INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 23,2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Centre Counseling Associates 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
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on the review of staff records and a discussion with the Project Director, the facility failed to document an individual training plan for the Project Director. The findings included:This Project is a Professional Corporation. The Project Director is the owner, sole remaining incorporator and only clinician and staff at the facility. All of his employment and training documentation was reviewed during the inspection. There was no documentation of an individual training plan for the November 1, 2009 through October 31, 2010 training year. The Project Director was asked how the duration of the training year was defined. The training year was identified by the Director as November to November each year. The finding was reviewed with the Director and he was unable to provide documentation of an individual training plan. The Project Director was given the opportunity to provide materials he did not have onsite at the time of the inspection. In a telephone conversation on 11/24/10 he said that he could have the documents sent to the Division by 11/26/10. As of 11/29/10 no documents had been received by the Division.
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Plan of Correction
The Project Director shall immediately place a written individual training plan for the the remainder of this training year (training year November 2010 to November 1, 2011) in an appropriate file in the Policy and Procedure Manual |
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 on a review of the Project Director/owner's training file and personnel file and a discussion with the Project Director, no documentation of the required six hour HIV / AIDS training or four hour TB/STD training was documented. This training is required within one year of the date of hire for clinical personnel. The Project Director is the only employee of the organization. The findings included:This Project is a Professional Corporation. The Project Director is the owner, sole remaining incorporator and only clinician and staff at the facility. All of his employment and training documentation was reviewed during the inspection. The Project Director's file- (#1), contained no documentation of the required six hours of HIV/AIDS training or the four hours of STD/TB and other communicable disease training. The Project Director was given permission to begin providing substance abuse treatment services effective February 3, 2006 and has continued to provide those services through to November 23, 2010.The Director stated that he had the training documents somewhere at home and would have to locate them. The Project Director was given the opportunity to provide materials he did not have onsite at the time of the inspection. In a telephone conversation on 11/24/10 he said that he could have the documents sent to the Division by 11/26/10. As of 11/29/10 no documents had been received by the Division.
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Plan of Correction
The Project Director shall place a copy of the appropriate documentation of his completion of these trainings in the proper file in the Policy and Procedure manual. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of staff records and a discussion with the Project Director/Sole remaining incorporator, the facility failed to document approved CPR certification and First Aid training to a sufficient number of staff persons so at least one person trained in those skills is onsite during the Project's hours of operation. The findings included:This Project is a Professional Corporation. The Project Director is the owner, sole remaining incorporator and only clinician and staff at the facility. All of his employment and training documentation was reviewed during the inspection. There was no documentation of approved CPR certification or First Aid training at the time of the inspection. The documentation of CPR training that was presented by the Project Director was obtained through online participation and was offered by an organization called ProCPR. Online training for CPR certification by the organization ProCPR has not been approved as defined by Licensing Alerts 01-09 and 01-10. These Licensing Alerts address "Satisfaction of Staff Training Requirements" and include an attachment listing the names of organizations the Department of Health has determined to be providing online independent training which was deemed equivalent to the requirements in 28 Pa. Code subsection 704.11. The organization "ProCPR" is not included on either list. In a discussion with the Project Director about other online training he documented in his file, he acknowledged that he was aware of the requirement that online training must be taken from a source approved by the Department and he was careful to insure that his other online training sessions were from an approved source.This issue was cited in the survey completed on 11/30/09. In the plan of correction approved on 1/15/10, the Project Director/owner stated: " The Facility Director shall, within 90 days, be required to take a qualified First Aid course to update his training requirements under this section."
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Plan of Correction
The Facility Director shall, immediately at the first available oportunity,take a qualified First Aid course to update his training requirements under this section."
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of employee training records and personnel records and an interview with the Project Director, there was no documentation of training in the use of a fire extinguisher.The findings included:The employee record of the sole incorporator was available for review at the inspection on 11/23/10. The sole incorporator is also the only employee of the corporation, there are no other staff or employees. There was no documentation that the sole incorporator had obtained training in the use of a fire extinguisher. The Project Director acknowledged that he did not have documentation of this training.
