INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 4-7, 2012 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.
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Plan of Correction
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the fire drill log, the facility failed to conduct a fire drill during sleeping hours within the past six months.
The findings were:
A review of the fire drill log was conducted on June 4, 2012. The last documented fire drill during sleeping hours occurred on October 29, 2011 at 5:30 AM. A conversation with the facility staff on June 4, 2012 confirmed that no fire drill was conducted during sleeping hours within the last six months.
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Plan of Correction
It was discovered during the site visit that a fire drill was not conducted during sleeping hours in the past six months. In order to ensure compliance with fire drill regulations, a yearly fire drill schedule will be developed and implemented. The schedule will identify the week a fire drill will be conducted and designate what shift the fire drill will occur on. The schedule will ensure a night fire drill is conducted every six months. Director of Inpatient will oversee this POC. |
709.81(b)(6) LICENSURE Intake and admission
709.81. 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, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in three of three partial hospitalization client records.
The findings include:
Forty-two client records were reviewed on June 5 through 7, 2012. Four of the forty-two were reviewed from the partial hospitalization client activity, #9, 10, 11 and 12. A psychosocial evaluation was reviewed in three client records, #9, 10 and 11. An interview with facility staff on June 7, 2012 confirmed the findings.
The psychosocial evaluations in client records #9, 10 and 11 did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, negative factors and how they would impact treatment.
The psychological evaluation in client records #10 and 11 did not include an evaluation of the client's attitude toward treatment and how it would impact treatment.
The psychosocial evaluation in client records #9, 10 and 11 did not include an evaluation of the counselor conclusions/impressions of the client.
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Plan of Correction
It was discovered during the site visit that counselors are not consistently documenting their clinical evaluations of the client in the client record. Counselors will need to be retrained on what is expected in a clinical evaluation to include all the above components. A consultant has been identified to conduct clinical trainings on documentation and these trainings will be mandatory for all staff to attend. Quality of documentation will be monitored by weekly chart review. Outpatient Coordinator will oversee this POC. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on the review of client records, the facility failed to give the client an opportunity to request reconsideration of a decision terminating treatment.
The findings include:
Forty-two client records were reviewed on June 5 through 7, 2012. The project was required to give the client an opportunity to request reconsideration of a decision terminating treatment in one client record. The project did not document that the client was given an opportunity to request reconsideration in client record #23. An interview with facility staff on June 7, 2012 confirmed the findings.
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Plan of Correction
When a client is involuntarily discharged from our facility, they are made aware of that decision in writing. However, the form does not include that client shall have an opportunity to request reconsideration of a decision terminating treatment. This information will be added to the involuntary discharge forms that clients are given, so clients are made aware of their ability to appeal an involuntary discharge from our facility. Special Projects Coordinator will oversee this POC. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in three of four short-term detoxification client records.
The findings include:
Forty-two client records were reviewed on June 5 through 7, 2012. Eight of the forty-two were reviewed from the short-term detoxification activity, #1, 2, 3, 4, 5, 6, 7 and 8. A psychosocial evaluation was reviewed in four client records, #1, 2, 3 and 4. An interview with facility staff on June 7, 2012 confirmed the findings.
The psychosocial evaluations in client records #1, 2 and 4 did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, negative factors and how they would impact treatment.
The psychosocial evaluation in client records #1 and 2 did not include an evaluation of the client's attitude toward treatment and how it would impact treatment.
The psychosocial evaluation in client records #1, 2 and 4 did not include an evaluation of the counselor conclusions/impressions of the client.
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Plan of Correction
It was discovered during the site visit that counselors are not consistently documenting their clinical evaluations of the client in the client record. Couselors will need to be retrained on what is expected in a clinical evaluation to include all the above components. A consultant has been identified to conduct clinical trainings on documentaiton and these trainings will be mandatory for all staff to attend. Quality of documentation will be monitored by weekly chart review. Inpatient Director will oversee this POC. |
709.63(a)(6) LICENSURE Aftercare plan
709.63. 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 client records, the facility failed to document a complete aftercare plan in two of four short term detoxification discharge client records.
