
Although the financial statement was provided for the 11/15/11 audit it was not a part of the published report. Effective in the 2011 report, the financial statement of income and expenses will be included in the published report. The Program Director will be responsible to work and remind Home Office quarterly to see that it is included. |
709.26(d)(4) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(4) Salary information.
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Observations
Based on a review of personnel records, the facility failed to document salary information in one of twelve personnel records, as required by regulation.
The findings include:
Twelve personnel records were reviewed on November 15, 2011. Per regulation, personnel records should include salary information. Personnel record #1 did not include documentation of salary information.
Employee #1 was hired on July 1, 1992. There was no documentation of salary information in personnel record #1.
The facility director was interviewed on November 15, 2011. It was confirmed that no salary information was documented in personnel record #1.
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Plan of Correction
Effective 2012 during the annual merit increases, the project director's salary information will be sent to the Dept. of Health Supervisor annually. The projects salary can be made available to the auditors during a license inspection upon there request and can be faxed to the facility. The Program Director will be responsible to work with the Home Office to see that it is done. |
715.16(b)(1-8) LICENSURE Take-home privileges
(b) The narcotic treatment physician shall consider the following in determining whether, in exercising reasonable clinical judgment, a patient is responsible in handling narcotic drugs:
(1) Absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol.
(2) Regular narcotic treatment program attendance.
(3) Absence of serious behavioral problems at the narcotic treatment program.
(4) Absence of known recent criminal activity.
(5) Stability of the patient 's home environment and social relationships.
(6) Length of time in comprehensive maintenance treatment.
(7) Assurance that take-home medication can be safely stored within the patient 's home.
(8) Whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risks of drug diversion.
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Observations
Based on the review of patient records, the facility granted take home privileges despite the fact the patient did not meet the eight point criteria for take-home privileges
The findings include:
Twenty-seven patient records were reviewed November 16-17, 2011. Seven patient records were reviewed for take home status. Patient # 1 was admitted March 31, 2011. The patient had been granted tri-weekly take home privileges. The counselor documented in the patient record that patient #1 reported involvement with law enforcement on November 8, 2011. The patient was AWOL from the clinic on this day. There was no documentation in the record that the patient tried to contact the clinic. The patient informed her counselor that she stopped for a motor vehicle violation and is presently being investigated for the offense of Driving Under the Influence. The patient's record also indicated that her brother also uses drugs and that her children's father has relapsed making the stability of her home environment and social relationships questionable.
This record was discussed with the facility director and confirmed this finding.
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Plan of Correction
This patient informed her counselor that she stopped for a motor vehicle violation and is presently being investigated for the offense of Driving Under the Influence. The patient's record also indicated that her brother also uses drugs and that her children's father has relapsed making the stability of her home environment and social relationships questionable. Each patient must meet the eight point criteria sent forth by the Dept. Of Health in order to receive take homes and maintain take homes. Effective 12/31/11, a training will be held by the Clinical Supervisor for all counselors regarding the 8 point criteria. The Clinical Supervisor will be responsible to review each record. The Dr. will make the final approval for take homes. The Clinical Supervisor will be responsible to review the record. The Program Director will do sporadic checks to ensure compliance. This patient was released of all charges and her brother is in treatment at the Dhcu. The Clinical Supervisor will be responsible to review each record. The Dr. will make the final approval for take homes. The Clinical Supervisor will be responsible to review the record. The Program Director will do sporadic checks to ensure compliance. |
715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
Based on the review of patient records, the facility failed to document all efforts to retain the patient in the program prior to initiating an involuntary termination in one of three patient records.
The findings include:
Twenty-seven patient records were reviewed November 16-17, 2011. Three patient records were reviewed for involuntary discharge. Patient # 19 was admitted August 19, 2009. On July 13, 2011, the patient's financial situation was discussed in a couple's session. A general note on the same day stated the patient would be placed on a payment plan the next day or July 15, 2011, with a start of a 10 day medically supervised withdrawal on July 18, 2011. The financial issue was added to the treatment plan on July 19, 2011. A letter regarding the commencement of an administrative taper was signed by non-medical staff on July 21, 2011, with an 8 mg per day taper to begin on July 22, 2011. The patient signed the letter on July 22, 2011. The letter stated the reason for the action was due to patient noncompliance with getting financial issues and refusal to pay on the bill. An order for the medically supervised withdrawal due to noncompliance with program rules was signed by the narcotic treatment physician on July 22, 2011. The patient continued to present for medication dosing and clinical sessions until the last day of the medically supervised withdrawal.
This record was discussed with the facility director and confirmed this finding.
