INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 20-22, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Family Center of Thomas Jefferson University (MATER) 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 January 18, 2011.
|
Plan of Correction
|
711.91(b)(3(ii) LICENSURE D & A History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
|
Observations
Based on the review of client records and an interview with the facility director, the facility failed to document a drug and alcohol history in five of eight client records.
The findings include:
Eight client records were reviewed on December 20-22, 2010 for drug and alcohol histories. The facility did not document a drug and alcohol history within four weeks of admission, as per facility policy, in client records # 1, 2, 3, 4 and 6.
The facility's policy titled "Psychosocial (PSH)/Biopsychosocial Assessments (BSA) - (PSH/BSA will be used) " sates:
"All assessments will be legible and completed within four weeks of admission. The PSH will reflect all identified presenting problems on the "problem list". Data gathered, both past and present, on the PSH will be used to assess the physical, psychiatric, trauma history, emotional, educational, maturational, spiritual, trauma, patient's strengths and barriers to treatment, history of risks for aggression, abuse, and suicidality in an effort to determine potential harm to self and/or others, patient's support system, nutritional, vocational, legal, sexual and social elements of a patient's life and of their children. The PSH and all treatment plans will include the DSM-IV (5) axes, GAF, and initial plans for discharge planning. All PSH will be completed by the primary counselor and reviewed and signed by a master's level licensed supervising clinician."
The admission date for client #1 was 8/3/10, but the drug and alcohol history was dated 8/13/10.
The admission date for client #2 was 8/11/10, but the drug and alcohol history was dated 9/17/10.
The admission date for client #3 was 3/12/10, but the drug and alcohol history was dated 5/4/10.
The admission date for client #4 was 4/9/10, but the drug and alcohol history was not dated or signed.
The admission date for client #6 was 4/1/10, but the drug and alcohol history was dated 7/30/10.
An interview with the facility director on December 22, 2010, confirmed that the drug and alcohol histories in the identified client records had not been documented within four weeks of admission.
|
Plan of Correction
All documentations has been morely closely monitored and documented by the Clinical Director. Weekly supervision, random chart monitoring, and, if necessary, progressive diciplinary actions have all been implemented to ensure compliance to policies and procedures.
Person (s) responsible: Clinical Director and Primary Therapist
Timeframce for completion: Immediate |
711.91(b)(3)(iii) LICENSURE Personal History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
Based on the review of client records and an interview with the facility director, the facility failed to document a personal history in five of eight client records.
The findings include:
Eight client records were reviewed on December 20-22, 2010 for personal histories. The facility did not document a personal history within four weeks of admission, as per facility policy, in client records # 1, 2, 3, 4 and 6.
The facility's policy titled "Psychosocial (PSH)/Biopsychosocial Assessments (BSA) - (PSH/BSA will be used) " sates:
"All assessments will be legible and completed within four weeks of admission. The PSH will reflect all identified presenting problems on the "problem list". Data gathered, both past and present, on the PSH will be used to assess the physical, psychiatric, trauma history, emotional, educational, maturational, spiritual, trauma, patient's strengths and barriers to treatment, history of risks for aggression, abuse, and suicidality in an effort to determine potential harm to self and/or others, patient's support system, nutritional, vocational, legal, sexual and social elements of a patient's life and of their children. The PSH and all treatment plans will include the DSM-IV (5) axes, GAF, and initial plans for discharge planning. All PSH will be completed by the primary counselor and reviewed and signed by a master's level licensed supervising clinician. "
The admission date for client #1 was 8/3/10, but the personal history was dated 8/13/10.
The admission date for client #2 was 8/11/10, but the personal history was dated 9/17/10.
The admission date for client #3 was 3/12/10, but the personal history was dated 5/4/10.
The admission date for client #4 was 4/9/10, but the personal history was not dated or signed.
The admission date for client #6 was 4/1/10, but the personal history was dated 7/30/10.
An interview with the facility director on December 22, 2010, confirmed that the personal histories in the identified client records had not been documented within four weeks of admission.
|
Plan of Correction
This citation, as with the other three, falls under the same POC, with an additional POC, as follows:
All documentations has been morely closely monitored and documented by the Clinical Director. Weekly supervision, random chart monitoring, and, if necessary, progressive diciplinary actions have been implemented to ensure compliance to policies and procedures.
Additionally for this particular citation, the Clinical Supervisor will monitor for signatures and dates that record when the data was enetered.
Person (s) responsible: Clinical Director and Primary Therapist
Timeframe for completion: Immediate
|
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on the review of client records and an interview with the facility director, the facility failed to document a psychosocial evaluation in five of eight client records.
The findings include:
Eight client records were reviewed on December 20-22, 2010 for psychosocial evaluations. The facility did not document a psychosocial evaluation within four weeks of admission, as per facility policy, in client records # 1, 2, 3, 4 and 6.
The facility's policy titled "Psychosocial (PSH)/Biopsychosocial Assessments (BSA) - (PSH/BSA will be used)" sates:
"All assessments will be legible and completed within four weeks of admission. The PSH will reflect all identified presenting problems on the "problem list". Data gathered, both past and present, on the PSH will be used to assess the physical, psychiatric, trauma history, emotional, educational, maturational, spiritual, trauma, patient's strengths and barriers to treatment, history of risks for aggression, abuse, and suicidality in an effort to determine potential harm to self and/or others, patient's support system, nutritional, vocational, legal, sexual and social elements of a patient's life and of their children. The PSH and all treatment plans will include the DSM-IV (5) axes, GAF, and initial plans for discharge planning. All PSH will be completed by the primary counselor and reviewed and signed by a master's level licensed supervising clinician."
The admission date for client #1 was 8/3/10, but the psychosocial evaluation was dated 8/13/10.
The admission date for client #2 was 8/11/10, but the psychosocial evaluation was dated 9/17/10.
The admission date for client #3 was 3/12/10, but the psychosocial evaluation was dated 5/4/10.
The admission date for client #4 was 4/9/10, but the psychosocial evaluation was not dated or signed.
The admission date for client #6 was 4/1/10, but the psychosocial evaluation was dated 7/30/10.
An interview with the facility director on December 22, 2010, confirmed that the psychosocial evaluations in the identified client records had not been documented within four weeks of admission.
|
Plan of Correction
This final citation, as with the other three, falls under the same POC, as follows:
All documentations has been morely closely monitored and documented by the Clinical Director. Weekly supervision, random chart monitoring, and, if necessary, progressive diciplinary actions have been implemented to ensure compliance to policies and procedures.
Person (s) responsible: Clinical Director and Primary Therapist
Timeframe for completion: Immediate
|