INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the Holcomb Associates, Inc. March 23, 2011 licensure renewal inspection. The follow-up inspection was conducted on January 27, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Holcomb Associates, 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:
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Plan of Correction
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill records, the facility failed to maintain a written fire drill record that included documentation of whether the fire alarm or smoke detector was operative.
The findings include:
Fire drill records were reviewed on January 27, 2012. The records were reviewed from the period covering May 2011 to December 2011. The facility did not have documentation for whether the fire alarm or smoke detector was operative in seven of eight months reviewed, specifically, May 5, 2011; June 2, 2011; July 5, 2011; August 1, 2011; October 7, 2011; November 3, 2011; and December 7, 2011.
The findings were confirmed during an ongoing dialogue with the clinical staff support coordinator on January 27, 2012 from approximately 3:00 P.M. to 3:15 P.M.
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Plan of Correction
The Clinical Supervisor will ensure that the fire drill conducted in March of 2012 (and all future fire drills) documents that the fire alarm was operational. The agency's Fire Drill Record form has been revised to prompt the Clinical Supervisor to note whether the alarm is operational. The Facility Director will review the Fire Drill Record logs each month to ensure that the section indicating whether the alarm is operational has been filled out. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill records, the facility failed to provide documentation that they set off a fire alarm or smoke detector during each fire drill.
The findings include:
Fire drill records were reviewed on January 27, 2012. The records were reviewed from the period covering May 2011 to December 2011. The facility did not have documentation for whether or not they set off a fire alarm or smoke detector during each fire drill in seven of eight months reviewed, specifically, May 5, 2011; June 2, 2011; July 5, 2011; August 1, 2011; October 7, 2011; November 3, 2011; and December 7, 2011.
The findings were confirmed during an ongoing dialogue with the clinical staff support coordinator on January 27, 2012 from approximately 3:00 P.M. to 3:15 P.M.
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Plan of Correction
The Clinical Supervisor will ensure that the fire alarm is activated during the fire drill conducted in March 2012 and that this is documented. The agency's Fire Drill Record form has been revised to prompt the Supervisor to indicate whether the fire alarm has been activated. The project's Facility Director will monitor the Fire Drill Records on a monthly basis to ensure that this issue has been addressed. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on review of administrative documentation, the facility failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services at the end of the fiscal year.
The findings include:
The administrative documentation was reviewed on January 27, 2012. The facility was required to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services at the end of their fiscal year. The facility's 2010 through 2011 fiscal year ended on June 30, 2011. However, the facility only had a draft of the financial audit for this period.
The findings were confirmed during an ongoing dialogue with the program coordinator
on January 27, 2012 from approximately 11:30 A.M. to 11:45 A.M.
This is a repeat citation. The facility was cited on March 23, 2011 for noncompliance with this standard.
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Plan of Correction
The facility's 2010/2011 fiscal year audit will be received by March 31, 2012. The Facility Director has notififed the Facility's Accounting Firm that the annual audit of financial activities associated with the project's drug/alcohol abuse services for fiscal year 2011/2012 must be received by by December 1, 2012. The Project Director will ensure, moving forward, that the financial audit is compoleted on time for upcoming years. |
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 a psychosocial evaluation in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Biopsychosocial Assessment", states:
"A complete biopsychosocial history/assessment will be conducted and recorded at the client's date of admission to the program .....Biopsychosocial assessment will include, at minimum:
A clear description of the client's presenting and underlying problems; client needs or problems that can or cannot be resolved through treatment or that might inhibit treatment.
The client's assets, strengths or other factors that can contribute to the resolution of identified problems; the potential or available client support systems; obstacles that might effect treatment are documented as well.
The client's preferred coping and defense mechanisms, conclusions regarding the client's appearance, behavior, and reactions during the evaluation will be documented and used to determined course of treatment.
Client's strengths/assets, support systems and preferred coping mechanisms. Potential treatment barriers that may impact the course of treatment. Mental status assessment.
Conclusions and treatment recommendations, including preliminary treatment planning. Recommendations should include treatment modalities and frequency."
