INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 25, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, Roxbury 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 March 2, 2010.
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Plan of Correction
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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
Based on a review of client records and an interview with the facility director, the facility failed to document psychosocial evaluations that included a clinical assessment of the client in ten of thirteen client records and failed to individualize three out of ten client records as required by regulation.
The findings include:
Thirteen client records were reviewed on January 25, 2010. Thirteen client records required the completion of psychosocial evaluations, per regulation. Thirteen client records did not include a clinical assessment of the client; furthermore six of those records had evaluations that were either verbatim or near identical. The facility failed to document a psychosocial evaluation that included a clinical assessment in client records # 1,2,3,4,5,6,7, 8, 9, 10,11, 12, and 13.
Client #'s 1,3, 7, and 9's psychosocial evaluations did not include a clinical assessment of the client's composite picture, problems and needs, assets and strengths, support systems, coping mechanisms, and negative factors, attitude toward treatment, and counselor conclusions/impressions. Furthermore client #'s 1, 7, and 9's evaluations were identical with the exception of reference to the client's name, age, marital status, and support systems.
Client # 2's psychosocial evaluation did not include a clinical assessment of the client's assets and strengths, support systems, and coping mechanisms. Furthermore, client #'s 2, 5, and 13's evaluations were near identical with slight differences in the composite picture and coping mechanisms.
Client # 4's psychosocial evaluation did not include a clinical assessment of the client's problems and needs, assets and strengths, support systems, coping mechanisms, and negative factors.
Client #'s 5 and 6's psychosocial evaluations did not include a clinical assessment of the client's composite picture, problems and needs, assets and strengths, support systems, coping mechanisms, and negative factors.
Client #'s 8, 10, 11, and 12's psychosocial evaluations did not include a clinical assessment of the client's assets and strengths, support systems, coping mechanisms, negative factors, attitude towards treatment, and counselor conclusions/impressions.
Client # 13's psychosocial evaluation did not include a clinical assessment of the client's problems and needs, assets and strengths, support systems, coping mechanisms, negative factors, attitude towards treatment, and counselor conclusions/impressions.
This was confirmed by the project director.
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Plan of Correction
The Director of OP Services will facilitate a training on 2/26/10 with pertinent clinical staff on psycho-social interviewing and documentation. This training will educate staff on the importance of completing the psychosocial evaluation from the clinician's perspective, with emphasis on covering all the recommended points in each composite picture, as the records do not sufficiently demonstrate their clinical assessment of the client.
Furthermore Performance Improvement Plans have been initiated and placed in HR files as of 2/22/10 with those clinicians whose psychosocial write-ups were not individualized and were lacking in specificity. Identified staff will be required to submit psychosocial summaries to the Director of OP Services for review and sign off until such time that improvement is evident.
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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, administrative policy and procedures and an interview with the project director, the facility failed to complete preliminary treatment and rehabilitation plans within five days of admission, as per agency policy, in eight out of thirteen client records.
The findings include:
Thirteen client records were reviewed on January 25, 2010. Thirteen client records required the completion of preliminary treatment and rehabilitation plans. Per agency policy, preliminary treatment and rehabilitation plans will be completed within five days of the admission date. Preliminary treatment and rehabilitation plans were not completed within the required time frames in client records # 1,5,7,8,9,10,12, and 13.
Client # 1 was admitted on December 1, 2009. The preliminary treatment and rehabilitation plan was due to be completed no later than December 6, 2009. The preliminary treatment and rehabilitation plan was not completed until December 15, 2009.
Client # 5 was admitted on September 9, 2009. The preliminary treatment and rehabilitation plan was due to be completed no later than September 14, 2009. The preliminary treatment and rehabilitation plan was not completed until September 24, 2009.
Client # 7 was admitted on September 1, 2009. The preliminary treatment and rehabilitation plan was due to be completed no later than September 6, 2009. The preliminary treatment and rehabilitation plan was not completed until September 15, 2009.
Client # 8 was admitted on April 4, 2009. The preliminary treatment and rehabilitation plan was due to be completed no later than April 9, 2009. The preliminary treatment and rehabilitation plan was not completed until April 30, 2009.
Client # 9 was admitted on June 1, 2009. The preliminary treatment and rehabilitation plan was due to be completed no later than June 6, 2009. The preliminary treatment and rehabilitation plan was not completed until June 9, 2009.
Client # 10 was admitted on August 10, 2009. The preliminary treatment and rehabilitation plan was due to be completed no later than August 15, 2009. The preliminary treatment and rehabilitation plan was not completed until August 31, 2009.
Client # 12 was admitted on October 13, 2009. The preliminary treatment and rehabilitation plan was due to be completed no later than October 18, 2009. The preliminary treatment and rehabilitation plan was not completed until October 21, 2009.
Client # 13 was admitted on August 4, 2009. The preliminary treatment and rehabilitation plan was due to be completed no later than August 9, 2009. The preliminary treatment and rehabilitation plan was not completed until August 27, 2009.
This was confirmed by the project director.
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Plan of Correction
The Project Director is currently revising agency policy. The revision will reflect that preliminary treatment and rehabilitation plans will be developed at the 2nd session, rather than the current agency policy wording which states "within 5 days of admission." The revised policy will be completed on or before 3/15/10. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up attempts in two of the three required records.
The findings include:
Thirteen client records were reviewed on January 25, 2010. Seven of the thirteen client records were clients who have been discharged. Three of those seven records were required to document follow-up attempts. Follow-up attempts were not documented in two of three required client records.
Record # 8 was admitted on April 4, 2009 and discharged on October 13, 2009. The follow up attempt was due on January 13, 2010 as of January 25, 2010 the facility failed to document that a follow-up attempt had been made.
Record # 10 was admitted on August 10, 2009 and discharged on October 6, 2009. The follow up attempt was due on January 6, 2010 as of January 25, 2010 the facility failed to document that a follow-up attempt had been made.
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Plan of Correction
Follow up attempts are occurring following discharge; however, the current procedure fails to sufficiently document the practice. Our process for documenting follow up attempts has been revised and will be implemented for follow ups occurring 3/1/10 and forward.
Staff will receive training on 2/26/10 on the new procedure. The Director of OP Services will monitor closed records for compliance. |