INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on April 17-19, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Butler Regional Recovery Day Program 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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711.93(a) LICENSURE Complete Client Record
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual which includes information relative to the client's involvement with the project in one of three client records.
The findings include:
Three outpatient client records were reviewed on April 17-20, 2012. Client record #22 was incomplete and did not include required documentation.
Client #22 was admitted on January 6, 2012. There was no documentation of a medical history, drug and alcohol history, personal history, psychosocial evaluation and comprehensive treatment and rehabilitation plan in client record #22.
An interview with the facility director took place on April 20, 2012 at which time the aforementioned information was confirmed.
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Plan of Correction
Policy will be changed to read: Psychosocial assessment and Diagnostic Summary will be completed by the fourth session or 60 calendar days, whichever comes first. If the client has not returned the Psychosicial self report. It will be done verbally in session on the fourth session or the last appointment within the 60 day time period, whichever comes first. The staff will be educated on the updated policy.Following education, 3 mos of chart audits will be done. The Supervisor of Program will be responsible. This will be in effect as of 5/15/12. |
711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in one of one successfully discharged client records.
The findings include:
Four discharged client records were reviewed on April 17-20, 2012. One client was successfully discharged and required documentation of an aftercare plan. Client record #28 did not contain documentation of an aftercare plan.
Client #28 was admitted on September 13, 2011 and successfully discharged on November 18, 2011. There was no documentation of an aftercare plan in client record #28.
An interview with the facility director took place on April 20, 2012 at which time it was confirmed that client record #28 did not contain an aftercare plan.
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Plan of Correction
The staff will be re-educated on the regulation and importance of the aftercare plan. Chart reviews will be conducted for 3 months. Program supervisor will be responsible for this plan which is effective immediately. |
711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up contact in two of four discharged client records.
The findings include:
Four outpatient discharged client records were reviewed on April 17-20, 2012. All four client records required the documentation of follow up contact. There was no documentation of follow up contact in client records # 25 and 28.
Client #25 was admitted on August 16, 2011 and discharged on November 8, 2011. Follow up was due to be completed by January 8, 2012. There was no follow up contact documented in client record #25. The last contact with the client took place on November 4, 2011 which was prior to discharge.
Client #28 was admitted on September 13, 2011 and discharged on November 8, 2011. Follow up was due to be completed by January 8, 2012. There was no follow up contact documented in client record #28.
An interview with the facility director took place on April 20, 2012. The aforementioned information was confirmed at that time.
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Plan of Correction
The staff will be re-educated on the importance of the follow up call and the need for it to occur following the discharge process. Chart review will be conducted for the next 3 months. The Program Supervisor will be responsible for this plan effective immediately. |