INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 11 through 12, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Western Pennsylvania Teen Challenge 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 12, 2009.
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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, the facility disclosed a list of full client names in one of five client records.
The findings include:
Five client records were reviewed on February 12, 2009. Client record #2 contained a document that included a list of four client's full names.
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Plan of Correction
Record #2 contained a scrap piece of paper that had 4 full names of clients. The scrap paper was removed and disposed of becuase it was not necessary for the file. All other files were checked and found to be in compliance.
The facility director met with all the counselors and explained that there are to be no full names of any other client contained within any given file. All of the counselors understood this regulation.
On each monday for the month of March and April, the lead counselor will examine all of the current student files to insure that there are no full names of any other clients contained within the files. If after two months the files are found to be in compliance, the files will be checked quarterly. |
709.51(b)(3)(i) LICENSURE Medical histories
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of client records, the facility failed to document medical histories in one of three client records.
The findings include:
Five client records were reviewed on February 12, 2009. Medical histories were required in three client records. The facility did not document a medical history in client record # 3.
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Plan of Correction
Record #3 was a discharged client, therefore it was not possible to get a medical history form filled out. All the other current students' files were checked and found to contain medical histories.
The facility director met with all the counselors and explained that there must be a medical history form in every file. All of the counselors understood this regulation.
On each monday for the month of March and April, the lead counselor will examine all of the current student files to insure that there are medical histories are contained within the files. If after two months the files are found to be in compliance, the files will be checked quarterly.
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709.52(a)(3) LICENSURE Support service type
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:
(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 treatment plans in two of three client records.
The findings include:
Five client records were reviewed on February 12, 2009. Support services were required to be documented on treatment plans in three client records. The facility did not document support services in client records # 1 and 2.
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Plan of Correction
Records 1 and 2 were discharged clients as of February 27th. All the other current students' files were checked and found to contain support services within the treatment plans.
The facility director met with all the counselors and explained that the support services must be documented within the treatment plans. All of the counselors understood this regulation.
On each monday for the month of March and April, the lead counselor will examine all of the current student files to insure that there are support services documented on the treatment plans. If after two months the files are found to be in compliance, the files will be checked quarterly.
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709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on the review of client records, the facility failed to document progress notes that were specific to client in two of three client records.
The findings include:
Five client records were reviewed on February 12, 2009. Progress notes were required in three client records. Documentation revealed that clinicians copied the plan portions of the progress notes in client records # 1 and 2. There was no individuality or specificity for the plan portion of the progress notes.
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Plan of Correction
Records 1 and 2 were discharged clients as of february 27. All the other current students' files were checked and two other files were found to have the same problem. These files were corrected to reflect individuality within the plan portion of the progress notes.
The facility director met with all the counselors and explained that there must be individuality within the progress notes. All of the counselors understood this regulation.
On each monday for the month of March and April, the lead counselor will examine all of the current student files to insure that the plan portion of the progress notes is individual to each client. If after two months the files are found to be in compliance, the files will be checked quarterly.
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