Observations
Based on a review of client records and clinical documentation, the facility failed to document an evaluative psychosocial assessment in three of three records reviewed.
The findings include:
Three client records were reviewed for an evaluative psychosocial assessment on May 29, 2013. The facility failed to document an evaluative psychosocial assessment in three of three records reviewed, client record # 2, 3, and 4.
Client # 2 was admitted to the program on 2/6/13. The psychosocial evaluation was documented on 3/6/13. However, the facility failed to document a psychosocial evaluation which included an assessment of the client's attitude toward treatment, assets/strengths, problems/needs, and negative factors. Additionally, the psychosocial evaluation did not include the counselor's conclusions/impressions of the client.
Client # 3 was admitted to the program on 2/6/13. The psychosocial evaluation was documented on 2/6/13. However, the facility failed to document a psychosocial evaluation which included an assessment of the client's attitude toward treatment, assets/strengths, problems/needs, negative factors, and support systems.
Client # 4 was admitted to the program on 2/5/13 and was still an active client at the time of review on 5/29/13. The psychosocial evaluation was to be documented in 30 days or by 3/5/13. The facility failed to document a psychosocial evaluation for client # 4 as of May 31, 2013.
The clinical supervisor did not dispute the findings.
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Plan of Correction
The program director will hold-in-service trainings to continue to address the need for comprehensive, individualized and strength based assessments. The trainings will be concentrated on staff development, and the need to provide clear descriptions or assessment of the necessity of treatment. The comprehensive assessment process should reflect engagement with the client, while building a relaxed rapport with him or her and address any immediate problems or crises that may present. It should individualize treatment-based factors known to have an effect on service outcomes (spirituality, culture, gender, strengths, experience of trauma, co-occurring conditions). It should promote hope and strengths, abilities, preferences, needs, and challenges that impact the client's hopes and dreams (goals). In addition, CBH and state OP/IOP standards will guide the trainings. The program director will also follow-up with clinicians' progress during weekly or bi-weekly individual supervisions in order to ensure assessment correction and that training's information is being implemented. |
Observations
Based on an interview with the Facility Director, the facility failed to obtain a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III.
The findings include:
A copy of the Department of Public Welfare provider agreement was requested on May 29, 2013, as the facility provides services to clients that receive reimbursement under the medical assistance program.
The facility failed to comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
The Facility Director confirmed during an interview that the facility did not currently have a provider agreement with the Department of Public Welfare.
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Plan of Correction
The program director has submitted the provider enrollment application to DPW with all necessary attachments effective June 14 in order to obtain the provider agreement. We anticipate enrollment within the next 60 days. |