INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 1-2 , 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Carbon-Monroe-Pike Drug and Alcohol Commission, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on April 5, 2011.
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on the review of supervision notes and employee personnel records and an interview with the clinical supervisor, the facility failed to document weekly case reviews with each counselor assistant for the required time period.
The findings included:
One employee was employed at this facility in counselor assistant status during the review period.
Employee #3 was hired on 1/11/10 and was promoted to counselor after completing one year in this position. This employee was required to receive close supervision for a six month period beginning on 1/10/11. The close supervision requirement means that the employee must be directly observed conducting at least one counseling session per week by a qualified, full time counselor or clinical supervisor and that, in addition, the employee participate in a weekly documented case review with the clinical supervisor or supervising counselor. The weekly observation of counseling sessions were documented consistently for this employee, however, no documentation of a weekly case review was documented.
The findings were discussed with the clinical supervisor and facility director on 2/28/2011 and were not disputed.
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Plan of Correction
704.9 Supervision of a counselor assistant
Weekly appointments have now been scheduled in the Group Wise Calendar for the counselor assistant and designated trained counselor (DATS). During weekly supervision session the counselor assistant is now bringing any problem cases for the week/questions to the session. The designated trained counselor (DATS) is discussing the cases and giving suggestions and feedback to the counselor assistant specific to the cases presented. These suggestions and feedback are documented weekly and maintained in a locked cabinet due to client identifying information being present. This running weekly log will be available for future onsite inspections. This task will be taken over by the Outpatient Treatment Supervisor once hired.
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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 an interview with the Facility Director, the facility failed to ensure that each employee received the required training in the use of a fire extinguisher.
The findings included:
Eight employee training records were reviewed during the onsite inspection conducted on February 28,2011. Seven of eight employee training records failed to include documentation that the employee had received fire extinguisher training.
Employee # 2 was hired on 9/24/96. The training record was reviewed and no documentation was recorded to indicate that the employee had ever received fire extinguisher training.
Employee # 3 was hired on 1/11/10. The training record was reviewed and no documentation was recorded to indicate that the employee had ever received fire extinguisher training.
Employee # 4 was hire on 8/9/10. The training record was reviewed and no documentation was recorded to indicate that the employee had ever received fire extinguisher training.
Employee # 9 was hired on 6/1/99. The training record was reviewed and no documentation was recorded to indicate that the employee had ever received fire extinguisher training.
Employee # 10 was hired on 9/10/07. The training record was reviewed and no documentation was recorded to indicate that the employee had ever received fire extinguisher training.
Employee # 11 was hired on 5/12/08. The training record was reviewed and no documentation was recorded to indicate that the employee had ever received fire extinguisher training.
Employee # 12 was hired on 6/109. The training record was reviewed and no documentation was recorded to indicate that the employee had ever received fire extinguisher training.
The Facility Director was interviewed on 2/28/11 and indicated that there is a checkoff on the employee orientation checklist indicating that the employee knows how to use a fire extinguisher. The documentation in the records never indicated that the employee was actually trained in the use of a fire extinguisher and the Facility Director acknowledged that if the employee indicated that they knew how to use an extinguisher no training was provided.
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Plan of Correction
705.28 Fire Safety
A fire extinguisher training has been downloaded from the FEMA website which will now be shown as part of orientation with the HR department for all new employees. Upon completion of the training a certificate will be issued to the new employee and a copy will be retained in the individual training files. All existing staff will participate in this training by April 30, 2011 and certificates will be issued and placed in the training files for all employees by May 15, 2011.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill logs and an interview with the facility director, the facility failed to activate a fire alarm or smoke detector during each fire drill.
The findings include:
The fire drill logs were reviewed on 3/2/11. Per regulation, the nonresidential facility shall set off a fire alarm or smoke detector during each fire drill. The fire drill log was reviewed for documentation of fire drills from the time period of July 2010 to February 2011. The facility failed to document on the fire drill logs that a smoke detector or fire alarm had been activated for the monthly fire drills documented during this period.
