INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on March 12-13, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, NET Treatment Services, 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on the review of personnel records, the facility failed to document direct observation supervision, for counselor assistants in three of three personnel records.
The findings include:
On March 12, 2012, thirteen personnel records were reviewed. Of the thirteen records reviewed, three were identified as a counselor assistant, specifically personnel records # 11, 12 and 13. Counselor assistants are required to receive at least one hour per week of direct observation. The facility did not document direct observation in personnel records # 11, 12 and 13.
The documented supervision notes in personnel records # 11, 12 and 13 did not indicate that at least one hour per week of direct observation was occurring.
An interview with the clinical supervisor on March 12, 2012 confirmed the findings.
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Plan of Correction
On 3.22.12, NET Care Management Supervisor met with Clinical Supervisors to review State Licensing regulation 704.9 as it relates to the documentation of direct observation. Clinical Supervisors will clearly document direct observation of Counselor Assistants within supervision notes. Direct observation will be clearly noted within the supervision notes for counselor assistants, citing the client ID and date the direct observation occurred. The documentation reflective of that specific supervision note will be signed by the counselor assistant themself as well as co-signed by the observing Clinical Supervisor.
As of 4.16.12, the Clinical Supervisor will document direct observation within the supervision notes for Counselor Assistants, citing specific client ID and session date.
NET's Care Management Supervisor will review supervision notes monthly for counselor Assistants to ensure direct observation has been clearly documented by the corresponding Clinical Supervisor. |
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 in relationship to the stated goals of the comprehensive treatment plan in four out of four records.
The findings include:
On March 12, 2012, four client records requiring treatment plan updates were reviewed, specifically records # 1, 5, 6 and 7. The facility did not document a treatment plan update to include an assessment of the client ' s progress in relationship to the stated goals of the comprehensive treatment plan in client records # 1, 5, 6 and 7.
Client # 1 was admitted on 11/7/11. The treatment plan updates in client # 1 ' s record dated 1/3/12 and 2/21/12 did not include an assessment of progress in relationship to the stated goals of the comprehensive treatment.
Client # 5 was admitted on 11/28/11. The treatment plan update in client # 5 ' s record dated 1/23/12 did not include an assessment of progress in relationship to the stated goals of the comprehensive treatment.
Client # 6 was admitted on 10/7/11. The treatment plan updates in client # 6 ' s record dated
12/28/11 and 2/13/12 did not include an assessment of progress in relationship to the stated goals of the comprehensive treatment.
Client # 7 was admitted on 10/26/11. The treatment plan updates in client # 7 ' s record dated
12/28/11 and 2/15/12 did not include an assessment of progress in relationship to the stated goals of the comprehensive treatment.
An interview with the clinical supervisor on March 12, 2012 confirmed the findings.
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Plan of Correction
NET clinical supervisors met with counseling staff on March 22nd, 2012 and educated the counseling staff on the need to ensure that all treatment plan updates include a clear assessment of the client's progress since entering treatment. NET clinical supervisors discussed the need for the counseling staff to include a clear prognosis of the client's progress on each update as well as include an overall assessment of the progress noted. Additionally, NET clinical supervisors educated the counseling staff on the need to ensure that each goal is addressed, and, should the client not make progress on any particular goal, an assessment of why a lack of progress will be noted for that goal as well as a modification to therapeutic interventions as a means of further supporting the client in making progress on such goal.
To ensure ongoing compliance, NET clinical supervisors will review weekly, for 4 months, all newly developed treatment plan updates to ensure the above is completed, and then randomly thereafter. The clinical supervisor's signature on the treatment plan update will signify compliance with above. |
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 document counseling services provided according to the individual treatment plan in seven of seven client records.
The findings include:
On March 12-13, 2011, progress notes in seven client records were reviewed for counseling services being provided according to treatment plans, specifically in records # 1, 2, 3, 4, 5, 6 and 7. The facility did not document counseling services according to the treatment plan in client records # 1, 2, 3, 4, 5, 6 and 7.
Client # 1 was admitted on 11/7/11. The master treatment plan in client # 1 ' s record dated 11/11/11 stated individual counseling " 2-4 times per month " . Client # 1 ' s record contained documentation of individual counseling only on 12/14/11.
Client # 2 was admitted on 2/10/12. The master treatment plan in client # 2 ' s record dated 2/27/12 stated individual counseling " 2-4 times per month or as needed " . Client # 2 ' s record did not contain documentation of individual counseling.
Client # 3 was admitted on 1/31/12. The master treatment plan in client # 3 ' s record dated 2/13/12 stated individual counseling " 2-4 times per month or as needed " . Client # 3 ' s record did not contain documentation of individual counseling.
Client # 4 was admitted on 1/24/12. The master treatment plan in client # 4 ' s record dated 2/8/12 stated individual counseling " 2-4 times per month or as needed " . Client # 4 ' s record contained documentation of individual counseling only on 2/29/12.
Client # 5 was admitted on 11/28/11. The master treatment plan in client # 5 ' s record dated 12/5/11 stated individual counseling " 2-4 times per month " . Client # 5 ' s record contained documentation of individual counseling only on 1/23/12.
Client # 6 was admitted on 10/7/11. The master treatment plan in client # 6 ' s record dated 11/2/11 stated individual counseling " 2-4 times per month " . Client # 6 ' s record contained documentation of individual counseling only on 1/11/12, 1/27/12, 1/30/12 and 2/18/12.
Client # 7 was admitted on 10/26/11. The master treatment plan in client # 7 ' s record dated 11/7/11 stated individual counseling " 2-4 times per month " . Client # 7 ' s record contained documentation of individual counseling only on 11/9/11 and 12/5/11.
An interview with the clinical supervisor on March 13, 2012 confirmed the findings.
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Plan of Correction
NET clinical supervisors met with clinical staff on March 22nd 2012, to discuss the need to clearly document the provision of Individual sessions as prescribed on the treatment plan. In the event that a client does not show up for the scheduled individual session, a DAP note documenting the client's absence will be submitted to the client record. Lastly, clinical supervisors have educated the clinical staff that, if a client does miss a scheduled individual session, then a make up session can be provided and should be noted within the documented Missed Individual Session DAP note. NET clinical supervisors will conduct weekly audits over the course of the next 4 months, and then randomly thereafter, to ensure this documentation of individual sessions provided as well as missed or rescheduled sessions is being clearly documented within the client record.
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