INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 15 through 18, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, WPIC Center For Psychiatric And Chemical Dependency Services 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 November 27, 2007.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based upon a review of the facility staffing forms and client caseloads for the staff members identified as clinical supervisors, the facility failed to ensure that they had the equivalent of a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both. Employee #2, identified as a clinical supervisor, works 30 hours at this location and devotes 6 hours of time to direct care service thus only leaving 24 hours of time for supervision.
Employee #3, identified as a clinical supervisor, works 20 hours per week in the outpatient program and 20 hours per week in the Partial Hospitalization program; however 20 hours of that time in each program is dedicated to direct care services thus leaving no time for supervision.
Employee #6, identified as a clinical supervisor, works 20 hours per week in the outpatient program and devotes 20 hours of that time to direct care services thus leaving no time for supervision.
Due to Employees #3 & 6 devoting all of their time to direct care services their function is that of a counselor and therefore the facility's number of counselors would be 13 with the clinical supervisor only affording 24 hours of supervision for 13 clinicians.
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Plan of Correction
At the time of the review, the excess caseloads were being managed by the Clinical Supervisors due to turnover created when clinical staff had left the agency. Two newly-hired clinicians started the week prior to the review. These new clinicians will assume full caseloads, being carried by the Clinical Supervisors at the time of the review, once their orientation period is completed. The facility director will monitor the client census along with the staffing patterns and staffing census and will adjust either the staff census or limit client intake until the proper ratio can be achieved.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based upon review of personnel records on October 16, 2007, the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum within the required time frames. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment. Two of six employees reviewed, #5 & 6, lacked documentation in their files to verify that the HIV/AIDS and TB/STD training were completed within one year of their hire date.
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Plan of Correction
There will be a WPIC AMS (Addiction Medicine Services) system-wide training utilizing the HIV curriculum and STD curriculum published in the DAPL licensing alerts from January and June of 1997. The statistics shall be updated to reflect the current data being reported by the CDC and the other authorities responsible for maintaining such information. This training shall be provided by a staff member qualified to present this training as defined by the Division. Staff of CPCDS will receive training by 1/1/08. Documentation of completed training will be included in staff personnel records. Facility Director will monitor the hire dates and cutoff dates for the training and will ensure that all staff recieve the training within the required time frames. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based upon review of personnel records, the facility failed to ensure that all counselors had completed the required 25 hours of annual training for the 2006 training year. One of two employee records reviewed, #3, only had documentation of 11 hours of the required 25 hours of training.
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Plan of Correction
The Facility Director and Clinical Supervisors shall ensure that all staff complete at least 25 clock hours of training from the approved curriculum list on an annual basis. This shall be monitored in on-going supervision, and staff will be facilitated opportunity to attend training. To be completed during the Addiction Medicine training year which runs 1/1/07 ? 12/31/07 |
704.12(a)(5) LICENSURE Partial Hosp Ratio
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(5) Partial hospitalization. Partial hospitalization programs shall have a minimum of one FTE counselor who provides direct counseling services to every ten clients.
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Observations
Based upon client census information provided on October 16, 17 & 18, 2007, along with client chart reviews, the facility failed to ensure that there was a minimum of one Full Time Equivalent (FTE) counselor to provide direct counseling services to every ten clients within the Partial hospitalization program. On 10/16/07 the facility indicated that there were 12 active clients in the Partial Hospitalization program with a ratio of 7:1.
On 10/17/07, due to clients appearing on both the active client list for the Partial program as well as on the Outpatient list, the facility was requested to provide a computer generated report. The computer generated report indicated that there were 798 active clients in the Partial Hospitalization program, yielding a ratio of 410:1.
On 10/18/07 in an effort to provide a more accurate reflection of the active client caseload, the facility attempted to compile a list of clients that received partial hospitalization services in the past 90 days. This resulted in a census of 50 clients yielding a ratio of 25:1.