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Plan of Correction
The Project Director shall find and participate in a fire extinguisher competency training as soon as possible. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on the review of facility policy and procedure, administrative materials and a discussion with the Project Director, the facility failed to document a written agreement with a licensed hospital or physician for 24-hour emergency psychiatric and medical coverage. The findings included: All administrative materials available onsite were reviewed during the onsite inspection of 11/23/10. No written agreement with a licensed hospital or physician for 24 hour emergency medical or psychiatric services was documented. The Project Director stated he had a letter of agreement but that it was not onsite.The Project Director was given the opportunity to provide materials he did not have onsite at the time of the inspection. In a telephone conversation on 11/24/10 he said that he could have the documents sent to the Division by 11/26/10. As of 11/29/10 no documents had been received by the Division of Drug and Alcohol Program Licensure.
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Plan of Correction
The Project Director shall immediately place in the appropriate file in the Policy and Procedure manual a copy of the letter which was previously obtained from the Mount Nittany Medical Center. |
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 the review of facility records and a discussion with the Project Director, the Project could not produce documentation of an annual audit and financial activities associated with the Project's drug and alcohol abuse services. The findings included: On November 23, 2010, the Project's policy and procedures and other records were reviewed as part of the annual onsite licensing inspection . The Project Director was asked for documentation of the annual audit. The Project Director was not able to produce documentation of an annual audit for fiscal year 2009. The plan of correction approved on 1/15/10 from last year's inspection (held on 11/30/09), stated that the director would draft a letter to ... request a waiver from having a formal accounting done because of the nature of the facility, and the fact that the facility director is the only employee of the facility. This was to be done within 90 days or by March 1, 2010. The Director stated that he sent in a letter requesting an exception and produced a draft copy of a letter dated 9/20/10. There is no record of such correspondence having been received by the Division and no record of follow up by the Project Director/Sole Proprietor. The approved plan of correction was not implemented.
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Plan of Correction
The Project Director will send via U.S. Mail a second copy of the the letter which was originally dated 9/20/10 to the appropriate address at the Licencing Division within 2 weeks.
If this request should be rejected the plan of correction is to detail that: The Project Director is the only individual associated with the facility. The facilty is under a Sole Proprietorship type of ownship. The Project Director is the Sole Proprietor, the facility receives no County, State, nor any type of Public funding. The total of all funds to the Facility is and always has been under $500,000. The Project Director can and will provide a W-9 Form and appropriate 1099 Forms to document this fact. The exception request will be submitted in accordance with the licensing alert on
exception requests.
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709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
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Observations
Based on a physical plant inspection and a discussion with the facility director, no fee schedule was posted in a prominent place.The findings include: A physical plant inspection was conducted on November 23, 2010. A fee schedule was not posted. In a discussion with the Project Director he stated he did not have access to a fee schedule in his office and that he would need to print one out at his home and bring it in.
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Plan of Correction
The Project Director shall immediately place a copy of the facility fee schedule in an appropriate viewing place in the facility. |
709.26(d)(1) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(1) The application for employment.
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Observations
Based on the review of personnel information provided by the Project Director during the onsite inspection, no documentation of an application or resume was included in the Project Director's personnel file. The findings included: The Project Director/owner is the only employee of the Project as of the date of the licensing inspection on 11/23/10. No resume or application was presented during the inspection. The Director stated that he had the document somewhere at home and would have to locate it. The Project Director was given the opportunity to provide materials he did not have onsite at the time of the inspection. In a telephone conversation on 11/24/10 he said that he could have the documents sent to the Division by 11/26/10. As of 11/29/10 no documents had been received by the Division.
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Plan of Correction
The Project Director shall immediately place a copy of his current resume in the appropriate file in the Policy and Procedure manual. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on the review of client records and a discussion with the Project Director, the facility failed to demonstrate efforts to inform clients of their rights while in treatment.The findings included:On November 23, 2010, three client records were reviewed for documentation that clients had been notified of their rights. Though the facility had written policies and procedures on client rights, there was no evidence of the client rights having been posted anywhere visible to the clients and there were no documents or progress notes on file in the client records to indicate that clients had ever been informed of these rights. The written policies and procedures did not describe how the clients would be made aware of their rights. Client record # 1 - The client was admitted on 12/12/07 and was last seen at the facility on 10/7/10. No documentation was on file to demonstrate that the client had been informed of his rights under this Chapter.Client record # 2 - The client was admitted on 10/31/07 and again on 9/23/10 and was last seen at the facility on 11/10/10. No documentation was on file to demonstrate that the client had been informed of his rights under this ChapterClient record # 3 - The client was admitted on 3/20/08 and was last seen at the facility on 10/18/10. No documentation was on file to demonstrate that the client had been informed of his rights under this ChapterThe findings were discussed with the Project Director. The Project Director disagreed with the finding but was unable to provide additional documentation to demonstrate that these requirements were met.
