INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 11, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Treatment Trends Inc. Confront 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 January 11, 2009.
|
Plan of Correction
|
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:
|
Observations
Based on a review of client records, the facility failed to timely document individual treatment plans in two of eight client records.
The findings include:
Nine client records were reviewed on December 11, 2008. Treatment plans, per the facility policy and procedure manual, are to be documented within 30 days of admission. Individual treatment plans were required in eight client records. The facility documented individual treatment plans two weeks late in client records # 2 and 4.
|
Plan of Correction
A monthly list of due dates for client treatment plans, case consultations, and PCPC updates will be compiled by the office secretary and circulated to all counselors. Counselors will be required to bring their clients' Master Treatment Plans with them for review during regularly scheduled supervision periods. These periods occur on a weekly basis. The Treatment Plans will be monitioed for their timeliness and signed by the client, the counselor, either the clinical supervisor or program director, and, when applicable, the psychiatrist. The program director will review all files whenever any termination of an individual counselor occurs specifically to monitor tardy or missing paperwork. The circumstances involving these two client files involved the cases being transfered to another clinitian due to the necessary immediate termination of the two counselors originally responsible for the files. We can not and will not recreate records. Our inspector was notified of these terminations before the review of the files. This plan of correction is currently in place. |
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.
|
Observations
Based on the review of client records, the facility failed to document case consultation notes in two of seven records and documented case consultation notes late in one of seven client records.
The findings include:
Nine client records were reviewed on December 11, 2008. Case consultation notes were required in seven client records. The facility did not document case consultation notes in client records # 1 and 2. The facility documented case consultation notes two weeks late in client record # 6.
|
Plan of Correction
A monthly list of due dates for client case consultations, treatment plans, clinical evaluations, and PCPC updates will be compiled by the office secretary and circulated to all counselors. Counselors will be required to complete case consultation forms either during the weekly staff meeting or in their weekly meeting with their clinical supervisor. The case consultation will be monitored for its timeliness by both the clinical supervisor and the program director. The circumstances of the two client files identified as missing case consultations involved the immediate termination of the individual counselors responsible for each file prior to the completion of the required paperwork. It is never ethical to attempt to recreate records. The termination of the two counselors who failed to appropriately document the case consultations was a situation out of our facility's control; it was absolutely necessary to fire them on the spot. We informed our inspector of this situation before the file review. This plan of correction is currently in place. |