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Plan of Correction
The Facility Director and Clinical Supervisors shall ensure through ongoing supervision that all inactive cases older than 90 days shall be discharged from the electronic record keeping system, (PsychConsult). It is the intention of WPIC CPCDS to use the caseload manager function of the PsychConsult documentation system to maintain an accurate active caseload list for each clinician employed by the clinic. Through this process, WPIC CPCDS will maintain an active caseload clinician ?to-patient ration of 10:1. The facility director and clinical supervisor will monitor through quality assurance case review that case load totals remain within established case load standards, and also that clinic remains within the licensed capacity of the partial program. Ongoing monitoring will begin immediately. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based upon client census information provided on October 16, 17 & 18, 2007, along with client chart reviews, the facility failed to ensure that there was a minimum of one Full Time Equivalent (FTE) counselor to provide direct counseling services to every thirty-five clients within the Outpatient program. On 10/16/07 the facility indicated that there were 264 active clients in the Outpatient program with a ratio of 37:1.
On 10/17/07, due to clients appearing on both the facility's list as being discharged but still showing in the system as being active when attempting to review the charts, and showing on the Partial program as well as on the Outpatient list, the facility was requested to provide a computer generated report. The computer generated report indicated that there were 1895 active clients in the Outpatient program, yielding a ratio of 270:1.
On 10/18/07 in an effort to provide a more accurate reflection of the active client caseload, the facility attempted to compile a list of clients who received outpatient services in the past 90 days. This resulted in a census of 135 clients yielding a ratio of 20:1.
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Plan of Correction
The Facility Director and Clinical Supervisors shall ensure through ongoing supervision that all inactive cases older than 90 days shall be discharged from the electronic recorded keeping system, (PsychConsult) It is the intention of WPIC CPCDS to use the caseload manager function of the PsychConsult documentation system to maintain an accurate active caseload list for each clinician employed by the clinic. Through this process, WPIC CPCDS will maintain an active caseload clinician ?to-patient ration of 35:1. Furthermore, in this same manner, WPIC CPCDS will ensure that the licensed capacity of the outpatient (300) and partial programs (20) will not be exceeded. |
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 upon review of the facility's fire drill log book on October 17, 2007, the facility failed to document the amount of time it took to evacuate, the number of persons in the building at the time of the drill and the exit route used. Fire drills conducted on 5/24/07, 6/27/07 and 7/26/07 did not include the amount of time to evacuate the facility. The facility failed to document the specific exit route used and the number of persons in the building for the fire drills conducted from 2/22/07 through 9/18/07.
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Plan of Correction
The Facility Director and the Administrative Manager shall meet with the Safety Officer for the Oxford building in which the programs are housed. They shall review the licensing standards to ensure understanding and compliance regarding the data required on the fire drill report form. The form shall be adapted for use for the WPIC CPCDS programs and will include 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. The Facility Director and Administrative Manager shall provide ongoing follow-up to ensure the information and report form is maintained correctly. Use of the complete report form will begin immediately |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based upon review of the facility's fire drill log book on October 17, 2007, the facility failed indicate that they prepared alternate routes to be used during fire drills. The facility had not identified specific exit routes used during the fire drills and therefore it could not be determined if the facility was utilizing alternate routes.
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Plan of Correction
The Facility Director and the Administrative Manager shall meet with the Safety Officer for the Oxford building in which the programs are housed. They shall review the licensing standards to ensure understanding and compliance regarding the data required on the fire drill report form. The form shall be adapted for use for the WPIC CPCDS programs and will include 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. The Facility Director and Administrative Manager shall provide ongoing follow-up to ensure the information and report form is maintained correctly. Use of the complete report form will begin immediately |
711.81(b)(3)(i) LICENSURE Medical History
711.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based upon a review of client records, the facility failed to document symptoms/illnesses in the medical histories and failed to complete them within the time frame as outlined in the facility's policy. Two of four client records reviewed, #1 & 7, contained medical histories that were completed beyond the time frame of the fifth group session. Two of four client records reviewed, #1 & 7, did not include client symptoms and/or illnesses.
