INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 11, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services, Lancaster 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 18, 2008.
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Plan of Correction
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the facility's policies and procedures, the facility failed to have a written procedure that complied with 4 Pa. Code 255.5. The facility's written procedures for the confidentiality of client identity and records contained a document entitled "Confidentiality Regulations and the Drug and Alcohol Treatment Programs". This procedure included the wording that allowed for the release of client information "with or without the client's consent" to judges and probation/parole.
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Plan of Correction
The Director of Quality Improvement has revised the "Confidentiality Regulations and the Drug and Alcohol Treatment Programs" procedure to state that client information can only be released with the client's consent to judges and probation/parole. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records and staff interview, the facility failed to comply with the limitation imposed by 4 Pa. Code 255.5. Information disclosed to the probation/parole officer included the client's balance owed for treatment in four of thirteen client records reviewed, #3, 7, 11 and 13.
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Plan of Correction
The Facility Director will oversee that staff are re-educated through staff meeting regarding the limitations imposed by 4 Pa. Code 255.5 and specifically regarding limitations which affect information that may be disclosed to the probation/parole officer. The Quality Improvement Department will oversee the revision of the form staff use to communicate with probation/parole, the area that documents the client's balance owed will be removed. |
709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
Based on a review of the client census reports generated by the data collection and record keeping system, the facility failed to document an accurate data collection and record keeping system. The facility was unable to produce admission dates on active clients listed on these computer generated forms. The facility was unable to determine which clients were admitted to the facility and which received an evaluation only and were not admitted to the facility.
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Plan of Correction
The data collection and record keeping system for this facility was updated to include admission dates on active clients. |
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, the facility failed to document a complete psychosocial evaluation in twelve of twelve client records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12. Psychosocial evaluations did not provide a composite picture of the client. The clinician used one or two word answers with little to no clinical assessment of the client's problems/needs, assets/strengths, potential or available support systems, coping mechanisms, negative factors that may inhibit treatment, and the client's attitude toward treatment.
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Plan of Correction
The Facility Director will oversee that staff are re-educated in staff meeting to provide a composite picture of the client in the psychosocial evaluation. Staff will be reminded to give more clinical insight and to avoid using one or two words answers when assessing the client's needs, strengths, support systems and other factors that may affect treatment. The Quality Improvement Department will also oversee the revision of our psychosocial evaluation to include additional room for staff to document more detailed clinical impressions. The Quality Improvement Department will also monitor the content of our psychosocial evaluations through ongoing chart audits. |
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, the facility failed to document a complete treatment plan update in nine of twelve records reviewed, #2, 3, 4, 5, 6, 8, 9, 10 and 11. The treatment plan update was missing in one record reviewed, #6. Treatment plan updates did not include an assessment of the client's progress in relationship to the goals stated on the comprehensive treatment plan in eight records reviewed, #2, 3, 4, 5, 8, 9, 10 and 11.
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Plan of Correction
The Facility Director will remind staff in staff meeting to complete all treatment plan updates in a timely manner. Staff will also be re-educated to include an assessment of the client's progress in relationship to the goals stated on the comprehensive treatment plan. The Project Director and Quality Improvement Department will also oversee an ongoing internal monitoring system by the office administration to ensure the timely completion of treatment plan updates. |
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 review of the client records, the facility failed to document complete progress notes in eight of twelve records review, #1, 2, 3, 4, 5, 6, 8 and 9. Progress notes for records one through six were illegible handwriting on many progress notes, group notes were missing either data, assessment or plan. Also, records # 8 and 9 were missing several sessions.
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Plan of Correction
The Facility Director will oversee that all staff are educated in staff meeting to legibly and thoroughly complete progress notes for each session. The Project Director and Quality Improvement Department will oversee an internal monitoring system to ensure that there is a note present for each session. The Quality Improvement Department will also monitor the content of progress notes through random chart audits. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations in four of ten records reviewed, #2, 4, 5 and 6. Case consultation were not documented within ninety days in three records, #2, 5 and 6 and in record #6 only one staff person present at the case consultation. The summary and disposition for the case consultation in client record #4 was incomplete.
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Plan of Correction
The Facility Director will oversee that all staff are reminded in staff meeting to thoroughly complete case consultations, including the summary and dispostion for the consult, in a timely manner. The Quality Improvement Department will oversee an internal monitoring system by office administration to ensure the timely completion of case consultations. |
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 a review of client records, the facility failed to document complete aftercare plans in five of five records reviewed, #5, 6, 11, 12 and 14. Aftercare plans did not include individualized goals and time frames for the completion of each goal in three records, #6, 12 and 14. Aftercare plans were missing in two records, #5 and 11.
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Plan of Correction
The Facility Director will oversee that staff are re-educated through staff meeting to complete aftercare plans that include individualized goals with specific time frames. The Quality Improvement Department will oversee an internal monitoring system to ensure that an aftercare plan is completed for every successful discharge. The Quality Improvement Department will also monitor the content of the aftercare plans through random chart audits. |
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 a review of client records, the facility failed to document a complete discharge summary in five of six records reviewed, #5, 6, 11, 13 and 14. Discharge summaries did not include the client's reason for treatment in two records, #6 and 13. The client's response to their treatment goals was missing in five records, #5, 6, 11, 13 and 14.
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Plan of Correction
The Facility Director will oversee that staff are re-educated through staff meeting to document a complete discharge summary which includes the client's reason for treatment and the client's response to their treatment goals. The Quality Improvement Department will monitor the content of the discharge summaries through random chart audits. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records and staff interview, the facility failed to document follow-up information in three of four client records reviewed, #5, 11 and 12. Follow-up information was missing
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Plan of Correction
The Facility Director will oversee that staff follow company procedure regarding discharge notification and follow-up to ensure that follow-up information is documented in each discharged client record. The Quality Improvement Department will provide ongoing monitoring through random chart audits. |