The director and the treatment supervisor was interviewed on 3/2/11 at 3:45 P.M., and confirmed the fire alarm or smoke detector was not activated each month. The facility is located in a building with other occupants, and the fire systems cannot be activated because it would be a disruption to other occupants of the building. The facility director also indicated that no exception had been filed with the Division to request approval for use of an alternative method of alerting staff for purposes of conducting a fire drill.
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Plan of Correction
The treatment program manager has sent a letter to the director of D/A Program Licensure and received a response letter dated on March 21, 2011 approving the use of an air horn for fire drills. This letter will be maintained both in administration and on-site for future inspections |
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 a review of letters of agreement and an interview with the Project Director, Facility Director and Clinical Supervisor, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24-hour emergency medical coverage.
The findings include:
The letters of agreement were reviewed on February 28 , 2011. No letter of agreement regarding 24- hour emergency medical coverage was documented. The Project Director, Facility Director and Clinical Supervisor were also interviewed on this date and acknowledged that no formal letter of agreement was on file. It was confirmed at that time that no other documentation of a 24- hour emergency medical coverage was available.
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Plan of Correction
709.24 Treatment/Rehabilitation Management
On 3/22/11 the Treatment Program Manager has contacted Blue Mountain Health System to request a contact to send the letter of agreement. The letter of agreement was sent on 3/30/2011, and we are awaiting a response from the Blue Mountain Health System. A copy of the letter is attached. If we do not receive the letter by April 15, 2011 the Treatment Program Manager will contact Blue Mountain Health System by phone to discuss any issues with completion of this agreement.
Reciprocal Referral Agreement
2011-2013
Between
Carbon Monroe Pike Drug and Alcohol Commission, Inc.
724 Phillips Street, Suite A
Stroudsburg, PA 18360
(570) 421-1960
And
Blue Mountain Health System
211 North 12th Street
Lehighton, PA 18235
The undersigned acknowledges that a reciprocal referral system has been developed for the purpose of providing program services to the Commission as mandated by the Commonwealth of Pennsylvania Department of Health, Division of Drug and Alcohol Program, General Standards for Treatment Activities, Section 709.24 (d), for 24 hour emergency psychiatric and medical coverage with a licensed hospital. Both parties agree to maintain awareness of each other's services, maintain communication, and provide referral, consultation, and case management and/or treatment services in keeping with the stated mission of each program. Both parties agree to continue communication and mutual support for community prevention and intervention programs. Appropriate release of information forms will accompany all referrals.
Furthermore:
(1) Acknowledges that, in receiving, storing, processing or otherwise dealing with any information from the Commission about its service Consumers, it is fully bound by the provisions of the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2; and
(2) Undertakes to resist in judicial proceedings any effort to obtain access to information pertaining to patients otherwise than as expressly provided for in the federal confidentiality regulations, 42 C.F.R. Part 2.
(3) Neither party shall discriminate against consumers on the basis of sex, race, religion, national origin, age, or handicap. This is affirmed by signatures below.
This agreement shall remain in effect until March 28, 2013
_________________________________
Richard L. Mroczka, M.S.
Executive Director, CMP D/A Commission, Inc.
________________________________
Authorized Signature of Blue Mountain Health System
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709.26(a)(10) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(10) Work performance evaluations.
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Observations
Based on a review of the facility policy and procedure manual, a sample of personnel records from the facility, and interviews with the Facility Director and the Administrative Assistant responsible for maintaining the personnel records, the facility failed to document annual work performance evaluations in adherence with written agency policy.
The findings included:
The agency policy and procedure manual was reviewed on February 28, 2011. Policy # 209 in the manual defined the performance evaluation process as incorporating an introductory period evaluation done at the completion of the first 180 days of employment. The procedure went on to state that after the introductory period, performance evaluations would be scheduled 12 months from the original date of hire.
During the inspection the personnel records of the facility Director, Clinical supervisor and two clinical staff hired within the past year were reviewed. One of two recently hired staff did not have an annual performance evaluation documented in compliance with written facility policy.
Employee # 3 was hired 1/11/10. Probationary evaluations were documented in accordance with written facility policy. No documentation of a written performance evaluation at the 12 month point after the employees hire date was documented.
