INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on May 8-9, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Deerfield Dual Diagnosis, LP 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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709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to document the type and frequency of services in the individual treatment and rehabilitation plan in seven of seven client records.
The findings include:
Seven client records were reviewed on May 8-9, 2012. The type and frequency of services were required in the individual treatment and rehabilitation plan in all seven client records. The facility did not document the type and frequency of services in the individual treatment and rehabilitation plan in client records #1, 2, 3, 4, 5, 6 and 7.
An interview with the facility director took place on May 9, 2012 at which time it was confirmed that the type and frequency of treatment and rehabilitation services was not documented on the aforementioned treatment and rehabilitation plans.
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Plan of Correction
The Clinical Supervisor will instruct the therapist to add documentation to the individual client treatment plans indicating the type and frequency of service a client will be receiving to address identified problems. Treatment Plans will be reviewed by the Clinical Supervisor over the next two months to ensure that this information is being added accurately. This will be initiated immediately. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document a follow-up within 7 days for referred clients in four of four client records.
The findings include:
Four discharged client records were reviewed on May 8-9, 2012. Per agency policy, a follow-up will be completed no later than 7 days after a client is discharged from the program if that client is referred to another agency for aftercare. The facility did not document a 7 day follow-up in client records # 4, 5, 6 and 7.
Client # 4 was admitted on March 27, 2012 and discharged on April 17, 2012. A follow-up was due to be completed no later than April 24, 2012. There was no documentation of a follow-up in client record # 4.
Client # 5 was admitted on February 10, 2012 and discharged on March 2, 2012. A follow-up was due to be completed no later than March 9, 2012. There was no documentation of a follow-up in client record # 5.
Client # 6 was admitted on April 5, 2012 and discharged on April 26, 2012. A follow-up was due to be completed no later than May 3, 2012. There was no documentation of a follow-up in client record # 6.
Client # 7 was admitted on March 5, 2012 and discharged on March 26, 2012. A follow-up was due to be completed no later than April 2, 2012. There was no documentation of a follow-up in client record # 7.
The clinical supervisor was interviewed on May 9, 2012 at which time the aforementioned information was confirmed.
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Plan of Correction
As part of the discharge process, the primary counselor will be reminded that they are responsible to have a Follow-up form completed with the client prior to discharge. A copy of the form will be added to the client chart while the original will be sent within 7 days. A log sheet will be developed that will document client name, discharge date, mailing date. The clinical Supervisor will review client charts and the cooreponding log book to ensure that the process is being followed. This will be initiated within the next 2 weeks. |