Observations
Based on a review of administrative documentation, the project failed to provide documentation of an independent annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
The project's administrative records were reviewed for a financial audit on November 26, 2012. The project's fiscal year runs from July through June. The project failed to provide documentation of an independent annual audit for the July 2010 through June 2011 fiscal year.
The Project Director confirmed the findings.
This is a repeat citation. The facility was previously cited on 12/1/11.
This was still out of compliance at the time of the follow-up conducted on May 15, 2013.
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Plan of Correction
Kirkbride Center has engaged the services of an independent public accountant firm to conduct the auditing of the Company's financial activities. The period of July 2010 through June 2011 fiscal year audit is currently underway commencing on May 6, 2013. The report will be available by June 30, 2013 for review by PA Dept. of Health's Division of D&A.
The CFO will conduct monthly reviews of the facilities financial activities and report findings to the Executive Management Committee.
The Executive Management Committee will have oversight of procuring and engaging the services of an Independent Audit Firm for fiscal year financial services audit and report. |
Observations
Based on the review of patient records, the facility failed to document psychosocial evaluations that provided a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the patient's current situation in ten of fifteen records.
The findings included:
On May 13-15, 2013, fifteen patient records were reviewed. All of the records were reviewed for the content of the psychosocial evaluation. Patient records # 1, 2, 7, 8, 9,10, 11, 12, 13 and 14 failed to include a psychological evaluation that included a composite picture of the client's problems and needs to be addressed in treatment, the client's assets and strengths, support systems, coping mechanisms, the negative factors that might inhibit treatment, and the counselor's impressions regarding the client.
Patient # 1 was admitted on 2/26/2013. The psychosocial evaluation was documented on 2/28/2013. The facility failed to document a psychosocial evaluation which included an assessment of the patient's problems/needs, assets/strengths, support systems and negative factors that might inhibit treatment.
Patient # 2 was admitted on 3/25/2013. The psychosocial evaluation was documented on 3/26/2013. The facility failed to document a psychosocial evaluation which included an assessment of the patient's problems/needs and support systems.
Patient # 7 was admitted on 5/3/2013. The psychosocial evaluation was documented on 5/6/2013. The facility failed to document a psychosocial evaluation which included an assessment that included a composite picture of the patient, an assessment of the patient's problems/needs, assets/strengths, support systems, and negative factors that might inhibit treatment.
Patient # 8 was admitted on 5/1/2013. The psychosocial evaluation was documented on 5/2/2013. The facility failed to document a psychosocial evaluation which included an assessment of the patient's problems/needs, assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
Patient # 9 was admitted on 1/4/2013. The psychosocial evaluation was documented on 1/7/2013. The facility failed to document a psychosocial evaluation which included an assessment of the patient's support systems and coping mechanisms.
Patient # 10 was admitted on 3/19/2013. The psychosocial evaluation was documented on 3/20/2013. The facility failed to document a psychosocial evaluation which included an assessment of the patient's support systems and coping mechanisms.
Patient # 11 was admitted on 4/13/2013. The psychosocial evaluation was documented on 4/14/2013. The facility failed to document a psychosocial evaluation which included an assessment of the patient's assets/strengths, support systems, coping mechanisms, negative factors and attitude towards treatment. The psychosocial evaluation was identical to the evaluation documented in patient record # 13.
Patient # 12 was admitted on 5/7/2013. The psychosocial evaluation was documented on 5/9/2013. The facility failed to document a psychosocial evaluation which included an assessment of the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, attitude towards treatment, and counselor conclusions and impressions.
Patient # 13 was admitted on 4/26/2013. The psychosocial evaluation was documented on 4/27/2013. The facility failed to document a psychosocial evaluation which included an assessment of the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors and attitude towards treatment. The psychosocial evaluation was identical to the evaluation documented in patient record # 11.
Patient # 14 was admitted on 4/23/2013. The psychosocial evaluation was documented on 4/25/2013. The facility failed to document a psychosocial evaluation which included an assessment of the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, attitude towards treatment, and counselor conclusions and impressions.
This is a repeat citation from the November 26-29, 2012 licensing inspection.
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Plan of Correction
The facility will mandate Comprehensive Behavioral Evaluation training for all primary Therapists. Temporary (fill-in) Therapists from the agency will be required to demonstrate proficiency in Psychosocial evaluations prior to assignments of a caseload. Kirkbride Center's Primary Therapists will receive internal trainings provided by clinical leadership and external trainings provided by CBH and other training resources; seminars and workshops. Whenever possible, temporary staff will participate in internal trainings and in-services on psychosocial evaluation development. Kirkbride Center has hired two new full time Therapists to reduce the need of temporary staff.
The Clinical Leadership Team partnering with Clinical Compliance will conduct chart audits weekly of 15% active MMT clinical records for a period of 4 months. Results will be reported monthly to the Chemical Dependency Dashboard for oversight and monitoring.
If audits reveal specific Therapists with particular weaknesses chart audits for that Therapist will be increased. Deficiencies will be addressed during 1 on 1 supervision with the therapist. Overall results will be reported monthly at the Drug & Alcohol Program Operations Executive Committee known as the Chemical Dependency Dashboard for oversight and monitoring.
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