INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 28, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Colonial House Outpatient 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 May 11, 2011.
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Plan of Correction
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709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on the review of client records and a interview with the facility director, the facility failed to ensure that client's was offered a copy of each consent in 5 of 8 client records..
The finding includes:
Eight client records were reviewed on April 18, 2011. Documentation that the client was offered a copy of each consent was not provided in records, #3, 4, 5, 6 and 8. An interview with the facility director on April 18, 2011 confirmed that the offer made to a client to receive a copy of the consent was not consistently documented on the consent to release forms.
Client record #3 contained consent to release forms, dated December 20, 2010, for emergency contact, probation/parole and an insurance agency. The record did not contain documentation that the client was offered a copy of the signed consent to release forms.
Client record #4 contained consent to release forms, dated October 27, 2010, for emergency contact, public defender office, drug and alcohol program and funding sources. The record did not contain documentation that the client was offered a copy of the completed consent to release information forms.
Client record #5 contained consent to release forms, dated December 16, 2010 and March 4, 2011, for emergency contact and insurance agencies. The record did not contain documentation that the client was offered a copy of the signed consent to release forms.
Client record #6 contained consent to release forms, dated September 29, 2010, for emergency contact, a drug and alcohol program and probation/parole. The record did not contain documentation that the client was offered a copy of the signed consent to release forms.
Client record #8 contained consent to release forms, dated December 21, 2010, for emergency contacts, probation/parole and the client's lawyer. The record did not contain documentation that the client was offered a copy of the consent to release forms.
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Plan of Correction
The facility director will replace exsisting consents with new consents that will include a place for the client to choose if they decline a copy or accept a copy by 5/12/11. On 5/12/11 the facility director will present the new consents at the weekly staff meeting with nstructions to pay specific attention to the area that asks if client accepts or declines a copy. The facility director will be responsible to follow up with the counselors during chart weekly chart reviews |
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 a review of client records and an interview with the facility director, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and the counselor's conclusions and impressions of the client in eight of eight client records.
The findings include:
Eight client records were reviewed on April 18, 2011. A psychosocial evaluation was required in all of these records, #1, 2, 3, 4, 5, 6, 7 and 8. An interview with the facility director on April 18, 2011 confirmed the findings.
The psychosocial evaluations in client records #1, 2, 3, 4, 5, 6, 7 and 8 lacked an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records #1, 2, 3, 4 and 7 lacked an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluations in client records #3, 4, 5, 6 and 8 lacked an evaluation of the client's coping mechanisms and how they would relate to/or impact treatment.
The psychosocial evaluations in client records # 3, 4, 5, 6, 7 and 8 lacked an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluations in client records # 3, 4, 5 and 6 lacked an evaluation of the counselor's conclusion and impression of the client.
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Plan of Correction
The facility director will complete a staff training on 6/4/11 with the clinical team and evaluator and reviewed that none present are not acceptable answers to the idenitifed questions.
Assets and strengths will be identified and how it will impact treatment. Assessment terms will be used and a clear description of how it is used will be assessed. The facility diretor will ensure that this is being completed when the assessment is read and reviewed and signed by the facility director weekly.
The section asking for the clients
support system and how they relate to treatment will include an assessement of who and how they work to support treatment. This will be read and reviewed by the facility director to insure that it is being completed properly on a weekly basis.
The section asking for the clients coping mechanisms will include the counselors impression of how the client uses this coping mechanism. The facility diretor will ensure that this is being completed by reading, reviewed and signed by the facility director weekly.
The section asking for the clients negative factors and how they will impact treatment will include the counselors impression of what the negative factors are and how they will affect treatment. The facility director will ensure that this is being completed when the assessment is read, reviewed and signed by the facility director weekly.
Counselors conclusion and impression of the client will include an assessment of what appears to be so as a result of the intake. The facility diretor will ensure that this is being completed when the assessment is read, reviewed and signed by the facility director weekly.
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709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records and a discussion with the Facility Director, the facility failed to provide documentation of a physician review and signature attesting to the review of a client's treatment plan to comply with 55 Pa. Code Part III (relating to the Medical Assistance Manual).
The findings include:
Eight client records were reviewed on April 18, 2011. Of these eight client records, only thee were medical assistance clients (#3, 4 and 5), required to have a physician review and signature on the clients' treatment plans. Per the Department of Welfare standards, all treatment plans are to be signed the physician within 15 days of the completion of the initial treatment plan. A discussion with the facility director on April 18, 2011 confirmed that the treatment plans were not signed by the physician within the required time frame.
Client record #3's initial treatment plan was completed on January 14, 2011; the physician did not sign the treatment plan until March 20, 2011.
Client record #4's initial treatment plan was completed on November 27, 2010; the physician did not sign the treatment plan until December 29, 2010.
Client record #5's initial treatment plan was completed on January 14, 2011; the physician did not sign the treatment plan until February 17, 2011.
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Plan of Correction
The facility director has implemented a weekly schedule to have all charts signed by the physician afer the completion of the assessment, the inital treatment plan, master treatmemt plan and the treatment plan review. This will occur weekly when the faciltiy director reviews weekly chart reveiw which at that time will be tagged for the doctors signature and checked weekly. |