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Plan of Correction
Effective 12/31/11, a training will be held by the Program Director regarding involuntary terminations shall only be initiated when all other efforts to retain the patient has failed. Prior to all involuntary terminations the Program Director will review the record to make sure the patient is not involuntarily discharged for financial issues. The Program Director will monitor each chart to make sure patients are not involuntarily discharged. |
715.29(4) LICENSURE Exceptions
A narcotic treatment program is permitted, at the time of application or any time thereafter, to request an exception from a specific regulation.
(4) The narcotic treatment program shall maintain documentation of the Department 's approval of an exception.
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Observations
Based on the review of documentation, the facility failed to follow the exception granted by the Department allowing the counselors to exceed the 35:1 caseload.
The findings include:
The facility staffing summary report and the client/counselor caseload list was reviewed during the November 15, 2011 through November 17, 2011 licensing renewal inspection. According the the Department's exception notice,"no more than one half of a caseload with a maximum caseload of 50 patients will be considered per counselor. Counselor Assistants may not be included in the variance." The facility failed to comply with this exception by allowing five of eight counselors to have over 50% of their caseload on reduced counseling hours.
Employee # 4 was assigned 37 patients. The counselor was permitted to have 18 assigned patients that could have reduced counseling hours. At the time of the inspection, this counselor had 26 patients on a reduced counseling schedule. This number of patients exceeded the permissible number of clients allowed to have reduced counseling hours.
Employee # 8 was assigned 36 patients. The counselor did not meet the qualifications to be a counselor and was not eligible to carry any patients with a reduced caseload. At the time of the inspection this counselor had 17 patients on a reduced caseload.
Employee # 9 was assigned 46 patients. The counselor was permitted to have 23 assigned patients that could have reduced counseling hours. At the time of the inspection, this counselor had 31 patients on a reduced counseling schedule. This number of patients exceeded the permissible number of clients allowed to have reduced counseling hours.
Employee # 10 was assigned 46 patients. The counselor was permitted to have 23 assigned patients that could have reduced counseling hours. At the time of the inspection, this counselor had 30 patients on a reduced counseling schedule. This number of patients exceeded the permissible number of clients allowed to have reduced counseling hours.
Employee # 13 was assigned 46 patients. The counselor was permitted to have 23 assigned patients that could have reduced counseling hours. At the time of the inspection, this counselor had 29 patients on a reduced counseling schedule. This number of patients exceeded the permissible number of clients allowed to have reduced counseling hours.
Employee # 14 was assigned 45 patients. The counselor was permitted to have 22 assigned patients that could have reduced counseling hours. At the time of the inspection, this counselor had 28 patients on a reduced counseling schedule. This number of patients exceeded the permissible number of clients allowed to have reduced counseling hours.
This finding was discussed with the facility director and she confirmed this finding.
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Plan of Correction
The Program Director and the clinical supervisor have been reviewing each counselor caseload. Effective 1/31/12, each counselor case load will have no more than 50% reduced counseling hours on their case loads. The Clinical Supervisor will look over each case load monthly to make sure of compliance and the Program Director will be responsible to monitor compliance with the waiver. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of the patient records, the facility failed to provide a personal history that included detail in the areas of family history, legal history, employment/vocational history, education history, military history, recreational history, prior treatment, client's perception of drug use, family drug abuse history and sexual history in fourteen of fourteen records.
The findings include:
Twenty-seven records were reviewed for compliance with the documentation of personal histories. Fourteen records did not document personal histories that included all components of a personal history, specifically, patient records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 20, 26, and 27.
Record # 1 - Patient was admitted on 3-31-2011. The personal history failed to include information in the area of sexual history.
Record # 2 - Patient was admitted on 8-5-2011. The facility failed to document a personal history to include employment/vocational history, military history, and sexual history.
Record # 3 - Patient was admitted on 7-28-2011. The facility failed to document a personal history to include family drug abuse history, employment/vocational history, and sexual history.
Record # 4 - Patient was admitted on 10-13-2011. The facility failed to document a personal history to include employment/vocational history.
Record # 5 - Patient was admitted on 8-16-2011. The facility failed to document a personal history to include family drug abuse history and sexual history.
Record # 6 - Patient was admitted on 8-4-2011. The facility failed to document a personal history to include military history and sexual history
Record # 7 - Patient was admitted on 9-20-2011. The personal history failed to include information in the area of legal history, employment/vocational history, and sexual history.
Record # 8 - Patient was admitted on 10-20-2011. The personal history failed to include information in the area of legal history, employment/vocational history, and sexual history.
Record # 9 - Patient was admitted on 8-11-2011. The personal history failed to include information in the area of legal history and employment/vocational history.