A discussion of the issue was conducted with the Facility Director and the Administrative Assistant. The administrative assistant indicated that her understanding of the application of the procedure was that an employee would be given their annual evaluation 12 months after the last introductory evaluation was conducted at the completion of the 180 day mark. This practice extended the evaluation period for the first annual performance evaluation from 12 months to 18 months. This was inconsistent with the facility's written policy and procedure. The Facility Director did not dispute this finding.
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Plan of Correction
709.26 Personnel Management
Performance Evaluations: The Treatment Program Manager will work with the Administrative Assistant in charge of Human Resources to update the policy to match the procedure occurring in house. The policy will now read the yearly evaluation will take place one year from the final probationary evaluation, and then annually. This policy will be updated, approved by the board of directors, and placed in the policy and procedure manual by April 30, 2011.
Below is the new policy:
Performance Evaluation
Supervisors and employees are strongly encouraged to discuss job performance and goals on an informal, day-to-day basis. Formal performance evaluations are conducted during an employee's introductory period in any new position. This period allows the supervisor and the employee to discuss the job responsibilities, standards and performance requirements of the new position. During the first month of employment, probationary evaluation forms are completed by the staff member and immediate supervisor on a weekly basis. During the second through the sixth month of employment, the probationary evaluation forms are completed monthly. Additional formal performance evaluations are conducted to provide both supervisors and employees the opportunity to discuss job tasks, identify and correct weaknesses, encourage and recognize strengths and discuss positive, purposeful approaches for meeting goals.
After the introductory period, performance evaluations are scheduled approximately every 12 months, coinciding generally with the date of the employee's last probationary evaluation.
When an employee receives an overall unsatisfactory evaluation, the employee usually will be given a sixty day period to improve their job performance and overall rating. In the event that the employee's evaluation does not improve from the overall unsatisfactory rating, this may result in the discharge of that employee.
The employee has the right to appeal the most recent evaluation to the Assistant Administrator. This should be done in writing with a full explanation with five working days of the evaluation. The Assistant Administrator will review the appeal with input from the Supervisor and the employee as needed and will make his/her decision if the evaluation will be changed or will remain the same within five working days. If the employee is not satisfied with the decision, a meeting with the employee, Supervisor, Assistant Administrator and Executive Director will be scheduled within ten working days to discuss the problem. Following the meeting, if the employee is still not satisfied, he/she may request a meeting with the Personnel Committee of the Board. The Executive Director will schedule the meeting as soon as a time is available. The Personnel Committee will give its final decision to the employee regarding the evaluation.
Policy No. 209 Issued 03/28/2003
Revised 03/31/2011
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709.91(a)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(1) Criteria for admission.
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Observations
Based on the review of the policy and procedure and an interview with the Project and facility directors, the facility failed to document criteria for admission which included relevant components .
The findings included:
During the onsite inspection of February 28 through March 4, 2011 the facility manual was reviewed. An interview was also conducted with the Project and Facility Directors on February 28, 2011. The facility policy manual section dealing with criteria for admission to the outpatient treatment program failed to document the requirements for admission which addressed age, sex, nature and severity of the problem and project limitations. The findings were reviewed with the Directors on February 28, 2011 and they were not disputed.
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Plan of Correction
The policy has been revised by the Treatment Program Manager to include specific criteria for admission and is listed below. This policy will be reviewed by the board of directors following approval will be sent out to staff in memo format, and placed in the policy and procedure manual for future inspections;
709.91
Carbon Monroe Pike Drug and Alcohol Commission
Intake and Admission
Revised 3-30-11
Criteria for Admission
Any person living in the catchment area who is experiencing problems related or caused by their own or other's substance abuse or dependence is eligible to receive Outpatient Services at the Commission. There are no restrictions on age or gender. We cannot provide services for a client who is experiencing overtly psychotic behavior, but will make appropriate referrals in such cases.
Specific Criteria for Client to be admitted into the Outpatient Unit include;
1. Client is not in active withdrawal
2. If any biomedical and/or psychiatric conditions are present they are stable enough to permit participation in outpatient counseling
3. The mental status of the client does not prohibit him/her from participating as evidenced by:
a. able to understand and comprehend materials presented
b. able to participate in treatment
c. client is at no risk of harming self/others
4. The client expresses willingness to participate in the program
Treatment Methodology
Individual and group counseling are the primary treatment methods used. Couples and family sessions will be held as appropriate based on a case by case basis.