The findings include:
Forty-two client records were reviewed on June 5 through 7, 2012. Per the facility policy, the counselor and client will complete an aftercare plan prior to discharge for successful completions. An aftercare plan was required in two client records, #5 and 8.
Client #5 was admitted on May 2, 2012 and discharged on May 7, 2012. The aftercare plan was documented on May 7, 2012 and failed to include the client's goals with time frames, contact person and reentry process.
Client #8 was admitted on May 17, 2012 and discharged on May 23, 2012. The aftercare plan was documented on May 22, 2012 and failed to include the client's goals with time frames, contact person and reentry process.
This was discussed and confirmed with the facility director on June 7, 2012.
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Plan of Correction
It was discovered during the site visit that our Aftercare Plan did not address some key elements that are required. The Aftercare Plan will be modified to include client goals with time frames, contact person and reentry process. Special Projects Coordinator will oversee this POC. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. 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, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in five of five residential treatment and rehabilitation client records.
The findings include:
Forty-two client records were reviewed on June 5 through 7, 2012. Fourteen of the forty-two were reviewed from the residential treatment and rehabilitation activity, #13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, and 26. A psychosocial evaluation was reviewed in five client records, #13, 14, 15, 16, and 17. An interview with facility staff on June 7, 2012 confirmed the findings.
The psychosocial evaluations in client records #13, 14, 15, 16 and 17 did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, negative factors and how they would impact treatment.
The psychosocial evaluation in client record #13 did not include an evaluation of the client's attitude toward treatment and how it would impact treatment.
The psychosocial evaluation in client records #13, 15, 16 and 17 did not include an evaluation of the counselor's conclusions/impressions of the client.
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Plan of Correction
It was discovered during the site visit that counselors are not consistently documenting their clinical evaluations of the client in the client record. Counselors will need to be retrained on what is expected in a clinical evaluation to include all the above components. A consultant has been identified to conduct clinical trainings on documentation and these trainings will be mandatory for all staff to attend. Quality of documentation will be monitored by weekly chart review. Inpatient Director will oversee this POC. |
709.53(a)(9) LICENSURE Aftercare plans
709.53. 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, the facility failed to document a complete aftercare plan in nine of nine nonresidential treatment and rehabilitation discharged client records.
The findings include:
Forty-two client records were reviewed on June 5 through 6, 2012. Per the facility policy, the counselor and client will complete an aftercare plan prior to discharge for successful completion. An aftercare plan was required in nine client records, #18, 19, 20, 21, 22, 23, 24, 25 and 26.
Client #18 was admitted on April 23, 2012 and discharged on May 14, 2012. The aftercare plan was documented on May 11, 2012 and failed to include the client's goals with time frames, contact person and reentry process.
Client #19 was admitted on April 11, 2012 and discharged on May 2, 2012. The aftercare plan was documented on May 1, 2012 and failed to include the client's goals with time frames, contact person and reentry process.
Client #20 was admitted on May 3, 2012 and discharged on May 16, 2012. The aftercare plan was documented on May 15, 2012 and failed to include the client's goals with time frames, contact person and reentry process.
Client #21 was admitted on May 1, 2012 and discharged on May 23, 2012. The aftercare plan was documented on May 19, 2012 and failed to include the client's goals with time frames, contact person and reentry process.
Client #22 was admitted on April 25, 2012 and discharged on May 1, 2012. The aftercare plan was documented on May 1, 2012 and failed to include the client's goals with time frames, contact person and reentry process.
Client #23 was admitted on May 1, 2012 and discharged on May 8, 2012. The aftercare plan was documented on May 8, 2012 and failed to include the client's goals with time frames, contact person and reentry process.
Client #24 was admitted on April 26, 2012 and discharged on May 8, 2012. The aftercare plan was documented on May 5, 2012 and failed to include the client's goals with time frames, contact person and reentry process.
Client #25 was admitted on April 18, 2012 and discharged on May 7, 2012. The aftercare plan was documented on May 2, 2012 and failed to include the client's goals with time frames, contact person and reentry process.
