INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 28-29, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Services of Beaver Valley, Inc., 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 July 31, 2009.
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on the review of personnel records, the facility failed to document that each counselor completed at least 25 clock hours of training annually in one of one personnel record.
Findings:
Eight personnel records were reviewed on June 30, 2009. Five personnel records were reviewed as counselors. One personnel record was required to have completed at least 25 clock hours of training annually. There was no documentation that the counselor had completed 25 clock hours of training annually in personnel record # 7.
Personnel record # 7 had 14 documented hours of training for the training year ending June 30, 2009. There was no documentation provided that the counselor was attending training on June 30, 2009 which was the close of the training year and the last day of the licensing inspection.
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Plan of Correction
In order to correct deficiencies regarding requied 25 hours of training, the following policy is now in place (effective 8/14/09): Each training record of all personnel will be reviewed on a monthly basis by the Director of Planning and Development. Any deficiencies will be noted and a memoranda sent to each person whose training plans are not being met. Any assistance which can be offered to remedy the deficiency will be offered. This process will be on going and monitored by the Director of Planning and Development on a monthly basis. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on the review of active client to counselor caseload list, the staffing requirements facility summary report, completed by the project director, and interviews with the project director and the clinical supervisor, the facility failed to maintain caseloads at the required 35:1 maximum.
Findings:
The facility's staffing compliance plan and active client list were reviewed on June 29-30, 2009. Interviews with the project director and the clinical supervisor occurred on June 29 and June 30, 2009. The facility's staffing compliance plan and active client caseload records report client numbers that equate to a ratio of 54:1
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Plan of Correction
In order to correct this deficiency, the Clinical Supervisor will provide training to all therapists, by August 20, 2009, on the importance of maintaining the required 35:1 client to counselor ratio. The Clinical Supervisor will monitor case loads on a weekly basis to ensure a 35:1 ratio is maintained by each therapist. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on the review of the facility's fire drill logs and an interview with the project/facility director and clinical supervisor, the facility failed to document that a fire alarm or smoke detector was set off during each fire drill.
Findings:
The fire drill logs were reviewed on June 30, 2009. There was no documentation provided that showed the facility had set off a fire alarm or smoke detector during each fire drill for the months of March, April, May and June, 2009. There was no documentation provided that the Department had approved an alternative procedure.
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Plan of Correction
In order to comply with fire drill requirements, Brobeck Security, which provides service to DASBV, has amended our key-pad system allowing alarms to be triggered for each monthly fire drill. The Director of Planning and Development's security code has been amended allowing him to digitally trigger the alarm system. The monthly recording of fire drills will reflect change in performance. This process will be on going and monitored by the Director of Planning and Development on a monthly basis. |
709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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Observations
709.14 Restriction on License (a)(5) Authorized capacity.
Based on the review of the active client case list and the review of the staffing requirements facility summary report, completed by the project/facility director, and interviews with the project/facility director and clinical supervisor, the facility to ensure that the client census did not exceed the authorized maximum capacity.
Findings:
The active client case list and the staffing requirements facility summary report, completed by the project/facility director, were reviewed on June 29 and 30, 2009. The interviews with the project/facility director and clinical supervisor occurred on June 29 and 30, 2009.
The facility had a census of 264 clients receiving outpatient treatment services at the time of the licensing inspection, which exceeds the authorized maximum capacity of 200.
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Plan of Correction
In order to correct this deficiency the Project Director will provide training to all staff on the importance of maintaining the authorized maximum capacity of 200. Training will be conducted by August 20, 2009. The Project Director will monitor capacity on a daily basis to ensure authorized capacity is maintained. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on the review of the agency policy and procedure manual and client records, the facility failed to develop a confidentiality policy and procedure consistent with 4 Pa. Code subsection 255.5.
Findings:
The policy and procedure manual was reviewed on June 29, 2009. The confidentiality policy and procedures did not address that disclosure of client-oriented information could be made without the client's consent as a result of a court order, in the reporting of child abuse and for the reporting of a crimes on the premises or against facility staff.
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Plan of Correction
In order to correct this deficiency, DASBV's Confidentiality Policy will be rewritten by August 24, 2009 to include "disclosure of client-oriented information could be made without the client's consent as a result of a court order, in reporting child abuse and for the reporting of a crime(s) on the premises or against facility staff." The Project Director will rewrite the Confidentiality Policy and Procedure to comply with this regulation. |
709.28(c)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of client records, the facility failed to document compliance with 4 Pa Code 255.5 in three of eight client records.
Findings:
Twelve client records were reviewed on June 30, 2009. Eight client records were required to include documentation of informed and voluntary consents. The facility did not document an informed and voluntary consent which complied with 4 Pa. Code 255.5(b) in client records # 1, 5 and 6.