On January 27, 2012, seven client records requiring documentation of a psychosocial evaluation were reviewed. The facility did not document a psychosocial evaluation according to their policy and procedures in seven of seven records reviewed, specifically, client records # 1, 2, 3, 4, 5, 6, and 7.
Client# 1 was admitted June 30, 2011. The psychosocial evaluation was completed on June 30, 2011; however, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, and attitude toward treatment.
Client# 2 was admitted September 29, 2011. The psychosocial evaluation was completed on September 29, 2011; however, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, and coping mechanisms.
Client# 3 was admitted August 2, 2011. The psychosocial evaluation was due August 2, 2011; however, the psychosocial evaluation in client record # 3 was not completed until August 12, 2011. Also, the psychosocial evaluation did not include an evaluation of the client's coping mechanisms and attitude toward treatment.
Client# 4 was admitted June 30, 2011. The psychosocial evaluation was completed on June 30, 2011; however, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, and attitude toward treatment.
Client# 5 was admitted December 5, 2011. The psychosocial evaluation was completed on December 5, 2011; however, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, and attitude toward treatment.
Client# 6 was admitted July 20, 2011. The psychosocial evaluation was completed on July 20, 2011; however, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, and attitude toward treatment.
Client# 7 was admitted November 5, 2011. The psychosocial evaluation was completed on November 5, 2011; however, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, and attitude toward treatment.
The findings were confirmed during an ongoing dialogue with the program coordinator
on January 27, 2012 from approximately 3:15 P.M. to 3:30 P.M.
This is a repeat citation. The facility was cited on March 23, 2011 and April 23, 2010 for noncompliance with this standard.
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Plan of Correction
Staff will be required to attend a training conducted by the agency's Chief Clinical Officer prior to 03/27/2012 emphazing that the assessment must be completed at the client's date of admission and must show an evaluation of the client's assets/strengths, support systems, coping mechanisms and attitude toward treatment. Staff will be required to attend an additional training conducted by the project's Facility Director prior to 03/27/2012 focusing on the same elements.
The Clinical Supervisor will review each assessment within 24 hours of admission to ensure that the assessment was completed on time and that it evaluates the client's assets/strengths,support systems,coping mechanisms and attitude toward treatment |
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
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan or document an individual treatment and rehabilitation plan in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Comprehensive Treatment Plan," states:
"A comprehensive treatment plan will be developed within 30 days of the date of admission."
On January 27, 2012, seven client records requiring documentation of an individual treatment and rehabilitation plan were reviewed. The facility did not document an individual treatment and rehabilitation plan in four of seven records reviewed, specifically, client records # 1, 4, 5, and 7. The facility also did not document an individual treatment and rehabilitation plan according to their policy and procedures in two of seven records reviewed, specifically, client records # 3 and 6.
Client # 1 was admitted June 30, 2011. The individual treatment and rehabilitation plan was due July 30, 2011; however, client record # 1 did not include documentation of an individual treatment and rehabilitation plan as of January 27, 2012.
Client # 3 was admitted August 2, 2011. The individual treatment and rehabilitation plan was due September 1, 2011; however, the individual treatment plan in client record # 3 was not documented until September 29, 2011.
Client # 4 was admitted June 30, 2011. The individual treatment and rehabilitation plan was due July 30, 2011; however, client record # 4 did not include documentation of an individual treatment and rehabilitation plan as of January 27, 2012.
Client # 5 was admitted December 5, 2011. The individual treatment and rehabilitation plan was due January 4, 2012; however, client record # 5 did not include documentation of an individual treatment and rehabilitation plan as of January 27, 2012.
Client # 6 was admitted July 20, 2011. The individual treatment and rehabilitation plan was due August 19, 2011; however, the individual treatment plan in client record # 6 was not documented until December 20, 2011.
Client # 7 was admitted November 5, 2011. The individual treatment and rehabilitation plan was due December 5, 2011; however, client record # 7 did not include documentation of an individual treatment and rehabilitation plan as of January 27, 2012.