Client #26 was admitted on April 25, 2012 and discharged on May 7, 2012. The aftercare plan was documented on May 5, 2012 and failed to include the client's goals with time frames, contact person and reentry process.
This was discussed and confirmed with the facility staff on June 7, 2012.
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Plan of Correction
It was discovered during the site visit that our Aftercare Plan did not address some key elements that are required. The Aftercare Plan will be modified to include client goals with time frames, contact person and reentry process. Special Projects Coordinator will oversee this POC. |
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, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in eight of eight outpatient client records.
The findings include:
Forty-two client records were reviewed on June 5 through 7, 2012. Eight of the forty-two were reviewed from the outpatient activity, #27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41 and 42. A psychosocial evaluation was reviewed in eight client records, #27, 28, 29, 30, 31, 32, 33 and 34. An interview with facility staff on June 7, 2012 confirmed the findings.
The psychosocial evaluations in client records #27, 28, 29, 30, 31, 32, 33 and 34 did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, negative factors and how they would impact treatment.
The psychosocial evaluation in client records #28, 29, 31, and 33 did not include an evaluation of the client's attitude toward treatment and how it would impact treatment.
The psychosocial evaluation in client records #27, 28, 29, 30, 31, 32, 33 and 34 did not include an evaluation of the counselor conclusions/impressions of the client.
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Plan of Correction
It was discovered during the site visit that counselors are not consistently documenting their clinical evaluations of the client in the client record. Counselors will need to be retrained on what is expected in a clinical evaluation to include all the above components. A consultant has been identified to conduct clinical trainings on documentaiton and these trainings will be mandatory for all staff to attend. Quality of documentation will be monitored by weekly chart review. Outpatient Coordinator will oversee this POC. |
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 a review of client records, the facility failed to document treatment plans in four of eight outpatient client records.
The findings include:
Forty-two client records were reviewed on June 5 through 7, 2012. Sixteen came from the outpatient activity, #27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41 and 42. Of the sixteen, four required a treatment plan, #27, 28, 29 and 30. Per the facility policy, treatment plans will be developed within 30 days of the client's admission date. An interview with facility staff on June 7, 2012 confirmed the findings.
Client #27 was admitted on May 2, 2012 and the treatment plan was to be developed by June 1, 2012. As of the date of the inspection, client #27's treatment plan was not developed.
Client #28 was admitted on May 2, 2012 and the treatment plan was to be developed by June 1, 2012. As of the date of the inspection, client #28's treatment plan was not developed.
Client #29 was admitted on May 7, 2012 and the treatment plan was to be developed by June 6, 2012. As of the date of the inspection, client #29's treatment plan was not developed.
Client #30 was admitted on May 1, 2012 and the treatment plan was to be developed by May 31, 2012. As of the date of the inspection, client #30's treatment plan was not developed.
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Plan of Correction
It was discovered during the site visit that there were some clients on the active client list who did not have treatment plans completed. Our new system for tracking timely completion of documentation was put into effect on May 1, 2012 and it became apparent to us that there were some flaws in the initial implementation. Since then, staff has been trained to use their clinical dashboards and timely completion of treatment plans is being monitored weekly by the clinical supervisor. We will continue to use weekly chart and computer checks to ensure compliance with treatment plans being completed within 30 days. Outpatient Coordinator 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 client records, the facility failed to document a complete aftercare plan in three of eight outpatient discharge client records.
The findings include:
Forty-two client records were reviewed on June 5 through 7, 2012. Per the facility policy, the counselor and client will complete an aftercare plan prior to discharge for successful completion. An aftercare plan was required in three client records, #35, 40 and 41.
Client #35 was admitted on August 24, 2011 and discharged on May 2, 2012. The aftercare plan was to be documented by May 2, 2012. As of the date of the client's discharge May 2, 2012 it was not documented.
Client #40 was admitted on May 1, 2012 and discharged on May 16, 2012. The aftercare plan was documented on May 15, 2012 and failed to include the client's goals with time frames, contact person and reentry process.
