INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and buprenorphine monitoring inspection. The inspection was conducted on April 12- 14, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, White Deer Run of Lancaster 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 the inspection:
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Plan of Correction
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to document a written involuntary termination notice in two of two client records.
Nine client records were reviewed on April 12-14, 2017. Two of the clients reviewed were involuntarily terminated from treatment at the project. Client records #7 and 9 did not include documentation of a written involuntary termination notice.
Client #7 was admitted on 2/25/27 and terminated on 3/13/17. There was no written involuntary termination notice in client record #7.
Client #9 was admitted on 12/11/16 and terminated on 12/30/16. There was no written involuntary termination notice in client record #9.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Any individual that is administratively discharged from the program will receive a copy of this form either in person or via mail 100% of the time. All clinical staff was instructed on the proper use of the form April 17th by the program director. The clinical supervisor will ensure through supervision that the individual counselor will fill out and explain the form at the time a decision is made to administratively discharge the individual. |
709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
The facility failed to document that counseling was provided to clients on a regular and scheduled basis.
Nine client records were reviewed on April 12-14, 2017. Client records #5, 6 and 7 did not include documentation that counseling was provided on a regular and scheduled basis.
Client #5 was admitted on March 20, 2017. There were progress notes documented for March 29, March 30 and April 6; however, these sessions were not documented on the record of service. There were no entries on the record of service for the time period of 3/26/17 - 4/10/17.
Client #6 was admitted on March 29, 2017. There were no progress notes or entries on the record of service from 4/4/17 - 4/10/17.
Client #7 was admitted on February 25, 2017 and discharged on March 13, 2017. There were no progress notes or entries on the record of service for the time period of 3/9/17 - 3/13/17.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will ensure that all group and individual notes will be completed and filed in individual records 24 hours after the group or individual session is completed. The clinical supervisor will conduct ongoing open chart audits on a weekly basis to ensure the notes are in place and coincide with the record of service. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
The facility failed to document a complete client record including records of service, progress notes and/or follow up in 6 of 6 inpatient client records.
Six inpatient client records were reviewed on April 12-14, 2017. Client records #1, 5, 6, 7, 8 and 9 did not include documentation of a record of service, progress notes and/or follow up.
Client #1 was admitted on March 18, 2017. According to the record of service, group sessions were completed on April 3, April 4 and April 10; however, there were no corresponding progress notes for those services.
Client #5 was admitted on March 20, 2017. There were progress notes documented for March 29, March 30 and April 6; however, these sessions were not documented on the record of service. There were no entries on the record of service for the time period of 3/26/17 - 4/10/17.
Client #6 was admitted on March 29, 2017. There were no progress notes or entries on the record of service from 4/4/17 - 4/10/17.
Client #7 was admitted on February 25, 2017 and discharged on March 13, 2017. There was a progress note for a group session on 2/27/17; however this session was not on the record of service. There were no progress notes or entries on the record of service for the time period of 3/9/17 - 3/13/17.
Client #8 was admitted on September 14, 2016 and discharged on October 13, 2016. There were entries on the record of service for 10/11 and 10/12/16; however, there were no corresponding progress notes. There was also no follow up contact for client #8.
Client #9 was admitted on December 11, 2016 and discharged on December 30, 2016. There was no follow up contact documented for client #9.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will ensure through ongoing weekly open chart audits that all components of the client record, including group/individual progress notes will coincide with the record of service and completed within 24 hours. Follow-up calls will be conducted by the case manager within seven days of discharge appropriately documented on the form. The clinical supervisor will ensure 100% compliance through closed chart audits. |