Requirements for Completion of Treatment
The Drug and Alcohol Treatment Specialist/Trainee, in conjunction with the Outpatient Treatment Supervisor, shall determine when a client should be discharged from the program using the discharge criteria of the PCPC for adults and ASAM for adolescents.
Normally, a successful completion of treatment will be achieved by a client when the mutually agreed upon goals of treatment have been achieved.
Involuntary Discharge
Clients may, however, be discharged administratively or involuntarily for the following reasons;
1. Moving out of the catchment area
2. Failure to actively participate in treatment or failure to keep appointments without good reason
3. Non-compliance with treatment goals or failure to attend regularly scheduled appointments within a 30 day period
4. Threatening personnel or other clients, either verbally or physically
5. Disorderly conduct or language in the office, including excessive profanity
6. Any violation of the law on the clinic premises, including possession of weapons, theft, illegal drug or alcohol possession or use
7. Appearing for treatment under the influence of alcohol or drugs
8. Absence from treatment for more than thirty days
The program will send the client written notification in the form of a letter of intent, which will clearly spell out a pending involuntary discharge if the client does not make contact with the program within five days of the letter being sent out
Clients may choose to exercise his/her right to appeal the decision (Grievance policy)
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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 a review of client record documentation, the facility failed to document complete personal histories which addressed family relationships in twelve of twelve client records reviewed.
The findings included:
At the time of the onsite inspection 12 client records were reviewed. Reviews occurred on March 1-2, 2011.
Client record #1 - This client was admitted on 9/22/10. The personal history failed to include documentation of details on family interrelationships. Comments regarding relationships with family members consisted of one or two word comments such as "good", and provided no insight into the dynamics of the families of origin or current family.
Client record # 2- This client was admitted on 2/17/10. The personal history failed to include documentation of details on family interrelationships. Comments regarding relationships with family members consisted of one or two word comments such as "good", and provided no insight into the dynamics of the families of origin or current family. The educational history had several areas marked "N/A" (not applicable), such as likes and dislikes while in school, and relationships with peers and teachers. This client reported a large number of sexual partners but no documentation was recorded to indicate this was explored further with the client or whether this was a relevant treatment concern or would indicate the need for a referral.
Client record #3 - This client was admitted on 7/9/10. The personal history failed to include documentation of details on family interrelationships. Comments regarding relationships with family members consisted of one or two word comments such as "outstanding" or " as good as can be expected", and provided no insight into the dynamics of the families of origin or current family. This client reported a large number of sexual partners, by virtue of being a "swinger", but no documentation was recorded to indicate that this was explored further with the client or whether this was a relevant treatment concern or would indicate the need for a referral.
Client record # 4 - This client was admitted on 11/4/10. The personal history failed to include documentation of details on family interrelationships. Comments regarding relationships with family members consisted of one or two word comments such as "good", and provided no insight into the dynamics of the families of origin or current family.
Client record #5 - This client was admitted on 4/12/10. The personal history failed to include document of details on family interrelationships. Comments regarding relationships with family members consisted of one or two word comments such as "good", and provided no insight into the dynamics of the families of origin or current family.
Client record # 6- This client was admitted on 6/29/10. The personal history was completed in a timely manner, however it failed to document details on family interrelationships. Comments regarding relationships with family members consisted of one or two word comments such as "OK", "wonderful", and "iffy", but provided no insight into the dynamics of the families of origin or current family and the resulting impact on the client
Client record # 7 - This client was admitted on 9/7/10 . The personal history failed to include documentation of details on family interrelationships. Comments regarding relationships with family members consisted of one or two word comments such as "good" and "great" but provided no insight into the dynamics of the families of origin or current family. This client reported a large number of sexual partners but no documentation was recorded to indicate that this was explored further with the client or whether this was a relevant treatment concern or would indicate the need for a referral.
Client record # 8 - This client was admitted on 12/15/10 . The personal history failed to include documentation of details on family interrelationships. Comments regarding relationships with family members consisted of one or two word comments such as "good". The record indicated that the father was an active alcoholic but did not explore the impact on the client, nor did it provide any insight into the dynamics of the families of origin or current family.