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Plan of Correction
The Facility Director and Clinical Supervisors will ensure, through supervision and quality assurance chart review, that the aspects of medical history comprises a history documenting the client's personal medical history, family medical history, and history of illness and symptoms. The information will be gathered and recorded within the required time frame as identified by policy, which is by the end of the 3rd outpatient session, and by the end of the first week of partial services. The necessity of inclusion of this information will be conveyed to staff by the Facility Director; and by the Clinical Supervisors at a staff meeting on 12/7/07. The reviews and supervision will begin immediately. |
711.81(b)(3)(ii) LICENSURE D & A History
711.81. 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
Based upon a review of client records, the facility failed to complete the drug and alcohol histories within the time frame as outlined in the facility's policy. Two of four client records reviewed, #1 & 7, contained histories that were completed beyond the time frame of the fifth group session.
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Plan of Correction
The Facility Director and Clinical Supervisors will ensure through supervision and quality assurance chart review, that the aspects of a drug and/or alcohol history shall be compiled that includes at a minimum the substances most frequently abused, the length and patterns of use and prior treatment episodes. The history shall include the client's perception of their effect on his/her social, physical and mental state. Any available substance abuse history of the family, or that of significant others will also be noted. The necessity of inclusion of this information will be conveyed to staff by the Facility Director; and by the Clinical Supervisors at a staff meeting on 12/7/07. The reviews and supervision will begin immediately. |
711.81(b)(3)(iii) LICENSURE Personal History
711.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based upon a review of client records, the facility failed to complete the personal histories within the time frame as outlined in the facility's policy. Three of four client records reviewed, #1, 2 & 7, contained histories that were completed beyond time frame of the fifth group session. Two of four client records reviewed, #1 & 7, contained personal histories that did not completely address four of seven areas, specifically, family, legal, recreational and sexual histories.
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Plan of Correction
The Facility Director and Clinical Supervisors will ensure, through supervision and quality assurance chart review, that the aspects of the aspects of personal history comprises a history documenting the client's historical and pertinent personal data including: family, legal, employment/vocational, educational, military, recreational, sexual and others where appropriate. The information will be gathered and recorded within the required time frame as identified by policy, which is by the end of the 3rd outpatient session, and by the end of the first week of partial services. The necessity of inclusion of this information will be conveyed to staff by the Facility Director; and by the Clinical Supervisors at a staff meeting on 12/7/07. The reviews and supervision will begin immediately. |
711.81(b)(6) LICENSURE Psychosocial Evaluation
711.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based upon review of client records, the facility failed to complete the psychosocial evaluations within the time frame as outlined in the facility's policy and the facility failed to provide the clinician's assessment based on the historical documentation gathered. Three of three psychosocial evaluations reviewed, #1, 2 & 7, were completed beyond the fifth group session. Two of three psychosocial evaluations reviewed, #1& 7, failed to provide the clinician's assessment but instead provided more of a repeat of the historical information and what the client stated.
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Plan of Correction
The Facility Director and Clinical Supervisors will ensure through supervision and quality assurance chart review, that the aspects of the psychosocial summary will be in compliance with licensing standards. The evaluation will provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions, and causes leading to the patient's current situation. The evaluation shall also include: 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; Client assets, strengths or other factors that can contribute to the resolution of identified problems; The potential or available client support systems; Negative factors that might affect treatment; The client's preferred coping mechanisms; Conclusions regarding the client's appearance, behavior and reactions during the intake process; Conclusions regarding the client's attitude toward and ability to participate in the treatment process.
The information will be gathered and recorded within the required time frame as identified by policy, which is by the end of the 3rd outpatient session, and by the end of the first week of partial services. The necessity of inclusion of this information will be conveyed to staff by the Facility Director; and by the Clinical Supervisors at a staff meeting on 12/7/07. The reviews and supervision will begin immediately.
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711.81(b)(7) LICENSURE Preliminary Tx Plan
711.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based upon review of client records, the facility failed to complete the preliminary treatment plans at the first session as per the facility's policy. Preliminary treatment plans in client records #1,2 & 7, were completed late. The admission dates and preliminary treatment plans are as follows:
Admission date for client #1 was 8/20/2007 - preliminary treatment plan developed 9/25/2007.
Admission date for client #2 was 8/06/2007 - preliminary treatment plan developed 8/23/2007.