Client #41 was admitted on July 20, 2012 and discharged on May 1, 2012. The aftercare plan was documented on May 1, 2012 and failed to include the client's goals with time frames, contact person and reentry process.
This was discussed and confirmed with the facility staff on June 7, 2012.
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Plan of Correction
It was discovered during the site visit that our Aftercare Plan did not address some key elements that are required. The Aftercare Plan will be modified to include client goals with time frames, conact person and reentry process. Special Projects Coordinator will oversee this POC. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a complete discharge summary in five of eight outpatient discharge client records.
The findings include:
Forty-two client records were reviewed on June 5 through 6, 2012. Per the facility policy, the counselor will complete a discharge summary 7 days after discharge. A discharge summary was required in eight client records, #35, 36, 37, 38, 39, 40, 41 and 42.
Client #35 was admitted on August 24, 2011 and discharged on May 2, 2012. The discharge was documented on May 2, 2012 and failed to include the client's response to treatment and their status at discharge.
Client #36 was admitted on July 10, 2009 and discharged on May 3, 2012. The discharge was documented on May 3, 2012 and failed to include the client's reason for treatment.
Client #37 was admitted on January 10, 2012 and discharged on May 2, 2012. The discharge was documented on May 2, 2012 and failed to include the client's reason for treatment.
Client #41 was admitted on July 20, 2011 and discharged on May 1, 2012. The discharge was documented on May 2, 2012 and failed to include the client's reason for treatment.
Client #42 was admitted on July 20, 2011 and discharged on May 3, 2012. The discharge was documented on May 3, 2012 and failed to include the client's reason for treatment.
This was discussed and confirmed with the facility staff on June 7, 2012.
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Plan of Correction
It was discovered during the site visit that discharge summaries were not being completely filled out. There are areas on the form for response to treatment, discharge status and reason for treatment, but counselors were not consistently documenting this information. Counselors will be instructed on the proper completion of the discharge summary and compliance will be monitored by weekly random chart checks. Outpatient Coordinator will oversee this POC. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up attempts in five of eight outpatient client records.
The findings include:
Forty-two client records were reviewed on June 5 through 7, 2012. Sixteen of the forty-two client records were from the outpatient activity. Five of those sixteen records were required to document follow-up attempts. Follow up was not documented in client records #35, 37, 38, 39 and 42. Per the facility's policy, the follow-up attempt will take place 7 days for referrals and 30 days all others. An interview with facility staff on June 7, 2012 confirmed the findings.
Record #35 was admitted on August 24, 2011 and discharged on May 2, 2012. The follow up attempt was due on June 1, 2012. As of the date of the licensing inspection, there was no documentation of a follow-up on client record #35.
Record #37 was admitted on January 10, 2012 and discharged on May 2, 2012. The follow up attempt was due on June 1, 2012. As of the date of the licensing inspection, there was no documentation of a follow-up on client record #37.
Record #38 was admitted on January 5, 2012 and discharged on May 2, 2012. The follow up attempt was due on June 1, 2012. As of the date of the licensing inspection, there was no documentation of a follow-up on client record #38.
Record #39 was admitted on March 7, 2012 and discharged on May 2, 2012. The follow up attempt was due on June 1, 2012. As of the date of the licensing inspection, there was no documentation of a follow-up on client record #39.
Record #42 was admitted on July 19, 2011 and discharged on May 3, 2012. The follow up attempt was due on June 2, 2012. As of the date of the licensing inspection, there was no documentation of a follow up on client record #42.
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Plan of Correction
It was discovered during the site visit that follow ups are not consistently being completed and documented. We will be implementing a new system to track clients in need of a follow up. We will use our EHR to track clients referred outside our agency. This tracking will place an alert on the clinicians "dashboard" that the client is in need of a follow up within 7 days. The Penn Foundation Recovery Center will use chart audits to ensure timely completion of the follow ups. Charts will not be closed until they have been reviewed for missing documentation and ensured that all required documentation is in chart. Outpatient Coordinator will oversee this POC. |