INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 15, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Rehab Management 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:
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Plan of Correction
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709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based upon a review of administrative documentation, the facility failed to provide through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric coverage.
The findings include:
Site specific administrative documentation was reviewed on March 15, 2013. The facility provided a document titled, "Agreement for Referral/Transfer" that specified that a hospital would provide for "24-hour medical/psychiatric Emergency services." However, an on-line review of the hospital's services revealed that while the hospital offers emergency medical services it does not provide for any psychiatric services. A follow-up phone call to the hospital's general information line confirmed that the hospital does not offer emergency psychiatric services.
The findings were reviewed with the Site Director during the administrative review and were not disputed.
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Plan of Correction
The Havertown Office of Rehab After Work has a signed Referral Agreement with Mercy Fitzgerald Hospital in Darby, PA for 24-hour emergency medical and psychaitric coverage. A copy will remain on file. The site director will monitor that this referral will remain active ongoing |
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 treatment plan updates to include an assessment of the client's progress relative to the identified goals on the comprehensive treatment plan in five of seven records.
The findings include:
Eight client records were reviewed on March 15, 2013. However, only seven records required an updated treatment plan. The facility failed to document treatment plan updates to include the client's progress in records # 3, 5, 6, 7 and 8.
Client # 3 was admitted on December 4, 2012, and was still an active client on the date of inspection. The record included a comprehensive treatment plan that was signed by the client on December 17, 2012. The record also included a treatment plan update that was dated February 28, 2013. The treatment plan update included goals and/or action steps, identified on the comprehensive treatment plan, that remained the same, were reworded or were revised. However, the treatment plan update failed to include an assessment of the client's progress relative to the identified goals and/or actions steps listed on the comprehensive treatment plan.
Client # 5 was admitted on June 20, 2012, and was discharged on August 27, 2012. The record included a comprehensive treatment plan that was signed by the client on June 27, 2012. The record also included a treatment plan update that was dated July 26, 2012. The treatment plan update included goals and/or action steps, identified on the comprehensive treatment plan, that remained the same, were reworded or were revised. However, the treatment plan update failed to include an assessment of the client's progress relative to the identified goals and/or actions steps listed on the comprehensive treatment plan.
Client # 6 was admitted on June 27, 2012, and was discharged on August 23, 2012. The record included a comprehensive treatment plan that was signed by the client on July 11, 2012. The record also included a treatment plan update that was dated August 9, 2012. The treatment plan update included goals and/or action steps, identified on the comprehensive treatment plan, that remained the same, were reworded or were revised. However, the treatment plan update failed to include an assessment of the client's progress relative to the identified goals and/or actions steps listed on the comprehensive treatment plan.
Client # 7 was admitted on December 17, 2012, and was discharged on February 6, 2013. The record included a comprehensive treatment plan that was signed by the client on December 27, 2012. The record also included a treatment plan update that was dated January 14, 2013. The treatment plan update included goals and/or action steps, identified on the comprehensive treatment plan, that remained the same, were reworded or were revised. However, the treatment plan update failed to include an assessment of the client's progress relative to the identified goals and/or actions steps listed on the comprehensive treatment plan.
Client # 8 was admitted on August 28, 2012, and was discharged on October 31, 2012. The record included a comprehensive treatment plan that was signed by the client on September 7, 2012. The record also included a treatment plan update that was dated October 5, 2012. The treatment plan update included goals and/or action steps, identified on the comprehensive treatment plan, that remained the same, were reworded or were revised. However, the treatment plan update failed to include an assessment of the client's progress relative to the identified goals and/or actions steps listed on the comprehensive treatment plan.
The findings were reviewed with the facility director during the exit interview.
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Plan of Correction
On 4-10-13 the Site Director of the Havertown location of Rehab After Work held a one-hour training for all staff regarding treatment plans and treatment plan updates. All plans are to include an assessment of the client's progress relative to the identified goals of the Master or Updated Treatment Plan. Progress needs to be noted and new goals developed on the Updated Treatment Plans. All staff attended and signed off. The site director will review charts monthly to ensure that treatment planning done as stated above |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based upon the review of client records and an interview with the facility director, the facility failed to document progress notes to include a plan section relative to that client's involvement with the project in four of eight records.
The findings include:
The facility director confirmed that clinicians typically utilize one group progress note to document group counseling sessions. The progress notes are to include include data, assessment and plans relative to the client's treatment.
Eight client records were reviewed on March 15, 2013, The facility failed to document group progress notes to include an individualized plan section, relative to the client's treatment, in records # 2, 4, 5 and 8.
Client # 2 was admitted on January 9, 2013, and was still an active client on the date of inspection. The record included group progress notes for the following dates: January 22 and 29, 2013; February 5, 12, 19 and 26, 2013; and March 5 and 12, 2013. However, the group notes for those dates included standardized plan sections that did not address client # 2's individual involvement with the project.
Client # 4 was admitted on July 30, 2012, and was still an active client on the date of inspection. The record included group progress notes for the following dates: August 1, 2, 6, 8, 9, 13, 15, 16, 20, 22, 23, 27 and 30, 2012; September 5 and 6, 2012. However, the group notes for those dates included standardized plan sections that did not address client # 4's individual involvement with the project.
Client # 5 was admitted on June 20, 2012, and was discharged on August 27, 2012. The record included group progress notes for the following dates: June 25, 27 and 28, 2012; July 2, 9, 11, 12, 16, 18, 19, 23, 25 and 26, 2012. However, the group notes for those dates included standardized plan sections that did not address client # 5's individual involvement with the project.
Client # 8 was admitted on August 28, 2012, and was discharged on October 31, 2012. The record included group progress notes for the following dates: August 31, 2012; September 4, 5, 6, 7, 11, 12, 14, 18 and 19, 2012. However, the group notes for those dates included standardized plan sections that did not address client # 8's individual involvement with the project.
The findings were reviewed with the facility director during the exit interview.
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Plan of Correction
On 4-10-13 the Site Director of the Havertown location of Rehab After Work held a one-hour training regarding the writing of Group Progress Notes. A Client's progress and participation needs to be noted in every note. Standardized plan sections are to be avoided. All Group Progress Notes are to include data, assessment and plan relative to the client's treatment. All staff attended and signed off. The site director will review charts monthly to ensure that group notes are done correctly and this deficiency does not recur |