Admission date for client #7 was 6/14/2007 - preliminary treatment plan developed 9/24/2007.
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Plan of Correction
The Facility Director and Clinical Supervisors will ensure through supervision and quality assurance chart review, that the aspects of the preliminary treatment plan will be in compliance with licensing standards. The Preliminary Treatment Plan shall be based upon information derived from the initial interview, psychosocial and other evaluations. This plan should also identify critical client problems and strategies for their resolution. The information will be gathered and recorded within the required time frame as identified by policy, which is by the end of the 3rd outpatient session, and by the end of the first week of partial services. The necessity of inclusion of this information will be conveyed to staff by the Facility Director and Clinical Supervisors at a staff meeting on 12/7/07. The reviews and supervision will begin immediately. |
711.82(a) LICENSURE Coordination of Client Treatment Services
711.82. Treatment and rehabilitation services.
(a) The project shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
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Observations
Based upon a review of progress notes and the record of services provided on October 15-17, 2007, the facility failed to ensure that services for clients in the Partial Hospitalization program received the required two weekly individual sessions in addition to the required two weekly group sessions. One of three records reviewed, #7, indicated that the client was not receiving two individual sessions per week.
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Plan of Correction
The Facility Director and Clinical Supervisors will ensure through supervision and quality assurance chart review, that a minimum of 2 individual sessions are provided on a weekly basis to all members of the partial program. The necessity of these sessions will be conveyed to staff by the Facility Director; and Clinical Supervisors at a staff meeting on 12/7/07. The reviews and supervision will begin immediately. |
711.82(c) LICENSURE Individualized Tx Plan
711.82. Treatment and rehabilitation services.
(c) 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 upon review of client records, the facility failed to complete the individualized comprehensive treatment plans by the fifth group session as per the time frame outlined in the facility's policy and/or failed to individualize them. One of three treatment plans, #2, was not completed prior to the client being discharged from the Partial Hospitalization program. Two of three treatment plans, #1 & 7, were not individualized as they were completed before the bio-psychosocial histories and psychosocial evaluations had been completed.
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Plan of Correction
Compliance to developing individualized treatment plans in timely fashion will be evidenced by periodic quality reviews by the Facility Director combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Training about the regulations and completion of treatment plans will occur as a group in treatment team meeting by the Facility Director. The necessity of inclusion of this information will be conveyed to staff by the Facility Director; and by the Clinical Supervisors at a staff meeting on 12/7/07. The reviews and supervision will begin immediately. |
711.82(d) LICENSURE Tx Plan Updates
711.82. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based upon review of client records, the facility failed to complete treatment plan updates as per the time frame outlined in the facility's policy. The treatment plan update for client #7 was conducted late, it was due on 7/20/2007 but was not conducted until 8/06/2007. Treatment plan updates were completed prior to the completion of the psychosocial evaluations and the preliminary treatment plans in records #1 & 7.
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Plan of Correction
Compliance to developing individualized treatment plan updates in timely fashion will be evidenced by periodic quality reviews by the Facility Director combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Compliance to developing treatment plans directly from the flow of the psychosocial assessment will be evidenced by periodic qualtity reviews by the Facility Director and Clincal Supervisors. Training about the regulations and completion of treatment plan updates will occur as a group in treatment team meeting by the Facility Director. The Faclity Diresctor and Clinical Supervisors will review with staff the necessity of documenting the preliminary treatment plan in the space so called for on the Psychiatric Evaluation Form (PEF). This training will also include review of the necessiy of the preliminary treatment plan covering the episode of care until the comprehensive treatment plan is ready for implementation. The necessity of inclusion of this information will be conveyed to staff by the Facility Director; and by the Clinical Supervisors at a staff meeting on 12/7/07. The reviews and supervision will begin immediately. |
711.82(e) LICENSURE Provision of Services re: TX Plan
711.82. Treatment and rehabilitation services.
(e) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based upon review of client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan. One out of three client records reviewed, client record #7, revealed that the facility failed to ensure that the client received two individual sessions weekly.
