INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 29, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, Brighter Visions Counseling 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:
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Plan of Correction
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709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
The facility failed to document a drug and alcohol history in three of seven client records reviewed on November 29, 2018.Client # 2- the drug and alcohol history stated only that the client had an extensive abuse history that is concurrent with legal issues. Client # 3 was admitted on March 16, 2018. The drug and alcohol history was dated November 23, 2018. Client # 7- the drug and alcohol history was not completed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The intake procedure will include documentation of the client's history of drug and alcohol use including age of onset, frequency, amount, and age of cessation if ceased for each substance. This history will also include documentation of episodes of treatment, levels of care, utilization of community resources to support recovery, and outcomes of these treatment episodes. This will be completed by the counselor performing the intake. Training for this procedure has been facilitated on December 11, 2018 by the Facility Director. A monthly review of charts by the Director will verify that this procedure has been instituted. Existing records will be updated at the client's next scheduled session. New charts will be compliant with this standard beginning December 11, 2018. |
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:
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Observations
The facility failed to document the individual treatment and rehabilitation plan was developed with a client and/or failed to document support services in five of seven client records reviewed on November 29, 2018. Client records #1 and 3 did not include documentation the client participated in the development of the individual treatment and rehabilitation plan.Client records # 3, 4, 5 and 6 did not document support services on the individual treatment and rehabilitation plan. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The individual treatment plan will be developed with the participation of the client. This participation will be documented and endorsed by the client's signature on the treatment plan. Training for this procedure has been facilitated on December 11, 2018 by the Facility Director. A monthly review of charts by the Director will verify that this procedure has been instituted. The facility will be compliant with this regulation beginning December 11, 2018. |
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
The facility failed to ensure the treatment and rehabilitation plans were reviewed and updated at least every 60 days in one of three client records reviewed on November 29, 2018. Client record # 2 documented a treatment plan update that was a copy of the client's treatment plan. The treatment plan update did not document that the plan had been updated and reviewed. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Treatment plans will be reviewed and updated at least every 60 days. This procedure will be carried out by the counselor. Training for this procedure has been facilitated on December 11, 2018 by the Facility Director. A monthly review of charts by the Director will verify that this procedure has been instituted. Treatment plan updates will be compliant beginning December 11, 2018. |
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
The facility failed to document follow up within 60 days of discharge in two of two client records reviewed on November 29, 2018. The facility's follow up policy is 60 days after discharge. Client records # 4 and 6 required documentation of a follow up. There was no follow up documented in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The client record will include documentation that the client was contacted as follow-up within 60 days after discharge. A follow up plan is part of the aftercare plan in successfully closed cases. When a session is cancelled or no-showed a reminder letter will be sent out asking the client to contact the office. In the event that a case is closed without a collaborative aftercare plan, the client will be contacted at 60 days from the final session and this contact will be documented in the client record. This follow-up contact will be carried out by the counselor or the director by phone, or by mail if phone contact is not successful. Training for this procedure has been facilitated on December 11, 2018 by the Facility Director. A monthly review of charts by the Director will verify that this procedure has been instituted. The facility will be compliant with this regulation beginning December 11, 2018. |