Client record # 9 - This client was admitted on 11/19/10. The personal history failed to include documentation of details on family interrelationships. Comments regarding relationships with family members consisted of one or two word comments such as "good" and "great" but provided no insight into the dynamics of the families of origin or current family.
Client record # 10 - This client was admitted on 1/5/11. The personal history failed to include documentation of details on family interrelationships. Comments regarding relationships with family members consisted of one or two word comments such as "good" and "great", but provided no insight into the dynamics of the families of origin or current family.
Client record # 11 - This client was admitted on 12/20/10. The personal history failed to include documentation of details on family interrelationships. Comments regarding relationships with family members consisted of one or two word comments such as "really good" but provided no insight into the dynamics of the families of origin or current family.
Client record # 12 - This client was admitted on 12/22/10. The personal history failed to include documentation of details on family interrelationships. Comments regarding relationships with family members consisted of one or two word comments such as "good" and "great" but provided no insight into the dynamics of the families of origin or current family.
The findings were reviewed with the Clinical Supervisor on an ongoing basis during the review and were not disputed.
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Plan of Correction
709.91 Intake and Admission
Personal History:
The Treatment Program Manager will meet with Outpatient Treatment Staff by April 30, 2011 and provide an in-service on completion of personal histories in relation to family history and provide examples of how to document family relationship issues, family of origin issues. Examples of how to carry these issues on the treatment plan and make appropriate referrals will also be discussed. As follow up to the in-service the Treatment Program Manager and Outpatient Supervisor will check charts for completion of these issues for each counselor and meet individually if additional supervision is needed. This process will become part of the weekly chart checklist maintained on the file.
Agenda fo meeting with staff:
Agenda April 19, 2011 In-Service for Staff on Licensing Issues
a. Review of all licensing deficiencies
b. View fire extinguisher training video
c. Review of new Chart Checklist form
d. Personal Histories:
1. Discussion on need to elaborate on answers, no one word answers
2. Practice session role playing client answering questions/discussion on responses
3. How to carry issues on the treatment plan as an issue to treat or refer
e. Treatment Plans:
1. Discussion on need to include time and frequency
2. Practice Session using example BPS to formulate tx plan and present to group for feedback
f. Psychosocial Evaluation:
1. Discussion on need to include all elements in the established prompts and not repeating of data
2. Practice session using example completed information to formulate a Psychosocial Evaluation and present to group for feedback
g. Record of Service
1. Discussion on need to turn in activity logs immediately upon completion of session and need for complete and accurate information to be noted
Questions/Further Discussion
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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 during the annual licensing inspection, the facility failed to document psychosocial evaluations which provided evaluations of the client's presenting and underlying problems, client needs or problems that could or could not be resolved through treatment or that might inhibit treatment. Client assets, strengths or other factors that could 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, and conclusions regarding the client's attitude toward and ability to participate in the treatment process were also missing from eight of twelve client records.
The findings included:
During the onsite inspection on March 1-2, 2011, 12 client records were reviewed. Eight of twelve client records reviewed failed to include documentation of the required components which provide insight into the clinical issues relevant to the treatment of the individual.
Client record # 2- This client was admitted on 2/17/10. The psychosocial evaluation failed to include documentation of the client's coping mechanisms, support systems, assets/strengths or underlying problems/issues to be addressed in treatment.
Client record # 4- This client was admitted on 11/4/10 . The psychosocial evaluation failed to include documentation of the client's underlying needs/problems.
Client record # 5 - This client was admitted on 4/12/10. The psychosocial evaluation failed to include documentation of the client's underlying needs/problems, coping mechanisms or support systems, the clinical impressions failed to document the counselor's conclusions in light of the collected historical data.
Client record # 6 - This client was admitted on 6/29/10. The psychosocial evaluation failed to include documentation of the client's underlying needs/problems.
Client record # 8 - This client was admitted on 12/15/10. The psychosocial evaluation failed to include documentation of the client's underlying needs/problems, coping mechanisms, negative factors which may impact treatment or the counselor's conclusions/impressions in light of the collected historical information.