Record # 11 - Patient was admitted on 8-4-2011. The personal history failed to include information in the area of family drug abuse history, legal history, military history, and sexual history.
Record # 12 - Patient was admitted on 11-1-2011. The personal history failed to include information in the area of legal history and employment/vocational.
Record # 20- Patient was admitted on 3-8-2011. The personal history failed to include information in the area of family drug abuse history, legal history, educational history, and sexual history.
Record # 26 - Patient was admitted on 9-20-2011. The personal history failed to include information in the area of family history, employment/vocational history, and sexual history.
Record # 27 - Patient was admitted on 10-6-2011. The personal history failed to include information in the area of employment/vocational history and sexual history.
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Plan of Correction
A training is scheduled for 12/8/11 with the Clinical Supervisor regarding the importance of having a detailed history in the area of : family, legal, employment/vocational, educational, military, recreational, prior treatment, and the client's perception of drug use, family drug abuse history and sexual history. The Lead Counselor and Clinical Supervisor are responsible to make sure each patient history is complete prior signing the document complete. The Program Director will be responsible to maintain compliance.
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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 review of patient records, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client, as required.
The findings include:
Twenty-seven patient records were reviewed on November 16, 2011 through November 17, 2011. Sixteen records were reviewed for treatment plans being developed with the client. Eight of the patient record failed to ensure that the treatment plan was developed with the client, specifically in patient records # 4, 5, 9, 10, 13, 14, 17, and 18.
Patient # 4 was admitted on October 13, 2011. The patient's personal history was documented on November 16, 2011. The comprehensive treatment plan was documented on November 14, 2011 prior to the patients personal history being completed. There was no documentation that this plan was developed with the patient's input due to the treatment plan being done prior to the patient's history being documented.
Patient # 5 was admitted on August 16, 2011. The comprehensive treatment plan was completed on September 12, 2011. Treatment plan updates are due every sixty days. The treatment plan update was completed on November 16, 2011. This was completed four days late. Additionally, the treatment plan update was reviewed and the plan was signed when the patient came in and dosed. There was no documentation in the progress notes that the treatment plan update was reviewed with the patient by their counselor.
Patient # 9 was admitted on August 11,2 011. The comprehensive treatment plan was completed on September 9, 2011. The treatment plan update was completed on November 10, 2011. The treatment plan update was signed when the patient came in and dosed. There was no documentation in the progress notes that the treatment plan update was reviewed with the patient by their counselor.
Patient # 10 was admitted October 31, 2008. The treatment plan update was completed on September 28, 2011. The treatment plan update was signed when the patient came in and dosed. There was no documentation in the progress notes that the treatment plan update was reviewed with the patient by their counselor.
Patient # 13 was admitted August 8, 2009. The treatment plan update was completed on November 8, 2011. The treatment plan update was signed when the patient came in and dosed. There was no documentation in the progress notes that the treatment plan update was reviewed with the patient by their counselor.
Patient # 14 was admitted February 3, 2009. The treatment plan update was completed on November 11, 2011. The treatment plan update was signed when the patient came in and dosed. There was no documentation in the progress notes that the treatment plan update was reviewed with the patient by their counselor.
Patient # 17 was admitted March 17, 2008. The treatment plan updates were completed on April 13, 2011 and June 13, 2011. There was no documentation in the progress notes that the treatment plan updates were reviewed with the patient by their counselor.
Patient # 18 was admitted October 20, 2010. The treatment plan update was completed on May 20, 2011. There was no documentation in the progress notes that the treatment plan update was reviewed with the patient by their counselor.
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Plan of Correction
A training is scheduled for 12/8/11 with the Clinical Supervisor regarding the importance of having an individual treatment and rehabilitation plan be developed with the client and each patient will sign the plan with their counselor. The Lead Counselor and Clinical Supervisor will be responsible to make sure this is done. The Program Director will monitor for compliance.
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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, the facility failed to document support services on five of thirteen client records reviewed.
The findings include:
Twenty-seven client records were reviewed on November 16, 2011 through November 17, 2011. Thirteen client records were reviewed for documentation of proposed support services on the client's treatment plan. Client records # 1, 3, 4, 6, and 7 had no documentation of proposed support services on the comprehensive treatment plan.
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Plan of Correction
A training is scheduled for 12/8/11 with the Clinical Supervisor regarding the importance of having an individual treatment and rehabilitation plan be developed with the client including proposed type of support services. The Lead Counselor and Clinical Supervisor will monitor each client record for compliance prior to signing the plan completed. The program Director will monitor for compliance. |