INITIAL COMMENTS
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This report is a result of an onsite inspection to determine the facilities compliance with the standards following the February 15, 2010 expiration of the settlement agreement between the Division of Drug and Alcohol Program Licensure and the facility. The inspection was conducted on March 23, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, New Insights, 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 24, 2010.
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Plan of Correction
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709.81(b)(6) LICENSURE Intake and admission
709.81. 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 that evaluate the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment in four of eight partial rehabilitation client records reviewed.
The finding includes:
Fifteen client records were reviewed on March 23, 2010. Psychosocial evaluations were required in seven records; of those records, four were partial rehabilitation clients.
Client record #8 failed to evaluate the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
Client record #9 failed to evaluate the client's assets and strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
Client ' s records #10 failed to evaluate the client's assets and strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
Client record #11 failed to evaluate the client's assets and strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
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Plan of Correction
The program director will review with the clinical staff at the staff meeting on 4/28/10 that the last page of the psycho-social profile must be completed before the composite, and comprehensive treatment plan is done. This last page includes the list of the client's defense mechanisms, client's strengths, problems identified for treatment, potential support system, and negative factors that could inhibit treatment. The program director will randomly review one of each clinician's charts every two weeks during clinical supervision to monitor for compliance. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. 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 a review of client records, the facility completed the documentation of the client's comprehensive treatment plan before completing the psychosocial in two of eight partial rehabilitation records reviewed.
The findings include:
Fifteen client records were reviewed on March 10, 2010. Comprehensive treatment plan, which are to be based in part on the collected historical information in order to identify possible relationships, conditions, causes leading to the client's current situation and the psychosocial evaluation; were completed prior to obtaining and documenting that historical information in two of eight partial rehabilitation client records reviewed.
Client record # 3 - The client was admitted on 1/25/10. The comprehensive treatment plan was completed on 2/2/10. The psychosocial evaluation was not completed until 2/12/10.
Client record # 4 - The client was admitted on 1/26/10. The comprehensive treatment plan was completed on 2/2/10. The psychosocial evaluation was not completed until 2/8/10.
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Plan of Correction
The program director will review with the clinical staff at the staff meeting on 4/28/10 that the psycho-social profile and compostie must be completed prior to the comprehensive treatment plan being formulated. The rational for completing the data collection prior to developing the treatment plan will be presented to the clinical staff at that staff meeting. The program director will randomly review one of each clinician's charts every two weeks during clinical supervision to monitor for compliance. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on the review of client records, the facility failed to ensure that clients were receiving at least 2 individual counseling sessions a week in three of four active partial client records reviewed.
The findings include:
Fifteen client records were reviewed on March 23, 2010. At least two individual sessions per week are required in four active partial client records reviewed, #8, 9, 10 and 11.
Client #9 was admitted on 1/12/10; a review of the client record revealed that, since the client's admission, the facility failed to document that the patient received at least two individual counseling sessions each week During the weeks 2/22/10, 3/4/10 and 3/11/10 there was only one individual session documented.
Client #10 was admitted on 1/25/10 and there were 3 weeks where the client did not receive at least two individual counseling sessions a week. During the weeks of 2/11/10 and 2/25/10 only one individual session each week was documented. During the week of 3/16/10 there were no counseling sessions documented.
Client #11 was admitted on 1/26/10 and there were 3 weeks where the client did not receive at least two individual counseling sessions a week. Weeks of 3/3/10 and 3/9/10 only one individual session documented. Weeks of 3/15/10 no individual counseling sessions documented.
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Plan of Correction
The records reviewed all had the required individual and g roup sessions for the Partial Hospitalization level of care. This is indicated by a "change of status" form and a treatment plan update that precedes a transfer to the outpatient level. The frequency of care is not the issue, but to have the change of status more visible. Therefore the Executive Director will revise the New Insights policy on clinical chart order. The change of status form will be entered in the progress note section in chronological order. This will assure no confusion or possibility of oversight when determining the clients level of care. This policy will be revised on April 12, 2010. This new policy will be distributed to both Lemoyne staff on 4/14/10 and the York staff on 4/21/10 during the next scheduled staff meeting. |
709.82(d)(2) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(2) Group counseling, at least twice weekly.
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Observations
Based on the review of client records, the facility failed to ensure that clients received at least 2 group counseling sessions a week in two of four active partial client records reviewed.
The findings include:
Fifteen client records were reviewed on March 23, 2010. At least two group sessions a week is required in four active partial client records reviewed, #8, 9, 10 and 11. Per the State standards for partial clients the facility must ensure that the partial client is being seen at least twice a week for their group counseling sessions.
Client #9 was admitted on 1/12/10 and there were 4 weeks where the client did not receive at least two group counseling sessions a week. Weeks of 2/22/10, 3/1/10, 3/8/10 and 3/15/10 only one group session documented.
Client #11 was admitted on 1/26/10 and there were 5 weeks where the client did not receive at least two group counseling sessions a week. Weeks of 2/27/10, 3/6/10 and 3/20/10 only one group session documented.
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Plan of Correction
The records reviewed all had the required individual and group sessions for the Partial Hospitalization level of care. This is indicated by a "change of status" form and a treatment plan update that precedes a transfer to the outpatient level. The frequency of care is not the issue, but to have the change of status more visible. Therefore the Executive Director will revise the New Insights policy on clinical chart order. The change of status form will be entered in the progress note section in chronological order. This will assure no confusion or possibility of oversight when determining the clients level of care. This policy will be revised on April 12, 2010. This new policy will be distributed to both Lemoyne staff on 4/14/10 and the York staff on 4/21/10 during the next scheduled staff meeting. |
709.83(a)(11) LICENSURE Client records
709.83. 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 accordance with the facility policy and procedures in three of four partial rehabilitation discharged records reviewed.
