INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 23 through 25, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on May 21, 2007.
709.14 Restriction on License (a)(5) Authorized capacity.
The program exceeded the licensed capacity of 50 with a current census of 56 clients.
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Plan of Correction
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709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
The annual report was not made available to the public within six months of the end of the facility's fiscal year (December).
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Plan of Correction
On May 10, 2007 the Director of Clinical Services (DSC) notified both the Chief Executive Officer (CEO) and the Public Relations Supervisor of Family Service Association of Bucks County's failure to make the facility's Annual Report for 2005-2006 available to the public within six months of the end of the facility's fiscal year (December 31, 2006). The Annual Report for 2005-2006 was printed in early fall 2006, distributed at the facility's November 3, 2006 Annual Meeting, and posted on the facility's website prior to the end of the fiscal year. However, a formal public notice did not occur until February 2007.
The CEO and the Public Relations Supervisor will work together to ensure that the facility's Annual Report for 2006-2007 is formally made available to the public prior to December 31, 2007. Beginning in July 2007 the DSC will regularly consult with both the CEO and the Public Relationships Supervisor to monitor compliance with this regulatory standard ensure timely public notification.
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709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
The policy and procedure manual was incomplete. There were policies and procedures that were missing.
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Plan of Correction
During the past year Family Service Association of Bucks County, under the direction of the Director of Quality Improvement (DQI), revised its Policies & Procedures Manual in preparation for reaccreditation by the Council on Accreditation (COA), schedule for June 11, 12, 13, 2007. The Director of Quality Improvement attempted to develop a comprehensive Manual which would meet Drug and Alcohol, Mental Health, and COA standards. However, some policies and procedures pertinent to Drug and Alcohol Licensure requirements were either not adequately stated or were missing.
The DQI and the Director of Clinical Services (DSC) will meet bi-weekly to develop and incorporate the policies and procedures required by Drug and Alcohol Licensure into the facility's Policies & Procedures Manual. This will be completed by June 30, 2007.
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709.24(a)(2) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(2) Treatment models utilized by the project.
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Observations
The treatment models identified by the facility did not include definitions of each model.
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Plan of Correction
By June 15, 2007 Director of Clinical Services (DCS) will specifically define each of the treatment models (Motivational Interviewing, Stages of Change Theory, Cognitive-Behavioral Therapy, Solution-Focused Brief Therapy, Functional Family Therapy, Structural Family Therapy, and Family Systems Therapy) identified by Family Service Association of Bucks County. The DCS will incorporate the definition of each identified model into the facility's Policies & Procedures Manual.
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709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Written procedures for the completion of client record items were missing. Specifically, procedures regarding medical histories, drug and alcohol histories, personal histories, psychosocial evaluations, preliminary treatment plans, medication records, record of services, case consultations, and discharge summaries were not addressed.
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Plan of Correction
0159
By June 30, 2007 the Director of Clinical Services (DCS) will update the Policies & Procedures Manual to include written procedures for the completion of client records. Written procedures will specifically address the content, person responsible, and required completion date for medical histories, drug and alcohol histories, personal histories, psychosocial evaluations, preliminary treatment plans, medication records, record of services, case consultations, and discharge summaries.
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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
Psychosocial evaluations did not include a composite picture of the client in four of seven records reviewed, # 1, 5, 6 and 7. Evaluations did not include support systems in six of seven records reviewed, # 1, 2, 3, 4, 5 and 6. Psychosocial evaluations did not include coping/defense mechanisms in five of seven records reviewed, # 2, 4, 5, 6 and 7.
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Plan of Correction
1871
The Director of Clinical Services (DCS) and the two Clinical Supervisors will meet with the Outpatient Treatment Staff on May 23, 2007. The DCS will review Drug and Alcohol Licensure Standards relevant to Psychosocial Evaluation and will specifically stress that all Psychosocial Evaluations must include: a composite picture of the client; a description of the client's support systems; and the client's coping/defense mechanisms.
Clinical Supervisors will regularly monitor client records to ensure that all required areas are evaluated and sufficiently addressed and will discuss omissions/deficiencies in regularly scheduled supervisory sessions.
During Utilization Reviews, held quarterly, the Peer Review Committee will devote particular attention to psychosocial evaluations to ensure that all required areas are evaluated and sufficiently addressed.
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709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Support services were not identified in three of seven client records reviewed, # 3, 5 and 6.
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Plan of Correction
1881
The Director of Clinical Services (DCS) and the two Clinical Supervisors will meet with the Outpatient Treatment Staff on May 23, 2007. The DCS will review Drug and Alcohol Licensure Standards relevant to Treatment/Rehabilitation Plans and will specifically stress the need to identify and include support services in all Treatment Plans.
Clinical Supervisors will regularly monitor client records to ensure that all Treatment Plans identify and include support services and will discuss omissions/deficiencies in regularly scheduled supervisory sessions.
During Utilization Reviews, held quarterly, the Peer Review Committee will devote particular attention to Treatment Plans to ensure that the Treatment Plans in the records reviewed identify and include support services.
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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
Medication records did not include the dosage in four of five records reviewed, # 2, 3, 5 and 7.
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Plan of Correction
1893
The Director of Clinical Services (DCS) and the two Clinical Supervisors will meet with the Outpatient Treatment Staff on May 23, 2007. The DCS will review Drug and Alcohol Licensure Standards relevant to Medication Records and stress that all medications listed must include the dosage.
Clinical Supervisors will regularly monitor client records, with particular focus on the Medication Records, to ensure that the medications listed also specify the dosage. Supervisors will discuss omissions/deficiencies in regularly scheduled supervisory sessions.
During Utilization Reviews, held quarterly, the Peer Review Committee, when reviewing Medical Histories/Medical Records, will particularly note whether the medications listed also specify dosage.
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709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
The follow-up policy did not include the manner of documented when client's are referred to other services or for client's who completed treatment.
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Plan of Correction
1923
By June 30, 2007, the Director of Clinical Services (DCS) will update the Follow-Up Policy to specifically include the manner in which follow-up calls are to be documented for clients who complete treatment and for client referred to another resource/facility.
Clients Who Complete Treatment. The client's written consent on the Aftercare Plan will permit agency-initiated follow-up contacts. The assigned Clinician will document follows up contacts at 15 and 30 days following the end of treatment on the last page of the Aftercare Plan.
Clients Referred to Another Facility. Within one week of the referral, the assigned clinician will contact the alternate resource/facility, determine the outcome of the referral, and document the contact in the Record of Service and in a Progress Note.
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