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Plan of Correction
The project director specified at the time of the inspection that he verbally notified each client of the client rights. He maintains that procedure is always part of the intake process but will post a copy of the clients rights in plain sight in the office and will review it with the client at the initial appointment. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on the review of client records and a discussion with the Project Director, the facility failed to document disclosure to the client of criteria for admission, treatment, completion and discharge in each client record.The findings included:On November 23, 2010, three client records were reviewed for documentation of the orientation of the client to the facility. The facility failed to document that the client was oriented to the facility's criteria for admission, treatment, completion and discharge in the client record. The written policy and procedure failed to indicate how the clients would be oriented to the facility's criteria for admission, treatment, completion and discharge.Client record # 1 - The client was admitted on 12/12/07 and was last seen at the facility on 10/7/10. No documentation was on record to verify that the client had been oriented to the facility's criteria for admission, treatment, completion and discharge.Client record # 2 - The client was admitted on 10/31/07 and again on 9/23/10 and was last seen at the facility on 11/10/10. No documentation was on record to verify that the client had been oriented to the facility's criteria for admission, treatment, completion and discharge in the client record for either admission.Client record # 3 - The client was admitted on 3/20/08 and was last seen at the facility on 10/18/10. No documentation was on record to verify that the client had been oriented to the facility's criteria for admission, treatment, completion and discharge.The findings were discussed with the Project Director and he disagreed with them. The Project Director stated that he routinely addressed this information during the initial session with each client, however, no documentation was provided to demonstrate compliance with this regulation.
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Plan of Correction
The Project Director reafirms that a verbal discussion of these items is part of the starndard client orientation and intake progess but will post a copy of the of the criteria for admission, treatment, completion and discharge, in plain sight in the office, which can be reviewed and discussed with the client at the initial intake appointment.
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709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on the review of client records and a discussion with the Project Director, the facility failed to document disclosure to the client of project policies in each client record.The findings included:On November 23, 2010, three client records were reviewed for documentation of the orientation of the client to the facility. The facility failed to document that the client was oriented to the facility's project policies in each client record. No postings of policies were observed in the facility. The written policy and procedure failed to indicate how the clients would be oriented to the facility's criteria for admission, treatment, completion and discharge.Client record # 1 - The client was admitted on 12/12/07 and was last seen at the facility on 10/7/10. No documentation was on record to verify that the client had been oriented to the project policies.Client record # 2 - The client was admitted on 10/31/07 and again on 9/23/10 and was last seen at the facility on 11/10/10. No documentation was on file in the record to verify that the client had been oriented to the project policies for either admission.Client record # 3 - The client was admitted on 3/20/08 and was last seen at the facility on 10/18/10. No documentation was on file in the record to verify that the client had been oriented to the project policies.The findings were discussed with the Project Director and he disagreed with them. The Project Director stated that he routinely addressed this information during the initial session with each client, however, no documentation was provided to demonstrate compliance with this regulation.
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Plan of Correction
The Project Director restates that the client was verbally oriented to the facility's project policies at the time of the initial intake interview but will post a copy of the facility's policies on these issues in plain sight in the office and will review it with the client visually and verbally. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on the review of client records and a discussion with the Project Director, the facility failed to document disclosure to the client of fee schedules in each client record.The findings included:On November 23, 2010, three client records were reviewed for documentation of the orientation of the client to the facility. The facility failed to document that the client was oriented to the facility's fee schedules in each client record. No postings of a fee schedule were observed in the facility. The written policy and procedure failed to indicate how the clients would be oriented to the facility's criteria for admission, treatment, completion and discharge.Client record # 1 - The client was admitted on 12/12/07 and was last seen at the facility on 10/7/10. No documentation was on record to verify that the client had been oriented to the facility's fee schedule.Client record # 2 - The client was admitted on 10/31/07 and again on 9/23/10 and was last seen at the facility on 11/10/10. No documentation was on file in the record to verify that the client had been oriented to the facility's fee schedule for either admission.Client record # 3 - The client was admitted on 3/20/08 and was last seen at the facility on 10/18/10. No documentation was on file in the record to verify that the client had been oriented to the facility's fee schedule.The findings were discussed with the Project Director and he disagreed with them. The Project Director stated that he routinely addressed this information during the initial session with each client, however, no documentation was provided to demonstrate compliance with this regulation.
