INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 24, 2011 through January 27, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Penn Foundation for Mental Health, 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 March 1, 2011.
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Plan of Correction
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709.83(a)(6) LICENSURE Client records
709.83. 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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of the facility's policy and procedure manual, a review of client records and a discussion with special projects coordinator, the facility failed to develop an aftercare plan in one of one client record reviewed.
The findings include:
The facility's policy and procedure manual was reviewed on January 24, 2011. The facility's written policy on aftercare planning states an aftercare plan will be developed for all clients, unless they refuse or leave AMA, during the last session.
Five partial hospitalization client records were reviewed on January 27, 2011. One of those five client records required an aftercare plan. An aftercare plan was not documented in client record #16.
Client #16 was admitted on 10/11/10 and successfully completed treatment on 10/29/10. The discharge summary documented within client record #16 stated that aftercare planning was completed. However, an aftercare plan was not documented in client record #16 as of January 27, 2011.
During a discussion with special projects coordinator, it was confirmed that the aftercare plan was not documented in client record #16.
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Plan of Correction
It was made clear during the site visit that aftercare plans are not being done consistently for partial hospital clients. It is clear that the aftercare plan needs to be computerized and tracked through our internal computer system, to assure that they are being completed on every client who needs one. Director of Recovery Center will develop a computerized aftercare plan and a system to track completion of the plan through the computer system. With this system in place, it will ensure the proper completion of this important document. Director of the Reocovery Center will oversee this POC. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 a review of the facility's policy and procedure manual, a review of client records and a discussion with special projects coordinator, the facility failed to develop an individual treatment and rehabilitation plan within the time frame in their written policy on treatment and rehabilitation services in five of eight client records reviewed.
The findings include:
The facility's policy and procedure manual was reviewed on January 24, 2011. The facility's written policy on treatment and rehabilitation services states an individual treatment plan will be developed within 72 hours of the client's admission.
Eight inpatient client records were reviewed on January 26, 2011. The individual treatment plan was developed late in five of those eight client records.
Client #6 was admitted on 12/23/10. According to the facility's policy, the individual treatment plan was due on 12/26/10; however it was not developed until 1/3/11.
Client #10 was admitted on 10/19/10. According to the facility's policy, the individual treatment plan was due on 10/22/10; however it was not developed until 10/26/10.
Client #11 was admitted on 9/20/10. According to the facility's policy, the individual treatment plan was due on 9/23/10; however it was not developed until 10/1/10.
Client #12 was admitted on 8/27/10. According to the facility's policy, the individual treatment plan was due on 8/30/10; however it was not developed until 9/8/10.
Client #13 was admitted on 8/26/10. According to the facility's policy, the individual treatment plan was due on 8/29/10; however it was not developed until 9/8/10.
During a discussion with special projects coordinator, it was confirmed that the individual treatment plans were developed late, as per the facility's written policy.
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Plan of Correction
It was clear during the site visit that treatment plans were not being consistly developed within the three day time frame of our internal policy. Special projects coordinator in conjunction with director of inpatient services, will meet with inpatient staff to discuss the 3 day requirement for completion of treatment plan. Staff will be expected to complete treatment plans within three days. This will be monitored by the computer tracking system to assure timely completion of treatment plans. Special projects coordinator and inpatient director will oversee this POC. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of the facility's policy and procedure manual, a review of client records and a discussion with special projects coordinator, the facility failed to review and update treatment plans within the time frame in their written policy on treatment plan updates in three of three client records reviewed.
The findings include:
The facility's policy and procedure manual was reviewed on January 24, 2011. The facility's written policy on treatment plan updates states a treatment plan update will occur every 15 days.
On January 26, 2011, three inpatient client records requiring treatment plan updates were reviewed. Treatment plan updates were documented late in two client records. A treatment plan update was not documented in one client record.
Client #6 was admitted on 12/23/10. The individual treatment plan in client record #6 was developed on 1/3/11. According to the facility's written policy, the treatment plan update in client record #6 was due on 1/18/11. As of 1/26/11, there was no treatment plan update documented in client record #6.
Client #7 was admitted on 1/5/11. The individual treatment plan in client record #7 was developed on 1/7/11. According to the facility's written policy, the treatment plan update in client record #7 was due on 1/22/11. The treatment plan update in client record #7 was documented on 1/25/11.
Client #8 was admitted into the inpatient program on 1/8/11. The individual treatment plan in client record #8 was developed on 1/7/11. According to the facility's written policy, the treatment plan update in client record #8 was due on 1/22/11. The treatment plan update in client record #8 was documented on 1/26/11.
During a discussion with special projects coordinator, it was confirmed that the treatment plan updates in client records #7 and 8 were developed late, as per the facility's written policy. It was further conformed that a treatment plan update was not documented in client record #6.
