INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the February 13, 2012 & February 16, 2012 licensure renewal inspection.
The follow-up inspection was conducted on July 2, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, John F. Kennedy Behavioral Health Center 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:
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Plan of Correction
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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 a review of client records and a review of the facility's policy and procedures manual, the facility failed to document a psychosocial evaluation per policy in three of four client records.
The findings include:
The facility's policy states: "A Psychosocial Evaluation will be completed by the therapist within 30 days of intake/admission. The evaluation will provide a composite picture of the client in relationship to his/her psychosocial history to identify possible relationships, conditions and underlying causes leading to the client ' s current situation"
On July 2, 2012, four client records requiring documentation of a psychosocial evaluation were reviewed. The facility failed to document a psychosocial evaluation per policy in three of four client records reviewed, # 3, 5, and 6.
Client # 3 was admitted to the program on 4/4/12.
The psychosocial evaluation was to be documented within 30 days, 5/4/12.
The facility documented the psychosocial late on 5/29/12. In addition, the facility failed to provide a composite picture in relationship to the client's psychosocial history as they provided a list of the client's assets/strengths and one word for the client's support systems.
Client # 5 was admitted to the program on 4/17/12.
The psychosocial evaluation was to be documented within 30 days, 5/17/12.
The facility failed to document a psychosocial evaluation for client # 5 at the time of review on 7/2/12.
Client # 6 was admitted to the program on 5/2/12.
The psychosocial evaluation was documented on 5/23/12; however the facility failed to provide a composite picture in relationship to the client's psychosocial history as they provided a list of the client's support systems and coping mechanisms.
The clinical supervisor did not dispute the findings.
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Plan of Correction
By 8/15/2012 the Clinical Supervisor will provide one staff training to improve timely documentation of psychosocial evaluations within 30 days of admission. The composite picture will also be revised to provide a narrative evaluation of the client's assets, strengths and support systems. The Clinical Supervisor will monitor psychosocial evaluations weekly to ensure compliance. |
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 a review of client record, the facility failed to review and update treatment plans at least every 60 days in three of three client records.
The findings include:
On July 2, 2012, three client records requiring documentation of a reviewed and updated treatment plan were reviewed. The facility failed to document reviewed and updated treatment plans in three of three client records reviewed, # 2, 4, and 5.
Client # 2 was admitted to the program on 1/26/12. A treatment plan update was documented on 3/30/12; however, the treatment plan was not reviewed or updated by psychiatrist.
Client # 4 was admitted to the program on 3/8/12. A treatment plan update was documented on 6/1/12; however the treatment plan failed to provide an assessment of the client's progress.
Client # 5 was admitted to the program on 4/17/12. The treatment plan was to be reviewed and updated at least every 60 days, 6/17/12. The facility failed to document a treatment plan updated for client # 5 at the time of review on 7/2/12.
The clinical supervisor did not dispute the findings.
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Plan of Correction
By 8/15/2012 the Clinical Supervisor will complete one staff training to improve timely documentation of treatment plan updates every 60 days. The Clinical Supervisor will monitor client records weekly to ensure compliance. |
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 client records and the facility's policy and procedure manual, the facility failed to document a complete client record which included an aftercare plan.
The findings include:
The facility's policy titled "Aftercare" states:
Aftercare plans are for clients who have successfully completed treatment. The plan is discussed and mutually constructed in the final session(s) of the treatment process.
On February 16, 2012, one client record requiring documentation of an aftercare plan was reviewed. The facility failed to document an after care plan in one of one record reviewed, specifically # 7.
Client # 7 was admitted to the program on 8/12/11 and successfully discharged on 12/1/11.
The facility was required to document an aftercare plan by the client's final sessions in treatment. There was no documented aftercare plan in client record # 7 at the time of review on 2/16/11.
The facility director did not dispute the findings.
This was still out of compliance at the time of the follow-up conducted on July 2, 2012.
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Plan of Correction
By 8/15/2012 the Clinical Supervisor will conduct one staff training on the timely completion of Aftercare Plans before the client's final session in treatment. The Clinical Supervisor will monitor client records, prior to discharge, to ensure compliance. |