INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 12, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Open Door Counseling at Mazzoni Center 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:
|
Plan of Correction
|
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
|
Observations
Seven client records were reviewed on April 12, 2018. The facility failed to document verification that the client was offered a copy of the consent in client records # 1, 2, 3, 4, and 5.
Client # 1 was admitted into treatment at the facility on 9/12/17, and had begun drug and alcohol treatment on 12/11/17. The client was still active in treatment at the time of the inspection. A consent to release information to a managed care organization, signed and dated by the client on 8/31/17, did not document verification that the client was offered a copy of the consent form.
Client # 2 was admitted into treatment at the facility on 7/27/17, and had begun drug and alcohol treatment on 10/11/17. The following consents to release information did not document verification that the client was offered a copy of the consent form:
-A consent to release information to a primary care physician, signed and dated by the client on 7/27/17.
-A consent to release information to a managed care organization, signed and dated by the client on 7/27/17.
-A consent to release information to a personal contact, signed and dated by the client on 7/27/17.
Client # 3 was admitted into treatment on 2/12/18 and was still active in treatment. The following consents to release information did not document verification that the client was offered a copy of the consent form:
-A consent to release information to a managed care organization, signed and dated by the client on 1/23/17.
-A consent to release information to a personal contact, signed and dated by the client on 1/23/18.
Client # 4 was admitted into treatment on 2/12/18 and was still active in treatment. The following consents to release information did not document verification that the client was offered a copy of the consent form:
-A consent to release information to a primary care physician, signed and dated by the client on 1/17/18.
-A consent to release information to an insurance company, signed and dated by the client on 1/17/18.
-A consent to release information to a personal contact, signed and dated by the client on 1/17/18.
Client # 5 was admitted into treatment on 6/20/17 and was discharged on 12/5/17. The following consents to release information did not document verification that the client was offered a copy of the consent form:
-A consent to release information to a primary care physician, signed and dated by the client on 3/6/17.
-A consent to release information to a managed care organization, signed and dated by the client on 3/6/17.
-A consent to release information to a personal contact, signed and dated by the client on 3/6/17.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Program Director reviewed policy and procedure with staff during post-inspection meeting. Staff were advised that all consent forms must indicate whether client received a copy. After reviewing the forms and procedure, staff have begun implementing this change and will continue to do so on an ongoing basis. Quality Assurance Specialist will review charts on a quarterly basis to ensure consistency and compliance with this regulation. Program Director will monitor for compliance on an ongoing basis. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Five client records were reviewed for the documentation of a psychosocial evaluation on April 12, 2018. The facility failed to document a psychosocial evaluation for client record # 4.
Client # 4 was admitted into treatment on 2/12/18 and was still active in treatment. A psychosocial evaluation was not found in the client's record.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
This finding was reviewed during our site visit on 4/12/18. Client #4 was the first client in our IOP program and the staff completing the evaluation failed to document the information corrected. Staff responsible for this error was counseled and has completed the psychosocial evaluation. Clinical Supervisor will continue to monitor completion of psychosocial evaluations by monthly audits and program director will monitor on an ongoing basis. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Five client records were reviewed for the documentation of an individual treatment and rehabilitation plan on April 12, 2018. The facility failed to specify the type and/or frequency of counseling services on comprehensive treatment plans completed for client records # 3 and 4.
Client # 3 was admitted into treatment on 2/12/18 and was still active in treatment. The individual treatment and rehabilitation plan documented in the client's record, completed on 2/22/18, did not specify the frequency of counseling services recommended for the client.
Client # 4 was admitted into treatment on 2/12/18 and was still active in treatment. The individual treatment and rehabilitation plan documented in the client's record, completed on 3/13/18, did not specify the type and frequency of counseling services recommended for the client.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Upon review, Treatment Plan templates for IOP did not contain language for type/frequency of counseling services. Forms were since updated on 4/13/18 and were put in use. Staff received training on the new forms on 4/13/18. Clinical Supervisor will monitor ongoing to ensure forms are being completed properly. |
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.
|
Observations
Seven client records were reviewed on April 12, 2018. The facility failed to document a treatment plan update at least every 60 days for client records # 1, 2, and 6.
Client # 1 was admitted into treatment at the facility on 9/12/17, and had begun drug and alcohol treatment on 12/11/17. A comprehensive treatment plan was completed for the client on 12/19/17. A treatment plan update was then completed for the client on 2/27/18.
Client # 2 was admitted into treatment at the facility on 7/27/17, and had begun drug and alcohol treatment on 10/11/17. A comprehensive treatment plan was completed for the client on 11/8/17. A treatment plan update was then completed for the client on 1/19/18.
Client # 6 was admitted into treatment on 1/14/16 and was discharged on 1/25/18. The first treatment plan update reviewed for this client record was completed on 3/30/17. A subsequent treatment plan update was completed on 6/7/17, followed by another treatment plan update completed on 8/24/17.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Treatment plan updates were not completed consistently within 60 days. Staff were counseled on the time-frames and due dates for treatment plan updates. Quality Assurance Specialist has developed a tracking system to ensure timely completion of plans. This will be reviewed with staff on a weekly basis and monitored by QA Specialist and Program Director on an ongoing basis. |