The findings were confirmed during an ongoing dialogue with the program coordinator
on January 27, 2012 from approximately 3:15 P.M. to 3:30 P.M.
This is a repeat citation. The facility was cited on March 23, 2011 and April 23, 2010
for noncompliance with this standard.
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Plan of Correction
All identified outstanding treatment plans will have been ameliorated by 3/9/12.
The Clinical Supervisor will review every new admission to ensure that a Comprehensive Treatment Plan is completed and made part of the chart. As part of the agency's electronic health record, a "tickler system" will be utilized to identify the Due Dates of all Comprehensive Treatment Plans and updates for both the IOP and traditional level of care. Data entry will be managed by support staff. The report from this system will be made available to all staff routinely and will be reviewed by the Clinical Supervisor weekly and discussed in supervision to ensure timely completion of treatment plans. Staff were re-trained on this process and the agency policy on 2/13/12.
The Facility Director will monitor the data report with the Clinical Supevisor and will conduct 5% of population random checks bi-weekly to ensure the integrity of the database and compliance with the requirement.
100% compliance with this standard expected by 3/31/2012. |
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
Based on a review of client records, the facility failed to document a treatment and rehabilitation plan update in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Treatment Plans," states:
"Treatment plans will be updated at minimum every 60 days. Treatment plan updates will include a review of the client's progress in relationship to the stated goals within the comprehensive treatment plan."
On January 27, 2012, four client records requiring documentation of treatment and rehabilitation plan updates were reviewed. The facility did not document treatment and rehabilitation plan updates in accordance with their policy and procedures in three of four records reviewed, specifically, client records # 1, 3, and 4.
Client # 1 was admitted June 30, 2011. A comprehensive treatment plan was required to be completed by July 30, 2011 with subsequent treatment plan updates to be completed no later than September 28, 2011, November 28, 2011 and January 26,2012. As of January 27, 2012 the only treatment plan in the client record was a treatment plan update dated December 29, 2011. The treatment plan update was to include a review of the client's progress in relationship to the stated goals within the comprehensive treatment plan. However, client record # 1 did not include documentation of a comprehensive treatment plan as of January 27, 2012.
Client # 3 was admitted August 2, 2011 and the comprehensive treatment plan was completed September 29, 2011. The treatment plan update was due November 28, 2011; however, the treatment plan update in client record # 3 was not documented until December 14, 2011.
Client # 4 was admitted June 30, 2011. A comprehensive treatment plan was required to be completed by July 30, 2011 with subsequent treatment plan updates to be completed no later than September 28, 2011, November 28, 2011 and January 26,2012. As of January 27, 2012 the only treatment plan in the client record was a treatment plan update dated December 30, 2011. The treatment plan update was to include a review of the client's progress in relationship to the stated goals within the comprehensive treatment plan. However, client record # 4 did not include documentation of a comprehensive treatment plan as of January 27, 2012.
The findings were confirmed during an ongoing dialogue with the program coordinator
on January 27, 2012 from approximately 3:15 P.M. to 3:30 P.M.
This is a repeat citation. The facility was cited on March 23, 2011 and April 23, 2010; December 22, 2009; and April 3, 2009 for noncompliance with this standard.
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Plan of Correction
The Clinical Supervisor will review that a progress review is included with all treatment plan updates and that the review sufficiently documents the client's progress toward noted treatment goals & objectives.
Re-training and reiteration of this standard will be implemented with staff during the week of 2/27/12.
Support staff will note for the Clinical Director and the Facility Director any treatment plan updates that are submitted without an corresponding Treatment/Progress Review.
The Facility Director will conduct a 20% random review of all treatment plan updates due on a monthly basis and will be responsible for ensuring that all treatment plan updates are documented on time in accordance with agency policy. |
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.
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Observations
Based on a review of client records, the facility failed to document a case consultation in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Case Consultation," states:
"Case consultation must be provided for each client on no less than a bi-monthly frequency."
