INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 25, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Abstinent Living at the Turning Point at Washington Women with Children Program 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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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on the review of client records, the facility failed to document treatment and rehabilitation plan updates that included an assessment of the client's progress in relationship to the stated goals of the treatment and rehabilitation plan in four of four client records.
The findings include:
Six client records were reviewed on April 23-24, 2013. Four client records reviewed required treatment plan updates. Per regulations, treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. The facility did not document an assessment of the client's progress in relationship to the stated goals of the treatment and rehabilitation plan in client records # 1, 2, 3 and 4. There was no clinical evaluation of the clients' status.
Client # 1 was admitted on December 18, 2012. The treatment and rehabilitation plan was completed on January 2, 2013. Updates, completed in February and March 2013 listed only "completed", "not completed" and/or "making progress" under each goal and did not include an assessment of the client's progress in relationship to the stated goals of the treatment and rehabilitation plan. There was no clinical evaluation of the client's status.
Client # 2 was admitted on December 18, 2012. The treatment and rehabilitation plan was completed on January 2, 2013. Updates, completed in February and March 2013 listed only "completed", "not completed" and/or "making progress" under each goal and did not include an assessment of the client's progress in relationship to the stated goals of the treatment and rehabilitation plan. There was no clinical evaluation of the client's status.
Client # 3 was admitted on January 14, 2013. The treatment and rehabilitation plan was completed on January 16, 2013. Updates, completed in February and March 2013, listed only "completed", "not completed" and/or "making progress" under each goal and did not include an assessment of the client's progress in relationship to the stated goals of the treatment and rehabilitation plan. There was no clinical evaluation of the client's status.
Client # 4 was admitted on March 8, 2012 and discharged on July 19, 2012. An update, completed in June listed only "completed", "not completed" and/or "making progress" under each goal and did not include an assessment of the client's progress in relationship to the stated goals of the treatment and rehabilitation plan. There was no clinical evaluation of the client's status.
The Facility Director and Operations manager were interviewed on April 25, 2013 and did not dispute the findings.
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Plan of Correction
While the required treatment and rehabilitation plan updates were completed, our staff only listed "did not do this" or "did this", and did not include an assessment of the client's progress in relationship to the stated goals of the treatment and rehabilitation plan. This requirement has been reviewed with applicable staff in their clinical supervision and staff meetings. The project director will ensure that all treatment and rehabilitation plan updates include an assessment of the client's progress in relationship to the stated goals of the treatment and rehabilitation plan. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 two of three client records.
The findings include:
Six client records were reviewed on April 25, 2013. Three client records reviewed required follow-up information. Per agency policy, follow-up is to be completed at 30, 60 and 90 days. The facility did not document follow-up information per agency policy in client records # 4 and 6.
Client # 4 was admitted on March 8, 2012 and discharged on July 19, 2012. Follow- up information was to be completed by August 19, September 19 and October 19, 2012. There was no follow-up information documented for September 19 and October 19, 2012.
Client # 6 was admitted on February 13, 2012 and discharged on June 3, 2012. Follow- up formation was to be completed by July 3, August 3 and , September 3, 2012. There was no follow-up information documented for September 3, 2012.
The Facility Director and Operations Manager were interviewed on April 25, 2013 and confirmed the findings.
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Plan of Correction
Follow-ups were not completed as required in some cases. The initial follow-ups, 30 days after discharge, were completed in all cases. However, the 60 and 90 day follow ups were not completed in one case, and the 90 day follow-up was not completed in the other case. Our policy, and this requirement, has been reviewed with applicable staff in their clinical supervision and staff meetings, and all future follow-ups will be made in accordance with our policy and this requirement. The operations manager and project director will oversee this matter. |