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Plan of Correction
The Project Director restates that the client was verbally oriented to the facility's fee schedules at the time of the initial intake interview but will post a copy of the facility's fee schedules in plain sight in the office and will review it with the client visually and verbally |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. 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 on the review of client records and a discussion with the Project Director, the facility failed to document a medical history in each client record which collected information on the client's personal medical history, family medical history, and history of illness and symptoms.There were records of only three clients who had been treated in the past year. Each was required to have documentation of a complete medical history. The findings included:On November 23, 2010, three client records were reviewed for documentation of the medical history of each client at intake. The facility failed to document the family medical history in each client record. The written policy and procedure for the management of treatment activities indicated that the medical history would be documented in the client record during the intake process.Client record # 1 - The client was admitted on 12/12/07 and was last seen at the facility on 10/7/10. No documentation was on record to verify that the family medical history was collected. No updates to the medical history were documented since the time of intake.Client record # 2 - The client was admitted on 10/31/07 and again on 9/23/10 and was last seen at the facility on 11/10/10. No documentation was on record to verify that the family medical history for either admission was collected. No updates to the medical history were documented since the time of intake in 2007.Client record # 3 - The client was admitted on 3/20/08 and was last seen at the facility on 10/18/10. No documentation was on record to verify that the family medical history was collected. No updates to the medical history were documented since the time of intake.The findings were discussed with the Project Director and he disagreed with them. No additional documentation was provided to demonstrate compliance with this regulation.
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Plan of Correction
The Project Director shall ensure that a written copy of the client's family medical history shall be included in the client's file. These histories will be periodically updated to show any changes that may occur during the course of treatment |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. 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 on the review of client records and a discussion with the Project Director, the facility failed to document a complete personal history in each client record. There were records of only three clients who had been treated in the past year. Each was required to have documentation of a detailed personal history.The findings included:On November 23, 2010, three client records were reviewed for documentation of the client's drug and alcohol history. The facility failed to document complete personal histories relative to family history, legal history, employment/vocational history, educational history, military history, recreational history and sexual history. The written policy and procedure for the management of treatment activities indicated that the personal history would be documented in the client record during the intake process.Client record # 1 - The client was admitted on 12/12/07 and was last seen at the facility on 10/7/10. No documentation was on record to address the client's personal history in the following areas: family, legal, employment/ vocational, educational, military, recreational, sexual . No updates to the personal history were documented since the time of intake.Client record # 2 - The client was admitted on 10/31/07 and again on 9/23/10 and was last seen at the facility on 11/10/10. No documentation was on record to address the client's personal history in the following areas: family, legal, employment/ vocational, educational, military, recreational, sexual .No updates to the personal history were documented since the time of intake in 2007. Client record # 3 - The client was admitted on 3/20/08 and was last seen at the facility on 10/18/10. No documentation was on record to address the client's personal history in the following areas: family, legal, employment/ vocational, educational, military, recreational, sexual . No updates to the personal history were documented since the time of intake.The findings were discussed with the Project Director. He disagreed with them but was unable to provide additional documentation to demonstrate that these requirements were met.
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Plan of Correction
The project director shall ensure that a written copy of the client's personal history in the following areas: family, legal, employment/ vocational, educational, military, recreational, and sexual shall be included in the client's file. These histories will be periodically updated to show any changes that may occur during the course of treatment |
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 the review of client records, a discussion with the Project Director and a review of facility policy, the facility failed to document a complete psychosocial evaluation in each client record in that the documentation failed to include coping mechanisms and provide a composite picture in three of three client records. The findings included:Facility policy and procedure stated that: "The evaluation should 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 client's current situation."On November 23, 2010, three client records were reviewed for documentation of the client's psychosocial evaluation. The facility failed to document a psychosocial evaluation in each client record which provided 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 client's current situation and failed to include coping mechanisms.Client record # 1 - The client was admitted on 12/12/07 and was last seen at the facility on 10/7/10. Documentation of the psychosocial evaluation in the client record failed to identify possible relationships, conditions and causes leading to the client's current situation or provide a clear description of the client's presenting and underlying problems. Coping mechanisms in the record did not identify the coping or defenses used by the client but stated that he uses polysubstance abuse as a defense.Client record # 2 - The client was admitted on 10/31/07 and again on 9/23/10 and was last seen at the facility on 11/10/10. Documentation of the psychosocial evaluation in the client record failed to identify possible relationships, conditions and causes leading to the client's current situation or provide a clear description of the client's presenting and underlying problems. No updates to the psychosocial evaluation were documented since the time of the initial intake in 2007. Coping mechanisms in the record did not identify the coping or defenses used by the client but stated that he uses drugs and alcohol and counseling as a defense.Client record # 3 - The client was admitted on 3/20/08 and was last seen at the facility on 10/18/10. Documentation of the psychosocial evaluation in the client record failed to identify possible relationships, conditions and causes leading to the client's current situation or provide a clear description of the client's presenting and underlying problems. Coping mechanisms in the record did not identify the coping or defenses used by the client but stated that he uses drugs and alcohol as a defense.The findings were discussed with the Project Director. He disagreed with them but was unable to provide additional documentation to demonstrate that these requirements were met.