Client record # 10- This client was admitted on 1/5/11. The psychosocial evaluation failed to include documentation of the client's underlying problems/needs, or the counselor's conclusions/impressions in light of the collected historical information.
Client record # 11 - This client was admitted on 12/20/10. The psychosocial evaluation failed to include documentation of the client's underlying needs/problems, coping mechanisms, assets/strengths or the counselor's conclusions/impressions in light of the collected historical information.
Client record # 12 - This client was admitted on 12/22/10 . The psychosocial evaluation failed to include documentation of the client's underlying needs/problems and coping mechanisms.
The findings were reviewed with the Clinical Supervisor on an ongoing basis throughout the review. The findings were not disputed.
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Plan of Correction
709.91 Intake and Admission
Psychosocial Evaluation:
The Treatment Program Manager will meet with the Outpatient Treatment Staff by April 30, 2011 and provide an in-service on utilizing the prompts established on the Psychosocial Evaluation. During the in-services each counselor will be given a case to complete a Psychosocial Evaluation and present to the group for feedback. Examples on how to properly include all required elements will be provided. As follow up to the in-service the Treatment Program Manager and Outpatient Supervisor will check charts for completion of these issues for each counselor and meet individually if additional supervision is needed. This process will become part of the weekly chart checklist maintained on the file.
CHART CHECKLIST
Client Name:________________________ Admit Date:______________
Supervisor check at chart review _____ Copy of Insurance Card
_____ Psychosocial Evaluation Contains all Elements _______BPS Contains Complete Personal/Family History
______BPS Completed _____Client Liability/SEA
______Client Co-pay Agreement _____ Admit PC/PC
______Proof of Residence/Income _____ Consent For Services _____Privacy Practices Form(HIPPA)
______Client Signed Fee Schedule ______Medical/TB Form
______Grievance/Appeals Form ______ Client Rights/Responsibilities Form
______ Treatment Contract _____ Case Management Note for Assessment
Releases:
_______ SCA Fiscal Department _____Emergency Contact
_____ Referral Source _____ Funding Source
_____ Lab ______AIDSNET
_____Pharmacy ________ Pharmacy Print out received or CM Note
***checked expiration dates for clients in treatment over year ________
For Medical Assistance Cases:
______ CCBH OPR ______ Faxed IOP Registration Confirmation
_____ CCBH CM Registration ______ Advocacy Alliance Form/ Our Release
Treatment Plans: At admission primary counselor document due dates for Initial/Master/Update#1 then highlight when complete and fill in next due date
_____________ Initial ___________ Master ____________ Update#1 ___________ Update #2
_____________ Update#3 ____________ Update#4 ____________ Update#5
___________Update #6 _____________ Update#7 ____________Update #7
Check for time and frequency: Date:_________ Date:_______ Date:________ Date:_______ Date:_________
Case Consults: At admission primary counselor document due date for consult#1, highlight when complete and fill in next due date
___________ Case Consult#1 ____________ Case Consult #2 ____________ Case Consult#3
__________ Case Consult #4 _____________ Case Consult #5 ____________Case Consult#6
Discharge: primary counselor check when completed and filed within 7 days of final session
_________Aftercare Plan _________Discharge Summary __________Discharge Narrative
Agenda April 19, 2011 In-Service for Staff on Licensing Issues
a. Review of all licensing deficiencies
b. View fire extinguisher training video
c. Review of new Chart Checklist form
d. Personal Histories:
1. Discussion on need to elaborate on answers, no one word answers
2. Practice session role playing client answering questions/discussion on responses
3. How to carry issues on the treatment plan as an issue to treat or refer
e. Treatment Plans:
1. Discussion on need to include time and frequency
2. Practice Session using example BPS to formulate tx plan and present to group for feedback
f. Psychosocial Evaluation:
1. Discussion on need to include all elements in the established prompts and not repeating of data
2. Practice session using example completed information to formulate a Psychosocial Evaluation and present to group for feedback
g. Record of Service
1. Discussion on need to turn in activity logs immediately upon completion of session and need for complete and accurate information to be noted
Questions/Further Discussion
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709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to document the type and frequency of service to be offered to each client on each treatment plan.