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Plan of Correction
The Facility Director and Clinical Supervisors will ensure through supervision and quality assurance chart review, that a minimum of 2 individual sessions are provided on a weekly basis to all members of the partial program. The necessity of these sessions will be conveyed to staff by the Facility Director; and by the Clinical Supervisors at a staff meeting on 12/7/07. The reviews and supervision will begin immediately. |
711.82(f)(1) LICENSURE Ind Counseling - 2X WK
711.82. Treatment and rehabilitation services.
(f) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based upon review of client records, the facility failed to assure that counseling services were provided on a regular and scheduled basis. One out of three client records reviewed, client record #7, revealed that the facility failed to ensure that the client was scheduled for two individual sessions weekly.
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Plan of Correction
The facility director and clinical supervisors will ensure through supervision and quality assurance chart review, that the two individual weekly sessions will be scheduled and provided on a regular basis. The necessity of these sessions will be conveyed to staff by the Facility Director and the Clinical Supervisors at a staff meeting on 12/7/07. The reviews and supervision will begin immediately. |
711.83(c)(1)(i) LICENSURE Confidentiality of Client Identity/Records
711.83. Client records.
(c) Confidentiality.
(1) A written procedure shall be developed by the project director which complies with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(i) Confidentiality of client identity and records.
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Observations
Based upon client records reviewed on October 15 through 17, 2007, the facility failed to ensure that an informed and voluntary consent to release information was obtained in 4 of 4 records reviewed, #1, 2, 7 & 9. It was possible for WPIC staff not involved in the provision of Substance abuse services to identify patients as participants in those services without written consent by accessing the electronic record keeping system which contained such information.
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Plan of Correction
WPIC Addiction Medicine Services has met with the Division of Drug and Alcohol Program Licensure on 2/29/08 in regard to the WPIC electronic medical records system which is used in five of the WPIC AMS programs licensed by the Division. WPIC AMS continues to work through a process pursuant to the outcome of this meeting in collaboration the Division. |
711.83(c)(1)(ii) LICENSURE Staff Access to client records
711.83. Client records.
(c) Confidentiality.
(1) A written procedure shall be developed by the project director which complies with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(ii) Staff access to client records.
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Observations
Based upon a review of the facility's policies and procedures on October 15, 2007, the facility failed to identify the staff that would have access to client's records. In addition the facility failed to provide for a system that ensures security of Drug and Alcohol treatment records in accordance with state law and federal regulations. Refer to 71 P.S. and 42 CFR part 2 Subpart C Subsection 2.32. The facility's policy did not specifically identify which staff would have access to the client's records. It was possible for WPIC staff not involved in provision of Substance abuse services to identify patients as participants in those services without written consent by accessing the electronic data base.
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Plan of Correction
The Clinical Administrator for WPIC Addiction Medicine Services shall develop the required policy for inclusion into the policy manual. The President and CEO of WPIC shall send a letter of formal invitation to the Director of DAPL to meet in person and discuss resolution of the issues related to the sharing of information among the various users of the electronic record keeping system, PsychConsult, within WPIC. The letter shall be sent by 12/15/07 with a meeting to occur no later than 1/17/07 or as soon as can be coordinated among the 2 principles and their respective designees. |
711.84(e) ELEMENT Follow-up Policy
711.84. Project management services.
(e) The project shall develop a written follow-up policy.
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Observations
Based upon a review of the facility's policies and procedures on October 15, 2007, the facility failed to provide a follow-up policy that indicated when the follow-up would be conducted. The facility's policy indicated that they "may" conduct a follow-up.
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Plan of Correction
The Clinical Administrator for WPIC Addiction Medicine Services shall develop the required policy for inclusion into the policy manual. |
711.14(b)(5) LICENSURE Subchapter B.Approval Procedures.Restrictions
711.14. Restrictions on certificate of compliance.
(b) Utilizing appropriate Department forms, the holder of a certificate shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based upon review of the client census information provided on October 15, 16 & 17, 2007 by the facility, the facility failed to ensure that they did not exceed their authorized capacity of 20 clients in the Partial Hospitalization program.
The findings were:
On 10/16/07 the facility indicated that there were 12 active clients in the Partial Hospitalization program.