In client record #1, the consent to release information signed by the client allowed for the disclosure of the client's assessment, service plan for drug and alcohol clients and a category for "other" to be released to a third party payer. The other category did not meet the requirement for a list of specific information to be released.
In client record #5, the consent to release information form signed by the client allowed for the disclosure of the client's treatment recommendation, assessment, service plan for drug and alcohol clients and a category for "other" to be released to a third party payer. The other category did not meet the requirement for a list of specific information to be released.
In client record #6, the consent to release information form signed by the client allowed for the disclosure of the client's assessment, service plan for drug and alcohol clients and a category for "other" to be released to a third party payer. The other category did not meet the requirement for a list of specific information to be released.
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Plan of Correction
In reviewing the Interpretive Guidelines, 28 Pa. Code subsection 709.28 which references 4 Pa. Code 255.5(b), it states; with the client's written consent, the provider may disclose the client's diagnosis which can be considered a part of the prognosis. However intimate details provided by the client to the provider and included on the psychsocial history and evaluation are not appropriate for release. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on the review of client records, the facility failed to demonstrate efforts towards informing the clients of their civil rights and civil liberties.
Findings:
Twelve client records were reviewed on June 20, 2009. Eight client records were required to have documentation that the client was informed of their rights. The facility failed to document efforts towards informing the client of their rights in client records # 1, 2, 3, 4, 5, 6, 7 and 8. The clients were not informed that the project director may temporarily remove portions of the records prior to the inspection by the client if the project director determined that the information may be detrimental if presented to the client and that the reasons for removing sections should be documented and kept on file.
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Plan of Correction
By August 24, 2009 the Policy and Procedure Manual and Client Handbook will be updated by the Project Director. This update will inform clients that the Project Director can determine that portions of the client's record may be removed prior to the client's inspection, if the Project Director has determined the information may be detrimental if presented to the client. Policy and Procedures will also reflect keeping documentation as to the reasons information was removed from the chart. These incidents will be kept on file. |
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 the review of client records, the facility failed to document a psychosocial evaluation that included a clinical assessment of the clients problems and needs, assets/strength, support systems, coping mechanism, negative factors and counselor conclusions and impressions in eight of eight client records.
Findings:
Twelve client records were reviewed on June 30, 2009. Eight client records were required to include documentation of a psychosocial evaluation. The facility did not document a psychosocial evaluation that was a clinical assessment of the client's problems and needs, assets/strength, support systems, coping mechanisms and negative factors in client records # 1, 2, 3, 4, 5, 6, 7 and 8.
In client records # 1, 2, 3, 4, 5, 6, 7 and 8, the psychosocial evaluations consisted of the clients' perception of problems and needs, assets/strength, support systems, coping mechanism and negative factors. The counselors' conclusions and impressions consisted of a reiteration of the historical information and were not clinical evaluations.
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Plan of Correction
In order to correct this deficiency the Clinical Supervisor will provide training to all therapists by August 20, 2009. Training will ensure therapists understand the importance of documenting a clinical assessment of client problems and needs, assets/strengths, support systems, coping mechanisms, negative factors, and counselor conclusions and impressions on a psychsocial evaluation. The Clinical Supervisor will monitor client charts by using a Chart Review Form. This is an on going process. |
709.92(a) 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:
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Observations
Based on the review of client records, the facility failed to document an individual treatment and rehabilitation plan in six of eight client records.
Findings:
Twelve client records were reviewed on June 30, 2009. Eight client records were required to have an individual treatment and rehabilitation plan completed by the 3rd session or by 30 days. The facility did not document that an individual treatment and rehabilitation plan had been completed according to policy in client records #2, 3, 4, 5, 6 and 8.
In client record #2, the client was admitted on November 11, 2008. The treatment plan was due on December 11, 2009. The treatment plan was completed on January 17, 2009.
In client record #3, the client was admitted on December 26, 2008. The treatment plan was due on January 26, 2009. The treatment plan was completed on February 9, 2009.
In client record #4, the client was admitted on January 9, 2009. The treatment plan was due on February 9, 2009. The treatment plan was completed on February 20, 2009.
In client record #5, the client was admitted on May 11, 2009. The treatment plan was due May 18, 2009. There was no documentation that a treatment plan had been completed as of June 30, 2009.
In client record #6, the client was admitted on April 27, 2009. The treatment plan was due on May 6, 2009. The treatment plan was completed on June 22, 2009.
In client record #8, the client was admitted on February 26, 2009. The treatment plan was due on March 26, 2009. There was no documentation that a treatment plan had been completed as of June 30, 2009.
