INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 23, 2009 through July 24, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Conewago Place 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 August 15, 2009.
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Plan of Correction
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed document treatment plan updates that included a review of the client's progress on each goal stated on the comprehensive treatment plan in four of six client records.
The finding include:
Six client records were reviewed on July 23, 2009 through July 24, 2009. Documentation of a completed treatment plan update was required in six client records. Client records #1, 3, 5 and 6 included treatment plan updates; however, the client's progress on each treatment plan goal was not documented on the treatment plan update. The treatment plan update only indicated whether each treatment plan goal was completed, in progress or not yet started.
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Plan of Correction
On July 24, 2009, the Facility Director and Clinical Director met with the Clinical staff in a group format to review and retrain staff on how to complete the Treatment Plan Update. A sample Treatment Plan Update was provided for Clinicians to review. Specifically, the focus of the retraining was on including an assessment of the progress for each Treatment Plan Goal, instead of just indicating the status such as Completed, In Progress, or Not Yet Started. The Clinical Director reinforced that an actual assessment of client progress for each goal is necessary so that an overall picture of the client's progress can be formulated and understood. Clinical Director and Corporate Compliance Officer will monitor compliance through periodic and monthly chart audits by 8/31/09. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed document progress notes that included data, assessment and plan in six of six client records.
The finding include:
Six client records were reviewed on July 23, 2009 through July 24, 2009. Documentation of individual and group progress notes was required in six client records. The individual progress notes in client records #1, 3 and 5 included data, but little to no assessment. More data was found to be documented in the assessment section rather than an assessment of the client. The plan was generalized and not specific to an assigned project for the next session or not specific as to what would be addressed at the next session. Group progress notes in client records #1, 2, 3, 4, 5 and 6 did not include an individual assessment of each client in the group. Only the individual presenting in the group that scheduled day was assessed. The plan section of the group note was generalized and not specific to an assigned project for the next session or not specific as to what would be addressed at the next session.
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Plan of Correction
On July 24, 2009, the Facility Director and Clinical Director met with the Clinical staff in a group format to review and retrain staff on proper documentation within Individual and Group Progress notes: the Data Assessment Plan (DAP) format was specifically reviewed. All clinicians were reminded that all data and factual information is to be included in the "D" portion of the progress note and should not be included in the "A" section unless it needed in support of the assessment. Clinicians were advised that the "A" section of the note is to contain the clinician's assessment of the client's progress to date and is also to include an assessment of the information contained in the "D" section. Lastly, Clinicians were reminded that the "P" section needs to specify in detail what treatment goals, objectives or assignments the client is to be working on next or what the clinician and client are planning to review in their next session. In regard to Group Progress Notes the same D.A.P. format was discussed and reviewed. The only difference in this part of the retraining was that for group components, in particular Therapeutic Groups, that each client assigned to that specific group needs to have an individualized assessment completed in the "A" section. Clinical Director will also review and reinforce the importance of proper Progress Note documentation with each clinician in their monthly supervision(s) by 8/31/09 and the training will be documented on their Monthly Supervision Form. Clinical Director and Corporate Compliance Officer will monitor compliance through periodic and monthly chart audits by 8/31/09. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document verification that work done by the client at the facility is an integral part of his treatment plan in three of six client records.
The findings include:
Six client records were reviewed on July 23, 2009 through July 24, 2009. Verification that work done by the client at the facility was required in six client records. Client records #2, 3 and 4 did not have work therapy documented on the treatment plan, yet all clients were identified as having performed work therapy.
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Plan of Correction
On July 24, 2009, the Clinical Director and Facility Director met with the Clinical Staff in a group format, to review the importance of not only incorporating Work Therapy into each client's treatment experience but also the importance of documenting how Work Therapy is a key component in that treatment experience. Clinical Director retrained counselors on this date as to how to document work therapy on the client treatment plan, including the importance of having attainable goals and objectives. Also included in the retraining was a discussion about the relationships between establishing work skills, having a strong work ethic, improving self worth and living a life in recovery. Clinical Director will also review and reinforce the importance of Work Therapy with each clinician in their monthly supervision(s) by 8/31/09 and the training will be documented on their Monthly Supervision Form. Clinical Director and Corporate Compliance Officer will monitor compliance through monthly chart audits by 8/31/09. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on the review of administrative materials and staff interview, the facility failed to document an annual evaluation of the overall training plan for the facility's 2008 training year.
The findings include:
The facility's training year operates on a calendar year. An annual evaluation of the overall training plan for the 2008 training year was not documented.
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Plan of Correction
An evaluation of the Facility's Training Plan will be completed by the Facility Director or Corporate Training Director for each calendar year. The Project Director will monitor compliance with the annual evaluation of the Facility's Training Plan. The 2009 Training Plan evaluation will be completed no later than Jan. 31, 2010. Facility Director completed a sample Training Plan evaluation on July 23, 2009 and submitted it to the Dept. of Health Licensing Specialists for review. The Licensing Specialists advised that the sample Training Plan evaluation was acceptable as a reference point for future use. |