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Plan of Correction
During the site visit, it was brought to our attention that treatment plan updates were not being completed on time. Director of Recovery Center has already changed the computer system to put the date the treatment plan update is due by on every treatment plan update. To clarify, when treatment plan is printed out, the treatment plan update is also printed out now - with the date it is due by. It is given to clinical staff by support staff several days prior to the due date to be completed. This will be monitored by the computer tracking system to assure that treatment plan updates will now be completed on time. Clinical staff will also be notified via email of the importance of completing these by the due date. Director of inpatient will oversee this POC. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of the facility's policy and procedure manual, a review of client records and a discussion with special projects coordinator, the facility failed to document a case consultation on one of four client records. The facility also documented a case consultation late, as per their policy, in one of four client records reviewed.
The findings include:
The facility's policy and procedure manual was reviewed on January 24, 2011. The facility's written policy on case consultations states case consultations will be held every 90 days for outpatient clients.
On January 27, 2011, four outpatient client records requiring case consultations were reviewed. A case consultation was not documented in client record #20. The case consultation in client record #22 was documented late, as per the facility's policy.
Client #20 was admitted on 8/18/10. According to the facility's policy, a case consultation was due on 11/18/10. As of January 27, 2011, there was no case consultation documented in client record #20.
Client #22 was admitted on 6/30/10. According to the facility's policy, a case consultation was due on 9/30/10 and again on 12/30/10. As of January 27, 2011, the only case consultation documented in client record #22 was dated 12/2/10. Therefore, the first 90 day case consultation was over two months late.
During a discussion with special projects coordinator, it was confirmed that the case consultation in client record #20 was missing and the case consultation in client record #22 was late, as per the facility's written policy.
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Plan of Correction
During the site visit, it became clear that case consultations were missing or late in some of the outpatient records. Computer system will be updated to include outpatient case consultations. Computer will track when case consultations are due and will generate an email to outpatient clinical staff and cc this email to outpatient coordinator. Clinician will need to complete the case consultation by the due date. At the next outpatient clinical meeting, counselors will be met with and explained the tracking system and their responsibility to complete case conferences on time. Outpatient coordinator and director of outpatient services will oversee this POC. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of the facility's policy and procedure manual, a review of client records and a discussion with special projects coordinator, the facility failed to develop aftercare plans in three of three client records reviewed.
The findings include:
The facility's policy and procedure manual was reviewed on January 24, 2011. The facility's written policy on aftercare planning states an aftercare plan will be developed for all clients, unless they refuse or leave AMA, during the last session.
On January 27, 2011, three outpatient client records requiring aftercare plans were reviewed An aftercare plan was not documented in three of three records reviewed, specifically, client records #23, 24 and 25.
Client #23 was admitted on 8/31/10 and successfully completed treatment on 11/18/10. The discharge summary documented within client record #23 stated that aftercare planning was completed. However, an aftercare plan was not documented in client record #23 as of January 27, 2011.
Client #24 was admitted on 8/30/10 and successfully completed treatment on 11/2/10. The discharge summary documented within client record #24 stated that aftercare planning was completed. However, an aftercare plan was not documented in client record #24 as of January 27, 2011.
Client #25 was admitted on 8/10/10 and successfully completed treatment on 10/6/10. The discharge summary documented within client record #25 stated that aftercare planning was completed. However, an aftercare plan was not documented in client record #25 as of January 27, 2011.
During a discussion with special projects coordinator, it was confirmed that the aftercare plan was not documented in client records #23, 24 and 25.
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Plan of Correction
It was made clear during the site visit that aftercare plans are not being done consistently for outpatient clients. It is clear that the aftercare plan needs to be computerized and tracked through our internal computer system, to assure that they are being completed on every client who needs one. Director of Recovery Center will develop a computerized aftercare plan and a system to track completion of the plan through the computer system. With this system in place, it will ensure the proper completion of this important document. Director of the Reocovery Center and outpatient coordinator will oversee this POC. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of the staffing requirements facility summary report that was completed by the facility and a review of personnel records, the facility failed to ensure that each counselor met the required qualifications in one of six counselors' records reviewed.
The findings include:
On January 26, 2011, six counselors' personnel records were reviewed. The facility hired a new counselor with a bachelor's degree in sociology on May 24, 2010. Upon review of the resume within the personnel record, the new counselor hired on May 24, 2010 did not have the required 1 year of clinical experience in a health or human service agency.
During a discussion with the special projects coordinator, it was confirmed that the new counselor did not have the required experience.
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Plan of Correction
It was brought to our attention during the site visit that one counselor's experience did not qualify as clinical experience. Counselor has already been made a counselor assistant, personnel file has been changed to reflect this change. Inpatient Director has started weekly supervision of this counselor to meet counselor assistant requirements. Inpatient director has overseen the implementation of this POC. |