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Plan of Correction
The Project Director shall revise the form that is used to document the psychosocial evaluation of the client to include possible relationships, conditions and causes leading to the client's current situation and provide a more precise description of the coping or defense mechanisms used by the client. This form shall be updated on a continual basis as various factors may evolve. |
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 the review of client records and a discussion with the Project Director, the facility failed to document an individual treatment plan with each client within 30 days as required by facility policy. The findings included:On November 23, 2010, three client records were reviewed for documentation of the client's individual treatment plan which was to be formulated within 30 days of admission as specified in agency policy. The treatment plan documents found in each client record consisted of the preliminary treatment plan, done at intake, and a checklist form which was used to identify goals the client was interested in working on. These documents were not comprehensive plans that targeted assessed client needs . They did not include short and long term goals, type and frequency of services to be offered or support services. Client record # 1 - The client was admitted on 12/12/07 and was last seen at the facility on 10/7/10. Documentation of the preliminary treatment plan was done at intake. No comprehensive treatment plan was documented within 30 days as specified in facility policy. The required components of the treatment plan, short and long term goals, type and frequency of services to be offered or support services, were not included on the document presented as the treatment plan.Client record # 2 - The client was admitted on 10/31/07 and again on 9/23/10 and was last seen at the facility on 11/10/10. Documentation of the preliminary treatment plan was done at intake. No comprehensive treatment plan was documented within 30 days as specified in facility policy. The required components of the treatment plan, short and long term goals, type and frequency of services to be offered or support services, were not included on the document presented as the treatment planClient record # 3 - The client was admitted on 3/20/08 and was last seen at the facility on 10/18/10. Documentation of the preliminary treatment plan was done at intake. No comprehensive treatment plan was documented within 30 days as specified in agency policy. The required components of the treatment plan, short and long term goals, type and frequency of services to be offered or support services, were not included on the document presented as the treatment planThe findings were discussed with the Project Director. He disagreed with them but was unable to provide additional documentation to demonstrate that these requirements were met.
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Plan of Correction
The Project Director shall revise the Treatment Plan form to reflect the required components of the treatment plan, short and long term goals, type and frequency of services to be offered or support services |
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 the review of client records and a discussion with the Project Director, the facility failed to document treatment plan updates at least every 60 days, which included an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in three of three client records. The findings included:On November 23, 2010, three client records were reviewed for documentation of the client's individual treatment plan update which was to be formulated every 60 days as specified in facility policy. The treatment plan update documents found in each client record consisted of an update form which listed the "goals" for the last 60 days. Goals consisted of statements from a checkbox list of areas the client expressed an interest in addressing during treatment. The "goals" were not formulated to reflect measurable criteria for achievement and no strategies were documented to assist the client in a step by step process to achieve each goal. The update on the goals consisted of documentation each 60 days which stated simply "GIP" an abbreviation for "Goal In progress- no change needed." This comment was noted on each goal in each file reviewed for each 60 day update. The treatment plan update failed to include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment planClient record # 1 - The client was admitted on 12/12/07 and was last seen at the facility on 10/7/10. Treatment plan updates did not address details on the progress of each goal every 60 days. No modifications were noted to the treatment plan during the course of this treatment episode. No measurable criteria were documented so that both the client and the counselor would be able to determine when the goal was achieved or whether progress was made during the past 60 day review period. The treatment plan update failed to include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.Client record # 2 - The client was admitted on 10/31/07 and again on 9/23/10 and was last seen at the facility on 11/10/10. Treatment plan updates did not address details on the progress of each goal every 60 days. No modifications were noted to the treatment plan during the course of this treatment episode. No measurable criteria were documented so that both the client and the counselor would be able to determine when the goal was achieved or whether progress was made during the past 60 day review period. The treatment plan update failed to include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.Client record # 3 - The client was admitted on 3/20/08 and was last seen at the facility on 10/18/10. Treatment plan updates did not address details on the progress of each goal every 60 days. No modifications were noted to the treatment plan during the course of this treatment episode. No measurable criteria were documented so that both the client and the counselor would be able to determine when the goal was achieved or whether progress was made during the past 60 day review period. The treatment plan update failed to include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.The findings were discussed with the Project Director. He disagreed with them but was unable to provide additional documentation to demonstrate that these requirements were met.
