INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on August 12-13, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Lebanon Treatment Center 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:
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Plan of Correction
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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 a review of the staff development and training documentation, the facility failed to provide an evaluation of the training activities for the previous training year.
The finding includes:
The staff development plan for the facility was reviewed on August 12, 2013. The annual evaluation of the overall training plan consisted of a summary of the training received by facility staff but failed to evaluate the extent to which the plan addressed the identified training needs, including a determination of the extent to which implementing the plan eliminated or satisfied the identified training needs for the facility staff.
The finding was reviewed with the Facility Director was not disputed. This is a repeat citation from the August 21-23, 2012 licensure inspection.
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Plan of Correction
The clinical supervisor and/or director will conduct an annual evaluation of the staff training plan and determine the extent to which the plan addressed the identified training needs for the facility for the prior year.
The clinical supervisor and/or director will document findings from the evaluation in the annual review of the facility training plan.
A computerized tracking system will be utilized to alert clinical supervisor/director of due date. This will be tracked by the regional director. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the facility's administrative materials including the annual report, the facility failed to make the annual report available to the public and failed to include a statement of income and expenses in the report.
The finding includes:
The annual report was reviewed on August 13, 2013. The facility director was asked if the report had been made available to the public in any way. She indicated that she could not document notification of availability to the public of the annual report. A review of the facility's annual report showed there was not a statement of income and expensed included in the annual report.
The finding was reviewed with the Facility Director and was not disputed.
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Plan of Correction
A computerized alert will be utilized to notify/remind clinic director to submit notice to local newspaper annually.
Once the annual report has been completed/received, a notice will be placed in the local newspaper. A copy of the notice will be requested and maintained on file in a location accessible by Lebanon Treatment Center staff as well as with the regional director.
A notice will be placed in a local newspaper by 10/31/13 to satisfy requirements for 2013. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the facility failed to complete the annual physical examination with a re-evaluation by the physician in two of two patient records reviewed.
The findings include:
Eleven patient records were reviewed on August 12-13, 2013. Two patient records were reviewed for annual physical examination that included an annual reevaluation by the narcotic treatment physician. The facility failed to document annual physical examinations in patient records # 1 and 2.
Patient # 1 was admitted 5-2-2011 and discharged on 7-8-2013. The annual physical examination was required to be completed on 5-2-2013. The last annual physical was documented on 5-14-12. There was no further documentation available at the time of the inspection.
Patient # 2 was admitted on 12-22-2011 and discharged on 4-25-2013. The annual physical examination was required by 12-22-2012. The annual physical examination was documented late on 2-8-2013.
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Plan of Correction
A computerized tracking system will be utilized to track annual physical evaluations. The Director of Nursing will complete monthly chart reviews to ensure annual physical evaluations are completed in a timely manner.
Clinic Director and Director of Nursing will meet with Medical Director on 10/19/13 to review requirements, deficiencies and plan of correction. |
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 upon a review of patient records, the facility failed to document a psychosocial evaluation that included an assessment of the client's assets and strengths, support systems, negative factors, attitude toward treatment and/or failed to document a psychosocial evaluation.
The findings include:
Eleven patient records were reviewed on August 12 and 13, 2013, seven of which were reviewed for psychosocial evaluations. Five out of seven records lacked documentation of a psychosocial evaluation that included an assessment of the patient's assets and strengths, support systems, negative factors, attitude toward treatment, specifically records # 4, 5, 6, 7 and 11. Two out of seven records lacked a psychosocial assessment, records #8 and 10.
Patient #4 was admitted on December 3, 2012. The psychosocial assessment failed to include an assessment by the counselor that included an assessment of the patient's assets and strengths, support systems, negative factors, attitude toward treatment. The documentation included a repeat of the patient reported information and did not include an evaluation by the clinician for the required components.
Patient #5 was admitted on June 6, 2013. The psychosocial assessment failed to include an assessment by the counselor that included an assessment of the patient's assets and strengths, support systems, negative factors, attitude toward treatment. The documentation included a repeat of the patient reported information and did not include an evaluation by the clinician for the required components.
Patient #6 was admitted on May 16, 2013. The psychosocial assessment failed to include an assessment by the counselor that included an assessment of the patient's assets and strengths, support systems, negative factors, attitude toward treatment. The documentation included a repeat of the patient reported information and did not include an evaluation by the clinician for the required components.
Patient #7 was admitted on May 8, 2013. The psychosocial assessment failed to include an assessment by the counselor that included an assessment of the patient's assets and strengths, support systems, negative factors, attitude toward treatment. The documentation included a repeat of the patient reported information and did not include an evaluation by the clinician for the required components.
Patient # 8 was admitted on April 17, 2013. The psychosocial evaluation is required to be completed as a part of the intake and admission of a new patient. As of the date of the inspection, there was no documentation of a psychosocial assessment for patient # 8.