The findings included:
During the onsite inspection conducted on March 1-2-, 2011, twelve client records were reviewed. Each record was required to document the type and frequency of treatment to be offered to each client on the master treatment plan. Five of twelve records failed to include documentation of the frequency of service to be offered to the client.
Client record # 2- This client was admitted on 2/17/10 . The treatment plan was formulated on 3/16/10. The type/frequency of treatment was documented on the treatment plan as: 1:1 - no frequency ( weekly , bi-weekly , monthly,etc.) was documented.
Client record # 4- This client was admitted on 11/4/10 . The treatment plan was formulated on 11//4/10. The type/frequency of treatment was documented on the treatment plan as: 1:1 individual- no frequency ( weekly , bi-weekly , monthly,etc.) was documented.
Client record # 7- This client was admitted on 9/7/10. The treatment plan was formulated on 9/1/10. The type/frequency of treatment was documented on the treatment plan as: 1:1 - no frequency ( weekly , bi-weekly , monthly,etc.) was documented.
Client record # 8- This client was admitted on 12/15/10. The treatment plan was formulated on 12/16/10. The type/frequency of treatment was documented on the treatment plan as: 1:1 - no frequency ( weekly , bi-weekly , monthly,etc.) was documented.
Client record # 10 - This client was admitted on 1/5/11. The treatment plan was formulated on 1/10/11. The type/frequency of treatment was documented on the treatment plan as: 1:1 - no frequency ( weekly , bi-weekly , monthly,etc.) was documented.
The findings were reviewed with the Clinical Supervisor on an ongoing basis throughout the review. The findings were not disputed.
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Plan of Correction
709.92 Treatment and Rehabilitation
Frequency of Services:
The Treatment Program Manager will meet with the Outpatient Treatment Staff by April 30, 2011 and provide an in-service on including the type and frequency on all Treatment Plan and Treatment Plan Updates. During the in-services each counselor will be given examples on how to document type of service and frequency on treatment plans and treatment plan updates. As follow up to the in-service the Treatment Program Manager and Outpatient Supervisor will check charts for completion of these issues for each counselor and meet individually if additional supervision is needed. This process will become part of the weekly chart checklist maintained on the file.
CHART CHECKLIST
Client Name:________________________ Admit Date:______________
Supervisor check at chart review _____ Copy of Insurance Card
_____ Psychosocial Evaluation Contains all Elements _______BPS Contains Complete Personal/Family History
______BPS Completed _____Client Liability/SEA
______Client Co-pay Agreement _____ Admit PC/PC
______Proof of Residence/Income _____ Consent For Services _____Privacy Practices Form(HIPPA)
______Client Signed Fee Schedule ______Medical/TB Form
______Grievance/Appeals Form ______ Client Rights/Responsibilities Form
______ Treatment Contract _____ Case Management Note for Assessment
Releases:
_______ SCA Fiscal Department _____Emergency Contact
_____ Referral Source _____ Funding Source
_____ Lab ______AIDSNET
_____Pharmacy ________ Pharmacy Print out received or CM Note
***checked expiration dates for clients in treatment over year ________
For Medical Assistance Cases:
______ CCBH OPR ______ Faxed IOP Registration Confirmation
_____ CCBH CM Registration ______ Advocacy Alliance Form/ Our Release
Treatment Plans: At admission primary counselor document due dates for Initial/Master/Update#1 then highlight when complete and fill in next due date
_____________ Initial ___________ Master ____________ Update#1 ___________ Update #2
_____________ Update#3 ____________ Update#4 ____________ Update#5
___________Update #6 _____________ Update#7 ____________Update #7
Check for time and frequency: Date:_________ Date:_______ Date:________ Date:_______ Date:_________
Case Consults: At admission primary counselor document due date for consult#1, highlight when complete and fill in next due date
___________ Case Consult#1 ____________ Case Consult #2 ____________ Case Consult#3
__________ Case Consult #4 _____________ Case Consult #5 ____________Case Consult#6
Discharge: primary counselor check when completed and filed within 7 days of final session
_________Aftercare Plan _________Discharge Summary __________Discharge Narrative
Agenda April 19, 2011 In-Service for Staff on Licensing Issues
a. Review of all licensing deficiencies
b. View fire extinguisher training video
c. Review of new Chart Checklist form
d. Personal Histories:
1. Discussion on need to elaborate on answers, no one word answers
2. Practice session role playing client answering questions/discussion on responses
3. How to carry issues on the treatment plan as an issue to treat or refer
e. Treatment Plans:
1. Discussion on need to include time and frequency
2. Practice Session using example BPS to formulate tx plan and present to group for feedback
f. Psychosocial Evaluation:
1. Discussion on need to include all elements in the established prompts and not repeating of data
2. Practice session using example completed information to formulate a Psychosocial Evaluation and present to group for feedback
g. Record of Service
1. Discussion on need to turn in activity logs immediately upon completion of session and need for complete and accurate information to be noted
Questions/Further Discussion
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709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on the review of client records and an interview with the Facility Director, the facility failed to document a complete record of service in each client record as required in three of nine client records.