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Plan of Correction
The Project Director shall revise the treatment plan update form to include and area that includes an assessment of the client's progress with measurable criteria in relationship to the stated goals of the comprehensive treatment plan.
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709.93(a) 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:
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Observations
Based on the review of client records and a discussion with the Project Director, the facility failed to document complete treatment records in three of three client records reviewed. The findings included:On November 23, 2010, three client records were reviewed for documentation of a complete client record. The documentation in the client records reviewed was missing medication records and progress notes. During the interview with the Project Director, he disclosed that all clients were being treated at a local clinic with Suboxone. The name of the medication and the dose and frequency were not documented in the client record. Progress notes did not provide detail on the individual counseling sessions and were not related to treatment issues for the clients served.Client record # 1 - The client was admitted on 12/12/07 and was last seen at the facility on 10/7/10. The medication record did not address the dose and frequency of the medications that the client was using .The progress notes were vaguely written and did not relate to treatment issues for the client. Client record # 2 - The client was admitted on 10/31/07 and again on 9/23/10 and was last seen at the facility on 11/10/10. The medication record did not address the dose and frequency of the medications that the client was using . The progress notes were vaguely written and did not relate to treatment issues for the client. Client record # 3 - The client was admitted on 3/20/08 and was last seen at the facility on 10/18/10. The medication record did not address the dose and frequency of the medications that the client was using . The progress notes were vaguely written and did not relate to treatment issues for the client. The findings were discussed with the Project Director. He disagreed with them but was unable to provide additional documentation to demonstrate that these requirements were met.
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Plan of Correction
The Project Director shall include within the client record a medication record that reflects type,name,the dose and frequency of use that the client was prescribed. This should be updated upon the reported change of any of the relevent medication criteria. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on the review of client records and a discussion with the Project Director, the facility failed to document complete treatment records. The client records reviewed did not include progress notes which were legible and addressed substantive treatment issues for each counseling session in three of three client records.The findings included:On November 23, 2010, three client records were reviewed for documentation of a complete client record. The documentation in the client records reviewed did not document progress notes which addressed the treatment issues being discussed with each client. Progress notes did not provide detail on the individual counseling sessions. Content of the notes was vague and generic.Client record # 1 - The client was admitted on 12/12/07 and was last seen at the facility on 10/7/10. The progress notes were vaguely written and did not relate to treatment issues for the client. Examples: Data only addressed that the client arrived on time in many of the notes reviewed; Assessment - generic comments used - "appearance is better"; "good session" :P- "continue to work on compliance" ; "continue on course"Client record # 2 - The client was admitted on 10/31/07 and again on 9/23/10 and was last seen at the facility on 11/10/10. The progress notes were vaguely written and did not relate to treatment issues for the client. Examples: Data only addressed that the client arrived on time in many of the notes reviewed; Assessment - generic comments used - "appearance is better"; "good session" :P- "continue to work on compliance" ; "continue on course"Client record # 3 - The client was admitted on 3/20/08 and was last seen at the facility on 10/18/10. The progress notes were vaguely written and did not relate to treatment issues for the client. Examples: Data only addressed that the client arrived on time in many of the notes reviewed; Assessment - generic comments used - "appearance is better"; "good session" :P- "continue to work on compliance" ; "continue on course"The findings were discussed with the Project Director. He disagreed with them but was unable to provide additional documentation to demonstrate that these requirements were met.
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Plan of Correction
The Project Director shall impliment a revised progress note methodology to reflect within the progress notes that they will address substantive treatment issues for each counseling session |