On 10/17/07 due to clients appearing on both the active client list for the Partial program as well as on the Outpatient list, the facility was requested to provide a computer generated report. The computer generated report indicated that there were 798 active clients in the Partial Hospitalization program.
On 10/18/07 in an effort to provide a more accurate reflection of the active client caseload, the facility attempted to compile a list of clients that received partial hospitalization services in the past 90 days. This resulted in a census of 50 clients.
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Based upon review of the client census information provided on October 15, 16 & 17, 2007 by the facility, the facility failed to ensure that they did not exceed their authorized capacity of 270 clients in the Outpatient treatment activity. On 10/16/07 the facility indicated that there were 264 active clients in the Outpatient program.
On 10/17/07, due to clients appearing on both the facility's list as being discharged but still showing in the system as being active when attempting to review the charts, and showing on the Partial program as well as on the Outpatient list, the facility was requested to provide a computer generated report. The computer generated report indicated that there were 1895 active clients in the Outpatient program.
On 10/18/07 in an effort to provide a more accurate reflection of the active client caseload for the outpatient activity, the facility attempted to compile a list of clients who received outpatient services in the past 90 days. This resulted in a census of 135 clients.
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Plan of Correction
The Facility Director and Clinical Supervisors shall ensure through ongoing supervision that all inactive cases older than 90 days shall be discharged from the electronic record keeping system, PsychConsult.lt It is the intention of WPIC CPCDS to use the caseload manager function of PsychConsult documentation system to maintain an accurate active caseload list for each clinician employed by the clinic. Through this process, WPIC CPCDS will maintain an active caseload clinician ?to-patient ration of 35:1. Furthermore, in this same manner, WPIC CPCDS will ensure that the licensed capacity of the outpatient (300) and partial programs (20) will not be exceeded. |
711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) 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 upon review of client records on October 15 through 17, 2007 the facility failed to complete an individualized comprehensive treatment plan for three of six clients in accordance with the facility's policy and procedures. Comprehensive treatment plans were completed after the due date for clients #2 & 6 and there was no comprehensive treatment plan completed for client #13.
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Plan of Correction
Compliance to developing individualized treatment plans in timely fashion will be evidenced by periodic quality reviews by the Facility Director combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Training about the regulations and completion of treatment plans will occur as a group in treatment team meeting by the Facility Director. The necessity of inclusion of this information will be conveyed to staff by the Facility Director; and by the Clinical Supervisors at a staff meeting on 12/7/07. The reviews and supervision will begin immediately. |
711.93(a)(4) LICENSURE Progress Notes
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(4) Progress notes.
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Observations
Based upon client records reviewed on October 15 through 17, 2007, the facility failed to ensure that individualized treatment was being provided. Progress notes for individual sessions in two of six client records reviewed, #7 & 11, were almost identical in their Data and Assessments. One of six client records reviewed, # 4, had progress notes that were almost identical on 7/9/07 & 7/17/07, and progress notes on 8/14/07 & 8/27/07 were identical.
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Plan of Correction
The Facility Director and Clinical Supervisors will ensure through supervision and quality assurance chart review, that individualized treatment will be provided as evidenced by clinical documentation within the patient record meeting all licensing standards, as well as standards for best practices in clinical documentation. The supervisors will ensure that the individual responsible for the cited examples will be addressed in particular, and the entire staff will review the issues during a staff meeting as well. Ongoing monitoring will be conducted by the program leadership to ensure that all clinical documentation will reflect the specific activities that occur within each clinical session. Additionally, the clinical record will be reviewed for evidence that docuementation is copied without variation from session to session. This will be conveyed to staff by the Facility Director; and by the Clinical Supervisors at a staff meeting on 12/7/07. The reviews and supervision will begin immediately. |
711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
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Observations
Based upon client records reviewed on October 15 through 17, 2007, the facility failed to ensure that aftercare plans were conducted in two of two records reviewed. Client records #11 & 13 lacked documentation to show that aftercare plans were completed.