The findings included:
The onsite inspection was conducted on March 1-2 , 2011. Twelve client records were reviewed. Nine of these were reviewed for complete records of services. Records of service were unavailable at the time of the record review for three of the records. The records of service are compiled in a computer program and must be printed when access is needed. The initial three records presented for review did not have these records printed out at the time of the review and were not counted. Of the nine applicable records reviewed, four did not include documentation of complete records of service given to each client.
Record #4 - The client was admitted on 11/4/10 . The record of service was incomplete. Progress notes for therapy sessions were documented for the following dates but were not included on the record of services: 10/25/10;11/4/10;11/9/10;11/11/10;11/23/10;11/29/10;11/20/10;12/7/10;12/15/10;12/14/10;1/5/11;1/6/11 and 1/13/11.
Record #5 - The client was admitted on 4/12/10. The record of service was incomplete. Progress notes for therapy sessions were documented for the following dates but were not included on the record of services: 4/12/10; 5/4/10; 5/24/10; 6/24/10,9/15/10 and 10/7/10.
Record # 11 - The client was admitted on 12/20/10 . The record of service was incomplete. Progress notes for therapy sessions were documented for the following dates but were not included on the record of services:1/12/11; 1/25/11; 2/23/11.
Record # 12 - The client was admitted on 12/22/10. The record of service was incomplete. Progress notes for therapy sessions were documented for the following dates but were not included on the record of services: 12/13/10; 12/22/10 and 2/15/11.
The Facility Director was interviewed on 3/2/11 and acknowledged that the data entry of the client sessions was frequently not up to date due to the rapid and substantial growth in the census at this facility.
The findings were reviewed with the clinical supervisor on an ongoing basis throughout the review and they were not disputed.
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Plan of Correction
Record of Service:
As noted the census for this site has been increasing. As a result an additional support staff position has been added as an additional person who knows how to enter the information into the data system which provides the record of service. This staff person will be trained in the next month and all activity logs will be entered on date of service as of May 1, 2011. During the in-service with the Outpatient Staff which will occur by April 30, 2011 the Treatment Program Manager will review the importance of turning in activity logs immediately and correctly. The process will be reviewed and sample logs discussed. The clerical support staff will immediately contact the Outpatient Treatment Supervisor and the Treatment Program Manager if they are experiencing any problems receiving timely and complete information from the Outpatient Staff.
Agenda April 19, 2011 In-Service for Staff on Licensing Issues
a. Review of all licensing deficiencies
b. View fire extinguisher training video
c. Review of new Chart Checklist form
d. Personal Histories:
1. Discussion on need to elaborate on answers, no one word answers
2. Practice session role playing client answering questions/discussion on responses
3. How to carry issues on the treatment plan as an issue to treat or refer
e. Treatment Plans:
1. Discussion on need to include time and frequency
2. Practice Session using example BPS to formulate tx plan and present to group for feedback
f. Psychosocial Evaluation:
1. Discussion on need to include all elements in the established prompts and not repeating of data
2. Practice session using example completed information to formulate a Psychosocial Evaluation and present to group for feedback
g. Record of Service
1. Discussion on need to turn in activity logs immediately upon completion of session and need for complete and accurate information to be noted
Questions/Further Discussion
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