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Plan of Correction
In order to correct this deficiency the Clinical Supervisor will provide training to all therapists on meeting timeframes of this regulation. Training will be conducted by August 20, 2009. The Clinical Supervisor will monitor timeframes for completing individual treatment and rehabilitation plans by using a Chart Review Form. Reviews will be on going. |
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 a review of client records, the facility failed to provide documentation of the proposed type of support services in the individual treatment and rehabilitation plans, in six of eight client records.
Findings:
Twelve client records were reviewed on June 30, 2009. The individual treatment and rehabilitation plans were required to document support services in eight client records. The facility did not document support services in client records # 1, 2, 3, 4, 5 and 8.
In client records # 5 and 8, there were no support services documented in the client's individual treatment and rehabilitation plan.
In client record # 1, the support systems listed were mother and sister. It was not identified how these individuals were a support system for the client.
In client record #2, the support system listed was mother. It was not identified how this individual was a support system for the client.
In client record #3, the support system was listed as family and friends. It was not identified how these individuals were a support system for the client.
In client records #4, the support system was listed as friend. It was not identified how this individual was a support system for the client.
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Plan of Correction
In order to correct this deficiency the Clinical Supervisor will provide training to all therapists on identifying support systems and documenting how they will provide the client with support. Training by the Clinical Supervisor will be conducted by August 20, 2009 and monitoring will be ongoing. The Clinical Supervisor will use a Chart Review Form to review charts. |
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 the review of client records, the facility failed to document that the treatment and rehabilitation plans were reviewed and updated at least every 60 days.
Findings:
Twelve client records were reviewed on June 30, 2009. Four client records were required to have treatment and rehabilitation plans reviewed and updated at least every 60 days. There was no documentation that the plans were reviewed and updated every 60 days in client records # 1 and 2.
In client record # 1, the comprehensive treatment and rehabilitation plan was completed on April 17, 2009. The treatment and rehabilitation plan update was due on June 17, 2009. There was no documentation provided that showed a treatment and rehabilitation plan update had been completed as of June 30, 2009.
In client record # 2, the comprehensive treatment and rehabilitation plan was completed on January 17, 2009. The treatment and rehabilitation plan update was due on March 17, 2009. There was no documentation provided that showed a treatment and rehabilitation plan update had been completed as of June 30, 2009.
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Plan of Correction
In order to correct this deficiency the Clinical Supervisor will provide training to all therapists on updating treatment and rehabilitation plans at least every sixty days. Training will be conducted by August 20, 2009. The Clinical Supervisor will monitor treatment plan updates on an ongoing basis. A Chart Review Form will be used to document the review. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to assure that counseling services were provided to clients according to their individual treatment and rehabilitation plan in eight of eight client records.
Findings:
Twelve client records were reviewed on June 20, 2009. Eight client records were required to have counseling services provided according to their individual treatment and rehabilitation plan. The facility did not document that the client received counseling services according to their individual treatment and rehabilitation plan in client records # 1, 2, 3, 4, 5, 6, 7 and 8.
In client records # 5 and 8, there was no comprehensive treatment plan completed. Type and frequency of the client's counseling services could not be determined.
In client record #1, the client was to receive 1 individual counseling session per week. The client was not scheduled for counseling services for the weeks of April 6, May 4, May 25 and June 22, 2009.
In client record #2, the client was to receive 1 individual counseling session per week. The client was not scheduled for counseling services for the weeks of February 23, April 20, May 4, May 18, May 25, June 1, June 8, June 15 and June 22, 2009.
In client record #3, the client was to receive 1 individual counseling session per week. The client was not scheduled for counseling services for the weeks of January 19, January 26, February 2, February 23, March 16, March 30, April 13, May 4, June 8, June 15 and June 22, 2009.
In client record #4, the client was to receive 1 individual counseling session per week. The client was not scheduled for counseling services for the weeks of January 12, January 26, February 9, February 23, March 9, March 16, March 23, April 6, April 20, May 4, May 18, May 25, June 8 and June 15, 2009.
In client record #6, the client was to receive 3 counseling session per week. The client was not scheduled for 3 counseling services for the weeks of May 4, May 11, May 18, May 25, June 1, June 8, June 15 and June 22, 2009. The client received only one counseling session for each week listed except for the week of June 15, 2009 where the client did not receive any counseling sessions.
In client record #7, the client was to receive 4 counseling session per week. The client was not scheduled for 4 counseling services for the weeks of March 2, March 9, March 16, March 23, March 30, April 6, April 13, April 20, April 27 and May 4, 2009. The client received only one counseling session for the weeks of March 2, March 16, April 20 and May 4, 2009. There was no documentation that the client had been scheduled for any counseling sessions for the weeks of March 9, March 23, March 30, April 24, April 13, and April 27, 2009.