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Plan of Correction
Compliance will be evidenced by reviews of all files pending discharge for thoroughly completed Aftercare Plans when applicable during individual supervision by the Facility Director and Clinical Supervisors. Reentry guidelines and contact procedures will be documented consistently when an Aftercare Plan is completed. Staff training about completion of Aftercare Plans will be provided by the Facility Director and Clinical Supervisors. This will be conveyed to staff by the Facility Director; and by the Clinical Supervisors at a staff meeting on 12/7/07. The reviews and supervision will begin immediately. |
711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based upon client records reviewed on October 15 through 17, 2007, the facility failed to ensure that follow ups were conducted in two of two client records reviewed. Client records #11 & 13 lacked documentation to show that follow ups were conducted.
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Plan of Correction
The Facility Director and Clinical Supervisors shall ensure that each clinician pursues the act of follow-up contacts on each patient who is discharged from services. Staff training about completion of follow ups will be provided by the Facility Director and Clinical Supervisors. This will be conveyed to staff by the Facility Director; and by the Clinical Supervisors at a staff meeting on 12/7/07. The reviews and supervision will begin immediately. |
711.93(c)(1)(ii) LICENSURE Confidentiality-Staff Access to Records
711.93. Client records.
(c) Confidentiality.
(1) A written procedure shall be developed by the project director which complies with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(ii) Staff access to client records.
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Observations
Based upon a review of the facility's policies and procedures on October 15, 2007, the facility failed to identify the staff that would have access to client's records. In addition the facility failed to provide for a system that ensures security of Drug and Alcohol treatment records in accordance with state law and federal regulations. Refer to 71 P.S. and 42 CFR part 2 Subpart C, Subsection 2.32. The facility's policy did not specifically identify which staff would have access to the client's records. It was possible for WPIC staff not involved in the provision of substance abuse services to identify patients as participants in those services without the client's written consent.
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Plan of Correction
WPIC Addiction Medicine Services has met with the Division of Drug and Alcohol Program Licensure on 2/29/08 in regard to the WPIC electronic medical records system which is used in five of the WPIC AMS programs licensed by the Division. WPIC AMS continues to work through a process pursuant to the outcome of this meeting in collaboration the Division. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based upon client records reviewed on October 15 through 17, 2007, the facility failed to ensure that an informed and voluntary consent to release information was obtained in 9 of 9 records reviewed. Client record #3 contained a release signed by the mother of the adolescent client and there was no consent to release information in the record from the client authorizing the mother to receive information. Refer to state law at 71 P. S. subsection 1690.112 and to federal regulation at 42 CFR Part 2, Subpart B, subsection 2.14(b), in the Commonwealth of Pennsylvania, only the minor can consent to the release of any information that would identify him as a participant in drug and alcohol treatment services. It was possible for WPIC staff not involved in provision of Substance abuse services to identify patients as participants in those services without the client's written consent.
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Plan of Correction
The Facility Director and Clinical Supervisors will ensure through supervision and quality assurance chart review, that the consents for release of confidential information obtained by clinic staff are obtained in each specific case, and also that these comply with 42 CFR part 2, and 4 PA 255.5. In particular, attention will be paid to the issue of the release of information to families where the patient concerned is a minor in the state of Pennsylvania. This will be conveyed to staff by the Facility Director; and by the Clinical Supervisors at a staff meeting on 12/7/07. The reviews and supervision will begin immediately. |
711.94(e) LICENSURE Follow-up Policy
711.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Base upon a review of the facility's policies and procedures on October 15, 2007, the facility failed to provide a follow-up policy that indicated when the follow-up would be conducted.
The facility's policy indicated that they "may" conduct a follow-up.
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Plan of Correction
The Clinical Administrator for WPIC Addiction Medicine Services shall develop the required policy for inclusion into the policy manual. The word "may" will be replaced by the word "shall", and in addition the policy will indicate that followups when a patient is referred will be made by the primary counselor through a telephone call to the referal agency within seven days of the date of the appointment and will be documented in the patient's chart. Follow ups for patients that have not been refered elsewhere will be conducted by the priamary counselor or designee via a telephnoe call or letter to the patient within seven days from discharge. |