On January 27, 2012, six client records requiring documentation of a case consultation were reviewed. The facility did not document a case consultation according to their policy and procedures in four of six records reviewed, specifically, client records # 1, 3, 4, and 6.
Client # 1 was admitted June 30, 2011. The case consultation was due August 31, 2011; however, the case consultation in client record # 1 was not documented until December 9, 2011.
Client # 3 was admitted August 2, 2011. The case consultation was due October 31, 2011; however, the case consultation in client record # 3 was not documented until November 30, 2011.
Client # 4 was admitted June 30, 2011. The case consultation was due August 31, 2011; however, the case consultation in client record # 4 was not documented until November 9, 2011.
Client # 6 was admitted July 20, 2011. The case consultation was due September 30, 2011; however, the case consultation in client record # 6 was not documented until November 20, 2011.
The findings were confirmed during an ongoing dialogue with the program coordinator
on January 27, 2012 from approximately 3:15 P.M. to 3:30 P.M.
This is a repeat citation. The facility was cited on March 23, 2011; April 23, 2010; December 22, 2009; and April 3, 2009 for noncompliance with this standard.
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Plan of Correction
For the highest level of care, Holcomb's policy is to conduct Case Consultations minimally every 60 days.
The agency's electronic health record's "tickler system" will provide the Clinical Supervisor with advance notice of all clients requiring a case consultation. The Clinical Supervisor will review this report, at minimum every week, to determine the consultations that are due for the upcoming two weeks. The consultation will be documented in the agency-established format and include all required elements. This new system was implemented in mid-December 2011, with improvement expected for all required consultations due after that time.
The Facility Director and/or other management personnel will conduct a 25% random audit of charts on a monthly basis to determine that compliance has been met. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan or document an aftercare plan that included a contact person.
The findings include:
The facility's policy titled: "Aftercare Plan," states:
"The counselor and client will develop an aftercare plan, at minimum, two weeks prior to the client's anticipated date of discharge from treatment.
The aftercare plan is the client's plan for the future and will include:
The client's future goals with time frame. A description of the services that can be provided by the project after discharge, if appropriate. The method and frequency of continuing contact to provide client support. Criteria for re-entry into the project along with phone number an method of re-starting treatment."
On January 27, 2012, four client records requiring documentation of an aftercare plan were reviewed. The facility did not document an aftercare plan that included a contact person in two of four records reviewed, specifically, client records # 8 and 10. The facility also did not document an aftercare plan in two of four records reviewed, specifically, client records # 9 and 11.
Client # 8 was admitted April 25, 2011 and was discharged August 10, 2011. The aftercare plan was completed on June 27, 2011, but did not include a contact person.
Client # 9 was admitted March 3, 2011 and was discharged July 15, 2011. The aftercare plan was due two weeks prior to the client ' s date of discharge on July 15, 2011. However, client record # 9 did not include documentation of an aftercare plan as of January 27, 2012.
Client # 10 was admitted May 27, 2011 and was discharged September 29, 2011. The aftercare plan was completed on June 13, 2011, but did not include a contact person.
Client # 11 was admitted July 14, 2011 and was discharged November 15, 2011. The aftercare plan was due two weeks prior to the client ' s date of discharge on November 15, 2011. However, client record # 11 did not include documentation of an aftercare plan as of January 27, 2012.
The findings were confirmed during an ongoing dialogue with the program coordinator
on January 27, 2012 from approximately 3:15 P.M. to 3:30 P.M.
This is a repeat citation. The facility was cited on March 23, 2011 and April 23, 2010
for noncompliance with this standard.
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Plan of Correction
The Aftercare Plans for the identified outstanding charts will have been ameliorated by 3/16/12.
The Clinical Supervisor will review probable discharges with all counselors to determine which clients have a pending discharge. During supervision at target date of discharge will be discussed, with a provisional identification of the due date of the aftercare plan. The Clinical Supervisor will monitor the counselors' progress toward developing a current aftercare plan within the established time frame.
Staff will be re-trained on this policy and procedure at a staff meeting on 3/12/12. Full implementation would be expected by 4/13/12. |