INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 24-25, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Alcohol and Drug Abuse Services, Inc - Port Allegany, 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 February 22, 2011.
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Plan of Correction
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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 and an interview with the clinical supervisor, the facility failed to document follow up contact as required by agency policy and regulation, in one of two inpatient client records.
The findings include:
Five inpatient client records were reviewed on January 25, 2011. Three of the client records reviewed were in regards to active clients and did not require documentation of attempts to follow up on clients. One of the client records reviewed required a 30 day and/or 180 day follow up contact, per facility policy. One of the client records reviewed was in regards to a referred client and required a 7 day follow up contact as required by facility policy and regulation. The facility did not document follow up contact in client records #4.
Client #4 was admitted on November 18, 2010 and discharged on December 16, 2010. Client #4 was referred to another project on December 16, 2010. Follow up contact was due by December 23, 2010. There was no documentation of follow up contact in client record #4.
An interview with the clinical supervisor took place on January 25, 2011 at approximately 2:45 PM. The clinical supervisor confirmed that there was no follow up documentation in the aforementioned client record and could not locate any additional documentation for review.
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Plan of Correction
The inpatient therapists will inform the facility's clerical staff of each client's aftercare appointment. The clerical staff will call the agency/resource the client was referred to and will document the outcome of the referral on the "Referral to Auxiliary Services" form within seven days of the appointment as per agency policy and licensing regulation.
This process will be monitored by the Inpatient Director as part of quarterly QA activities.
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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 and an interview with the clinical supervisor, the facility failed to document follow up contact as required by facility policy and regulation, in two of two outpatient client records.
The findings include:
Three outpatient client records were reviewed on January 25, 2011. One of the client records reviewed was in regards to an active client and did not require follow up contact. Two of the client records reviewed required a 30 day and/or 180 day follow up contact, per agency policy. The facility did not document follow up contact in client records #7 and 8.
Client #7 was admitted on February 17, 2010 and discharged on March 30, 2010. Follow up contact was due by April 30, 2010 and September 30, 2010. There was no documentation of follow up contact in client record
# 7.
Client #8 was admitted on October 15, 2010 and discharged on November 24, 2010. Follow up contact was due by December 24, 2010. There was no documentation of follow up contact in client record #8.
An interview with the clinical supervisor took place on January 25, 2011 at approximately 2:45 PM. The clinical supervisor confirmed that there was no follow up documentation in the aforementioned client records and could not locate any additional documentation for review.
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Plan of Correction
The facility's clerical staff has been instructed to add all intensive outpatient clients to the mailing list of clients to receive follow-up contact at 30 days and 180 days as per agency policy. This list is already compiled for the inpatient clients so no additional changes in procedure were required.
This process will be monitored by the Inpatient Director as part of quarterly QA activities. |