Patient # 10 was admitted on April 3, 2013. The psychosocial evaluation is required to be completed as a part of the intake and admission of a new patient. As of the date of the inspection, there was no documentation of a psychosocial assessment for patient # 10.
These findings were reviewed with the facility director and were not disputed.
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Plan of Correction
Clinical staff will attend a training on 10/31/13 regarding completion of the psychosocial assessment to include assessing strengths, supports systems, negative factors and attitude toward treatment.
Lead Counselor/Clinical Supervisor will review completed psychosocial assessments.
Lead Counselor/Clinical Sueprvisor will track completion of psychosocial assessments to ensure completion in a timely manner. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on the review of patient records, the facility failed to document support services on the treatment and rehabilitation plan in three of seven patient records reviewed.
The findings include:
Eleven patient records were reviewed on August 12-13, 2013. Seven patient records were reviewed for documentation of proposed support services on the patient's treatment and rehabilitation plan. Patient records # 7, 8 and 9 had no documentation of proposed support services on the treatment and rehabilitation plans.
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Plan of Correction
Clinical staff will attend training on 10/24/13 regarding inclusion of support services in treatment planning.
Clinical Supervervisor and/or Director will complete monthly review of treatment plans to monitor inclusion of support services in treatment planning. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of patient records, the facility failed to document treatment plan updates at least every sixty days in three of nine records reviewed.
The findings include:
Eleven patient records were reviewed on August 12-13, 2013. Nine patient records were reviewed for treatment and rehabilitation plans to be updated at least every 60 days. The facility failed to document treatment plan updates within the required time frame in patient records # 1, 3 and 9.
Patient #1 was admitted May 2, 2011 and discharged on July 8, 2013. The last treatment plan update in the patient record was dated January 7, 2013. There was no further documentation of treatment plan updates in the patient record.
Patient # 3 was admitted on August 28, 2009 and discharged on May 21, 2013. There was a treatment plan update in the patient record dated October 5, 2012. The next treatment plan update was due on December 5, 2012. The treatment plan update was not documented until January 13, 2013. The next treatment plan update was documented on February 8, 2013. The next treatment plan update was due on April 8, 2013. The treatment plan update was not documented until April 26, 2013.
Patient #9 was admitted on August 24, 2012 and discharged on May 14, 2013. The comprehensive treatment plan was dated October 5, 2012. The treatment plan update was due on December 5, 2012. The treatment plan update was not documented until December 28, 2012. The next treatment plan update was documented on February 8, 2013. The next treatment plan update was due on April 8, 2013. The treatment plan update was not documented until April 19, 2013.
These findings were discussed with the facility director and were not disputed.
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Plan of Correction
A computerized tracking system will be utilized to track and identify treatment plan dates.
Clinical Supervisor and/or Clinic Director will utillize computer system to monitor timely completion of treatment planning.
Clinical staff will complete training on 10/31/13 regarding treatment planning and due dates. |
709.93(a) 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:
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Observations
Based on the review of patient records, the facility failed to ensure there was a complete client record that included all required components of the record.
The findings include:
Eleven patient records were reviewed on August 12-13, 2013. Patient records # 1, 2, 4, 7, 9 and 11 were missing components of the patient record.
Patient record #1 was admitted on May 2, 2011 and successfully discharged on June 24, 2013. The record failed include an aftercare plan that included goals with timeframes. According to the facility's policy and procedures, the facility would follow-up within thirty days of discharge for patients that successfully complete the program. The facility failed to document follow-up for this patient.
Patient # 2 was admitted on December 22, 2011 and discharged on April 25, 2013. The facility failed to document a discharge summary in the patient record.
Patient # 4 was admitted on December 3, 2012 and left against facility advice on May 31, 2013. According to the facility's policy and procedures, the facility would follow-up within fourteen days of discharge for patients that left the facility against program advice. The facility failed to document follow-up for this patient.
Patient # 7 was admitted on May 8, 2013 and remained in treatment at the time of the inspection. The facility failed to document a case consultation in this patient record.
Patient # 9 was admitted on August 24, 2012 and discharged on May 14, 2013. The record failed include an aftercare plan that included goals with timeframes. The case consultation completed on March 26, 2013 failed to include what staff members were in attendance. Additionally, the record failed to include the patient's response to treatment on the discharge summary.
Patient # 11 was admitted to the program on April 16, 2013. The case consultation documented on July 31, 2013 failed to include what staff members were in attendance.
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Plan of Correction
The aftercare planning form will be altered to include timeframes for completion of measurable and individualized goals.
Staff will attend training on 10/24/13 regarding completion of the discharge planning forms and documentation of patient follow up. Training will also include completion of case consultations.
A computerized tracking system will be utilized to track and monitor timely completion of discharge forms and patient follow up.
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