INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 7 & 8, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Trehab Center, 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 February 11, 2008.
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based upon review of personnel training records on January 7, 2008, the facility failed to ensure that Clinical Supervisor, who has functioned less than two years as a supervisor in the provision of clinical services, completed the core curriculum in clinical supervision.
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Plan of Correction
Due to staffing issues and the Clinical Cupervisor being on maternity leave, the needed clinical supervisor training was not completed. Clinical Supervisor will make it top priority this year to complete this necessary training this year. Clinical Supervisor has contacted BDAP and the training will be offered in Northeast PA around September of 2008. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based upon a review of the facility fire drill records on January 7, 2008, the facility failed to prepare alternate exit routes used during fire drills. Records indicated that the facility consistently utilized the outpatient side door exit for all drills conducted from April 2007 through December 2007.
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Plan of Correction
Immediately after the audit was completed this year, staff training was performed by the Clinical Supervisor on the importance of fire drills - Clinical Supervisor discussed the importance of using different exit routes during the drills in preparation for all fire scenarios, where in the past only the closest fire exit was used. Clinical Supervisor will be responsible for making sure that other routes are utilized. |
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 upon a review of client records on January 8, 2008, the facility failed to provide a complete employment history for 3 of 3 applicable records reviewed. Client records #1, 4 and 5 only address the client's current employment.
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Plan of Correction
Immediately after the audit was completed this year, staff training was performed by the Clinical Supervisor on the importance of completely filling out all aspects of the bio-psych-social. Staff and Clinical Supervisor reviewed the importance of filling out the employment section and why that information is necessary in treatment. Staff was reminded that this is an very important aspect of treatment that should never be overlooked. Clinical Supervisor will audit charts regularly to ensure that this is being done. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based upon a review of client records on January 8, 2008, the facility failed to document goals in terms of measurable criteria in 5 of 5 client records reviewed. Goals lacked action steps with time frames to provide a means for measuring progress.
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Plan of Correction
Immediately after the audit was completed this year, staff training was performed by the Clinical Supervisor on the importance of establishing goals on a treatment plan with measurable time frames and needed action steps. All treatment plans will include these measureable short and long term goals and the needed actions steps for a successful recovery. Staff was reminded that this is an very important aspect of treatment that should never be overlooked- Clinical Supervisor will audit charts regularly to ensure that this is being done. |
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 upon a review of client records on January 8, 2008, the facility failed to review and update client treatment plans at least every 60 days in 3 of 5 records reviewed. Client records #1 and 5 had no documented treatment plan updates in the records. Client record #2 contained a treatment plan update conducted on 12/11/2007 which would have been 96 days after the comprehensive treatment plan dated 9/05/2007.
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Plan of Correction
Immediately after the audit was completed this year, staff training was performed by the Clinical Supervisor on the importance of treatment plan updates every 60 days for active clients in treatment. Staff was reminded that this is an very important aspect of treatment that should never be overlooked- this needs to be done in a timely fashion and reviewed with the client on an individual basis. Clinical Supervisor will audit charts regularly to ensure that this is being done. |
709.93(a)(2) 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:
(2) Medication records.
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Observations
Based upon a review of client records on January 8, 2008, the facility failed to document the name of current medications and/or the does and/or frequency for the medications in 2 of 2 client records requiring documentation. Client record #2 lacked documentation indicating the dosage, and client record #3 indicated that the client was on an inhaler but failed to identify the medication, the dosage and the frequency of use.
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Plan of Correction
Immediately after the audit was completed this year, staff training was performed by the Clinical Supervisor on the importance of maintaining accurate records regarding medications. All staff will continue to follow up with every client that does not have the necessary medication information at the time of evaluation- a record of this will be kept. Staff was reminded that this is an very important aspect of treatment that should never be overlooked. Clinical Supervisor will audit charts regularly to ensure that this is being done. |
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 upon a review of client records on January 8, 2008, the facility failed to maintain a complete record of services provided in 3 of 5 records reviewed. Records of service in client records # 1, 2 and 5 did not list all of the individual sessions provided.
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Plan of Correction
Immediately after the audit was completed this year, staff training was performed by the Clinical Supervisor on the importance of maintaining a complete record of services on all clients. Staff was reminded that this is an very important aspect of treatment and record keeping that should never be overlooked. Clinical Supervisor will audit charts regularly to ensure that this is being done. |
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 upon a review of client records on January 8, 2008, the facility failed to include progress notes for each individual session with clients. There were no progress notes for individual sessions for the formulation of treatment plan updates in 3 of 5 client records reviewed, #1, 2 and 5. Group notes in 4 of 5 client records reviewed, #1, 2, 4 and 5 were almost identical in the areas of assessment and plan and were not individualized for each client.
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Plan of Correction
Immediately after the audit was completed this year, staff training was performed by the Clinical Supervisor on the importance of including progress notes for all individual sessions,group sessions, and treatment plan updates, and that progress notes are an extremely important aspect of treatment that should never be overlooked. It was also reviewed with staff the importance of making sure the right information is included in the progress note and that the note gives thorough information regarding what it needs to capture. Staff and Clinical Supervisor reviewed this at length. Clinical Supervisor will audit charts regularly to ensure that this is being done. |
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 upon a review of client records on January 8, 2008, the facility failed to conduct quarterly case consultations in 2 of 4 records reviewed. Client records #1 & 5 had no documented case consultations in the client records.
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Plan of Correction
Immediately after the audit was completed this year, staff training was performed by the Clinical Supervisor on the importance of quarterly case consultations and that this important aspect of treatment that should not be overlooked. Clinical Supervisor will audit charts regularly to ensure that this is being done. |
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 upon a review of client records on January 8, 2008, the facility failed to provide time frames for the goals in the aftercare plan in 2 of 2 client records reviewed, #4 & 5.
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Plan of Correction
Immediately after the audit was completed this year, staff training was performed by the Clinical Supervisor on aftercare plans and the need for time frames to be included. Time frames will therefore always be included on all aftercare plans, effective immediately. Clinical Supervisor will audit charts regularly to ensure that this is being done. |