INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use a narcotic agents, specifically methadone, in the provision of residential maintenance treatment for opioid dependence. This inspection was conducted on July 13, 2009 through July 15, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kirkbride Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on August 14, 2009. .
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Plan of Correction
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715.23(b)(11) LICENSURE Patient records
(b) Each patient file shall include the following information:
(11) Counselor notes regarding patient progress and status.
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Observations
Based on the review of client records, the facility failed to document a complete progress note in six of thirteen client records.
Findings:
Nineteen client records were reviewed on July 14, 2009 through July 15, 2009. Progress notes were required in thirteen client records.
Client record #5 did not include documentation of group notes. The treatment plan dated 6/10/09 stated that client record #5 would have one individual counseling session a week and six group treatment sessions a week. the group progress notes were missing.
Client records #6, 7 and 10 did not include legible progress notes.
Client record #8 - A group note was last documented on 4/3/09 and individual progress notes were last documented on 6/26/09, but the client's record of services documented that the last individual treatment session and last group treatment session occurred on 7/10/09. Several progress notes were missing.
Client record #9 did not include documentation of individual or group progress notes since the client was admitted on 5/21/09.
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Plan of Correction
1. By policy, therapy group notes are required four times weekly; individual session notes are required at least weekly.
2. All Primary Therapists participated in an external retreat on July 9, 2009, designed to ensure the team is on track with respect to clinical documentation. The retreat was led by the Clinical Director and the Clinical Operations Supervisor.
3. The Clinical Operations Supervisor has developed a test for Primary Therapits to match actual progress notes with biopsychosocial narratives and treatment plans. The test is designed to increase Primary Therapists' awareness of creating clinical documentation that is specific to each patient.
4. The Facility Director, the Clinical Director and the Clinical Operations Supervisor will conduct clinical supervision weekly to ensure compliance with documentation requirements. Compliance with group and individual progress notes will be discussed.
5. Monthly, the Clinical Director will audit 10 percent of open charts and determine compliance with documentation requirements.
6. Results will be reported to the Executive Committee, internally called Dashboard, for oversight and monitoring. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on a review of client records, the facility failed to complete psychosocial evaluations in fourteen of nineteen client records.
Findings:
Nineteen client records were reviewed on July 14, 2009 through July 15, 2009. Psychosocial evaluations were required in fourteen client records. The counselors did include documentation of the written evaluation of the clients relative to the clients' problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselors conclusion/impressions of the client in client records #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 15, 16, 18 and 19.
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Plan of Correction
1. The Clinical Operations Supervisor will revise the Biopsychosocial Narrative to include specific prompt sections to better identify:
A. Patient problems/needs
B. Assets/strengths
C. Support systems
D. Coping strategies
E. Negative factors that might
negtatively impact the successful
outcome of treatment
F. Diagnostic impressions
2. Once the revisions have been completed, they will be reviwed by the Project Director, Facility Director and Clinical Director for final revisions.
3. After the management team has approved the final version, Primary Therapists and Social Workers will be trained in its application.
4. The Facility Director, the Clinical Director and the Clinical Operations Supervisor will review clinical records during weekly supervision to ensure compliance.
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715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on a review of client records, the facility failed to document follow-up information in five of eleven client records.
Findings:
Nineteen client records were reviewed on July 14, 2009 through July 15, 2009. Follow-up information was required in eleven client records. In accordance with the facility's policy and procedure, Attempts to follow-up on clients will be done 7 days after the client's date of discharge.
Client record #11 includes documentation that the client was admitted on 11/6/08 and discharged on 11/17/08. There was no documentation of a follow-up attempt.
Client record #12 includes documentation that the client was admitted 11/18/08 and discharged on 12/4/08. There was no documentation of a follow-up attempt.
Client record #13 includes documentation that the client was admitted on 9/25/08 and discharged on 10/15/08. There was no documentation of follow-up attempt.
Client record #14 includes documentation that the client was admitted on 4/9/09 and discharged on 4/28/08. There was no documentation of a follow-up attempt.
Client record #18 includes documentation that the client was admitted on 10/20/08 and discharged on 12/2/08. There was no documentation of a follow-up attempt.
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Plan of Correction
1. The Facility Director, the Clinical Director and the Clinical Operations Supervisor will ensure that Primary Therapists and Detox Counselors check with the Medical Records Department weekly to ensure that they have completed any seven-day follow-ups that may have required during the previous week.
2. This will include routine and non-routine discharges.
3. Closed-chart audits, which include the Seven-Day Follow-Up, are conducted regularly by the Medical Records Department. Aggregated results are provided monthly to the Executive Committee, internally called Dashboard, for monitoring and oversight.
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715.23(d) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
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Observations
Based on the review of client records, the facility failed to document short term goals with action steps in twelve of fourteen client records reviewed.
Findings:
Nineteen client records were reviewed on July 14, 2009 through July 15, 2009. Short and long-term goals were required in fourteen client records. Action steps were not documented under the client's short term goals in client records #1, 2, 3, 4, 6, 7, 9, 10, 15, 16, 17 and 19.
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Plan of Correction
1. The Clinical Operations Supervisor and the Clinical Director will review the treatment plan template and make revisions to better delineate long- and short-term goals.
2. After the revisions have been completed, Primary Therapists will be trained in better distinguishing long- from short-term goals and appropriate objectives that should be developed in support of the short-term goals.
3. The Facility Director, the Clinical Director and the Clinical Operations Supervisor will review treatment plans in weekly supervision sessions. |
715.23(d)(2) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on a review of client records, the facility failed to document complete treatment plan updates in eight of ten client records.
Findings:
Nineteen client records were reviewed on July 14, 2009 through July 15, 2009. Treatment plans updates were required in ten client records. In client records #1, 2, 3, 4, 6, 7, 17 and 19 treatment plan updates did not include the client's progress in relationship to the stated goals of the treatment plan, but rather stated generalized comments that were not specific to the client's progress in treatment.
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Plan of Correction
1. The Facility Director, the Clinical Director and the Clinical Operations Supervisor will conduct a training for Primary Therapists in the appropriate completion of updated treatment plans to ensure individualized patient progress is notated on individual treatment plans.
2. The Facility Director, the Clinical Director and the Clinical Operations Supervisor will monitor compliance by Primary Therapists through ongoing weekly supervision sessions. |