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Plan of Correction
In order to correct this deficiency the Clinical Supervisor will provide training to all therapists on providing counseling services per the client's treatment and rehabilitation plan. Training will be conducted by August 20, 2009. The Clinical Supervisor will provide ongoing monitoring by using a Chart Review Form. |
709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on the review of client records, the facility failed to document that clients were provided counseling on a regular and scheduled basis in eight of eight client records.
Findings:
Twelve client records were reviewed on June 30, 2009. Eight client records were required to have counseling services provided on a regular and scheduled basis. The record of service and progress notes did not document that the clients were provided counseling services on a regular and scheduled basis for client records #1, 2, 3, 4, 6, and 7 .
In client record #1, the client was to receive 1 individual counseling session per week. The client was not scheduled for counseling services for the weeks of April 6, May 4, May 25 and June 22, 2009.
In client record #2, the client was to receive 1 individual counseling session per week. The client was not scheduled for counseling services for the weeks of February 23, April 20, May 4, May 18, May 25, June 1, June 8, June 15 and June 22, 2009.
In client record #3, the client was to receive 1 individual counseling session per week. The client was not scheduled for counseling services for the weeks of January 19, January 26, February 2, February 23, March 16, March 30, April 13, May 4, June 8, June 15 and June 22, 2009.
In client record #4, the client was to receive 1 individual counseling session per week. The client was not scheduled for counseling services for the weeks of January 12, January 26, February 9, February 23, March 9, March 16, March 23, April 6, April 20, May 4, May 18, May 25, June 8 and June 15, 2009.
In client record #6, the client was to receive 3 counseling session per week. The client was not scheduled for counseling 3 services for the weeks of May 4, May 11, May 18, May 25, June 1, June 8, June 15 and June 22, 2009. The client received only one counseling session for each week listed except for the week of June 15, 2009 where the client did not receive any counseling sessions.
In client record #7, the client was to receive 4 counseling sessions per week. The client was not scheduled for 4 counseling services for the weeks of March 2, March 9, March 16, March 23, March 30, April 6, April 13, April 20, April 27 and May 4, 2009. The client received only one counseling session for the weeks of March 2, March 16, April 20 and May 4, 2009. There was no documentation that the client had been scheduled for any counseling sessions for the weeks of March 9, March 23, March 30, April 24, April 13, and April 27, 2009.
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Plan of Correction
In order to correct this deficiency, the Clinical Supervisor will provide training to all therapists on documenting that clients were provided counseling on a regular and scheduled basis. Training will be conducted by August 20, 2009. The Clinical Supervisor will monitor that clients are having counseling sessions on a regular and scheduled basis by using a Chart Review Form. Reviews will be ongoing. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document case consultation notes in four of five client records.
Findings;
Twelve client records were reviewed on June 30, 2009. Five client records were required to have case consultation notes every 90 days as per agency policy. There was no documentation that case consultations had been completed in client records # 1, 2, 3 and 7.
In client record #1, the case consultation was due June 25, 2009. There was no documentation that a case consultation had been completed.
In client record #2, case consultations were due on February 26, 2009 and May 26, 2009. There was no documentation that the case consultations had been completed as of June 30, 2009.
In client record #3, case consultations were due on March 26, 2009 and June 26, 2009. There was no documentation that the case consultations had been completed as of June 30, 2009.
In client record #7, a case consultation was due on April 16, 2009. There was no documentation that a case consultation had been completed as of June 30, 2009.
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Plan of Correction
In order to correct this deficiency the Clinical Supervisor will provide training to all therapists on ensuring case consultation notes are documented in the charts. Training will be conducted by August 20, 2009. The Clinical Supervisor will monitor charts by using a Chart Review Form to ensure case consultations are documented. Case reviews will be an ongoing process. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on the review of the active client case list and the review of the staffing requirements facility summary report, which was completed by the project/facility director, and based on interviews with the project/facility director and clinical supervisor, the facility failed to ensure that the client census did not exceed the authorized maximum capacity.
Findings:
The active client case list and the review of the staffing requirements facility summary report, completed by the project/facility director, were reviewed on June 29 and 30, 2009. The interviews with the project/facility director and clinical supervisor occurred on June 29 and 30, 2009. The facility had a census of 264 clients receiving outpatient treatment services at the time of the licensing inspection, which exceeds the authorized maximum capacity of 200.
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Plan of Correction
In order to correct this deficiency the Project Director will monitor the capacity on a daily basis. All staff have been informed that the capacity will be monitored and this facility will not exceed the authorized maximum capacity. |