INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 25,2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Perry Human Services, 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 19, 2010.
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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 the review of client records, the facility failed to ensure the psychosocial evaluations were a clinical assessment or presented a composite picture of the client in relationship to the collected historical data in four of eight client records.
The findings include:
Eight client records were reviewed on February 25, 2010. Eight client records were reviewed for psychosocial evaluations. The content of the evaluations consisted of a summary of the historical data collected and statements of what the client reported without a clinical impression of the information in client records # 1 , 2, 3 and 6.
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Plan of Correction
Clinical Supervisor met with counselors on 3/8/10 and reviewed finding that psychosocial evaluation must include clinical assessment/clinical impressions by counselor for each client. Beginning with treatment meeting on 3/15/10 counselors will review 1 to 2 client records per counselor to critique clinical assessment section. At each intiial client file review, Clinical Supervisor will review carefully the clinical assessment/impressions section to ensure counselors are completing this section appropriately. Client files reviewed beginning 4/1/10 will have appropriate clinical assessments. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of eight patient records on February 25, 2010, the facility failed to document in eight of eight client records the treatment plan updates failed to document the patient's progress in relationship to the goals in the individual treatment and rehabilitation plan. A review of three of eight patient records revealed that the documentation in the treatment plan updates did not address the patient's progress of the past 60 days or include revised individual treatment goals.
The findings include:
Eight client records were reviewed on February 25, 2010. Eight client records were reviewed to determine if progress note documentation was consistent with the patient's treatment plan. Client records # 2, 3 and 4 did not include any information on the status of the stated goals to include progress or lack of progress.
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Plan of Correction
Clincal Supervisor met with counselors on 3/8/10 and reviewed finding regarding progress notes failing to document progress in relationship to goals in client treatment plan. Further discussion continued on 3/15/10 during monthly treatment meeting. After 3/22/10 during all client file initial and update reviews, Clinical Supervisor will carefully review progress notes in relationship to individual treatment goals to ensure status of stated goals include progress or lack of progress. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on an interview with the Facility Director and the review of client census information, the facility failed to comply with the maximum approved capacity for the outpatient treatment activity.
The findings included:
During the licensing inspection conducted on February 25, 2010, client census material provided by the Facility Director and an interview with the Facility Director confirmed that the current census for active clients was at 84. The maximum approved capacity on the day of the inspection was 75..
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Plan of Correction
On 2/26/10 Executive Director submitted a letter to Director of Licensure requesting an increase in maximum number of persons for agency outpatient license from 75 to 91 clients. Director of Licensure approved request on 3/3/10. Revised Certificate of Licensure was printed and posted. Agency is in compliance effective 3/3/10.
At the end of each month the CIS report will be printed to determine the current number of active clients. The Clinical Supervisor will compare this number to the maximum client capacity to ensure that the agency is not above capacity. |