The findings include:
Fifteen client records were reviewed on March 23, 2010. Follow-up information was required in four partial rehabilitation discharge records #12, 13, 14 and 15. Per the facilities policy and procedure all follow-ups will be done within 30 days of clients discharge if not being referred and 7 days of the client ' s appointment date if being referred.
Client record #12 was admitted on 2/3/10 and discharged on 3/8/10 and as of to date no follow-up documented. Client was transferred to another facility, but no documentation of client arriving at the facility.
Client record #13 was admitted on 1/4/10 and discharged on 1/17/10 and as of to date no follow-up documented.
Client record #14 was admitted on 1/13/10 and discharged on 2/17/10 and as of to date no follow-up documented.
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Plan of Correction
The front office will develop a "tickler file" with a folder for each of the 12 months of the year. When a clinician discharges a client because of their successful completion of treatment, a discharge status form will be placed in the "tickler file" in the folder of the following month. At the end of each month, the front office staff will send out our standard follow up letter to all clients in that months folder. This system will be explained to the front office staff at the staff meeting on 4/28/10 and will be initiated on or before 5/10/10. The office manager will monitor the "tickler file" monthly for compliance. In the event that a client has been referred to an outside agency for on going treatment, the clinician will call the referral agency within seven days to confirm the client kept his or her initial appointment and document it as a collateral call in the client's chart. This will be explained to the clinical staff at the staff meeting on 4/28/10. |
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 failed to obtain an informed and voluntary consent from the client for the disclosure of information in seven of fifteen client records
The findings include:
Fifteen client records were reviewed on March 23, 2010. Informed and voluntary consent forms were required in fifteen client records reviewed.
Client #1 - There was a consent to release to another treatment facility dated 3/22/10 but it did not document what specific information to be released and the purpose for the release.
Client #3- Did not see a consent to release form for a third party payer and a fax went out on 2/17/10. Another fax went out to OTR on 2/18/10 with no consent to release in client record reviewed.
Client #4 - Did not see a consent to release form for a third party payer but information from the third party payer was in the clients record.
Client #5 - A fax letter was sent to a person, did not state who she was or what agency she was a part of, fax sent 3/4/10 did not see a consent to release form for this particular person. Also, there were two letters from a third party payer dated 1/27/10 and 1/29/10; however, I did not see a consent to release form in the clients record.
Client #9 - Exceeded what is to be sent out to an employer. The clients consent to release from documented that the client HR department can receive the client treatment dates, diagnosis, discharge status and the type of treatment the client is currently in. Another consent to release from exceeded what is to be sent out to an employer but allowing the facility to give the client treatment dates. A letter dated 1/18/10 was faxed out giving an update on the client and recommended time frame for the client not to be allow to work.
Paperwork was in clients record for a third party payer dated 1/22/10 and 1/1510 with no consent to release in clients record. A fax was sent to a person not sure of the agency or relationship with the client dated 1/15/10 with no consent to release form for this particular person.
Client #11 - There were two consent to release forms dated 1/26/10 and 2/8/10, one was dated to the client mother and the other to a agency. The two consent to release forms did not mark the purpose for the release. Also, there were no consent to release form for a third party payer but documentation was reviewed in client ' s record.
Client #14 - There were no consent to release form in client record for a third party payer, but paperwork was reviewed in client record.
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Plan of Correction
The program director will review with the clinical staff at the staff meeting on 5/12/10 our standard release of information form. The clinician's will be reminded that the all consent to release information forms must include what specific information is to be released and the purpose for release of information. PA Code 255.5 will be reviewed in the staff meeting. Consent to release information to third party payers will be given to the client at the time of their initial appointment with their blank medical history form. Front office staff hours will be adjusted to better cover the evening hours when clients are scheduled for their initial evaluation. The clinician evaluating the client will confirm that the client's medical history and consent to release information to a third party payer has been signed at the beginning of the session. The front office staff will confirm that a release of information to third party payers, when clients are not selfpay, was signed at the time of assembling and labeling the new client's chart. The program director will randomly review one of each clinician's charts every two weeks during clinical supervision to monitor for compliance. |
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 psychosocial evaluations that evaluate the client ' s assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
in three of seven outpatient client records reviewed.
The finding includes:
Fifteen client records were reviewed on March 23, 2010. Psychosocial evaluations were required in seven records of those seven three were outpatient clients.
Client record #1 failed to evaluate the client ' s assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
Client record #2 failed to evaluate the client ' s assets and strengths, support systems, coping mechanisms and clients negative factors that might inhibit treatment.
Client ' s records #4 failed to evaluate the client ' s assets and strengths, support systems, coping mechanisms, clients negative factors that might inhibit treatment, clients attitude toward treatment and the counselor conclusions/impressions.
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Plan of Correction
The program director will review with the clinical staff at the staff meeting on 4/28/10 that the last page of the psycho-social profile must be completed before the composite, and comprehensive treatment plan is done. This last page includes the list of the client's defense mechanisms, client's strengths, problems identified for treatment, potential support system, and negative factors that could inhibit treatment. The program director will randomly review one of each clinician's charts every two weeks during clinical supervision to monitor for compliance. |