INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 21, 2008 through August 22, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site 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 and a plan of correction is due on September 23, 2008.
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Plan of Correction
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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 annual report and proof of publication provided by the facility on August 21, 2008 through August 22, 2008, the facility failed to make the annual report available to the general public within six months of the end of the fiscal year.
Findings:
Based on a review of the newspaper article showing proof of publication, the facility did not make the annual report available to the public until eight months after the end of the fiscal year. The facility's fiscal year runs January to December and the proof of publication showed the annual report for January 2007 through December 2007 was made available to the public on August 14, 2008. Interviews with facility staff confirmed this to be true.
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Plan of Correction
The Annual Report will be published for general public review in the newspaper within 6 months of the end of the fiscal year (June 30) by the Clinic Director. The 2008 annual report will meet the deadline of June 30, 2009. Clinic Director will monitor for compliance. |
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 on August 21, 2008 through August 22, 2008, the facility failed to document a complete psychosocial evaluation .
Findings:
Based on a review of sixteen client records, fourteen were required to have completed psychosocial evaluations. The psychosocial evaluations included client stated comments rather than a clinical assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, client's attitude toward treatment and overall impressions/conclusions in ten of fourteen client records where required, #2, 3, 4, 5, 6, 7, 11, 13, 15 and 16.
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Plan of Correction
Clinical staff will receive training on clinical assessment via clinical team meetings, intranet (CRC), and conference call. Clinical Supervisor will review charts for compliance, and review with staff in individual and team supervision. Clinical Supervisor will maintain compliance. Facility will be in compliance by October 20, 2008. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records on August 21, 2008 through August 22, 2008, the facility failed to document a complete aftercare plan.
Findings:
Based on a review of sixteen client records, one record was required to have an aftercare plan. The aftercare plan contained very generalized goals with no time frames in one of one client records reviewed where required, specifically client record #12.
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Plan of Correction
Aftercare plans will be completed on all required discharges. The aftercare plans will be patient specific with target dates. This process will be reviewed in Clinical Treatment team with follow up in individual supervision as needed. The Clinical Supervisor will provide training in clinical team with compliance by October 1, 2008. Clinical supervisor will maintain oversight for compliance. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records on August 21, 2008 through August 22, 2008, the facility failed to document a complete discharge summary.
Findings:
Based on a review of sixteen client records, eight were required to have a discharge summary. The discharge summary listed the reason for treatment as drug/alcohol abuse without giving any individualized specific reason for treatment in eight of eight client records reviewed, #9, 10 , 11, 12, 13, 14, 15 and 16. The response to treatment was missing in one of eight client records reviewed, #13.
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Plan of Correction
Discharge summaries are to be specific to patient. Reason for treatment needs to address what led the patient to request services. The process for completion of discharge summary particularly addressing the issue of individualized specific reason for treatment will be addressed in Clinical team and followed up in individual supervision as necessary. Full compliance will be in place by October 1, 2008. Clinical Supervisor will monitor for continued documentation. |