INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 25-26, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Persad 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 October 28, 2008.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on the review of eight personnel records, the facility failed to document that staff persons received at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum in one of five records where required.
Findings:
There was no documentation that the staff had received the required training in personnel record # 3.
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Plan of Correction
Plan of Correction: The Clinical Director will ensure that the agency meets the standards established in 704.11 and 704.11(c) (1) by
1. Adding HIV /AIDS and TB/STD training to the new employee orientation check list by November 15, 2008
2. Utilizing the Bureau of Drug & Alcohol Training website to locate and schedule training within expected time frame
3. Scheduling all staff that are currently in need of 4 hours of department approved curriculum for TB and STD training
4. Scheduling all staff that are currently in need of 6 hours of department approved HIV / STD training.
The agency will be in compliance with standard by December 11, 2008
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709.24(a)(2) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(2) Treatment models utilized by the project.
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Observations
Based on the review of the policy manual and interviews with the project director and facility director on September 25 and 26, 2008, the facility failed to adopt, with governing body approval, a complete written plan for the coordination of client treatment and rehabilitation services.
Findings:
The facility did not document the treatment models utilized by the project.
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Plan of Correction
Plan of Correction:
1. The Clinical Director will conduct a review of treatment models used at Persad; state regulations; and best practice standards for the agency's target population. submit a written treatment and rehabilitation management plan including specific treatment models used, to the Executive Director for review by November 15, 2008.
2. The Executive Director will submit a written treatment and rehabilitation management plan to the program committee of the agency's board of directors for approval /adoption by January 15, 2009.
The agency will be in compliance with the standard by January 15, 2009
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709.30(3) LICENSURE Client Rights
709.30. Client rights.
(3) A client has the right to inspect his own records. The project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.
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Observations
Based on the review of seven client records on September 25-26, 2008, the facility failed to document that the client was informed that the project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file. Documentation was missing in seven of seven client records where required.
Findings:
The facility did not document that the client was informed of this information in client records # 1, 2, 3, 4, 5, 6 and 7.
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Plan of Correction
Plan of Correction:
1. The Clinical Director will review the current client orientation handbook according to the regulations and ensure that all information regarding client rights is included by October 31, 2008.
2. A statement of correction to the client rights information will be given to the 7 clients that were not informed of the information contained in 709.30(3)
3. Updated client orientation handbooks will be implemented on November 3, 2008 (the first business day following approval of the update.
The agency will be in full compliance by November 3, 2008.
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709.30(4) LICENSURE Client Rights
709.30. Client rights.
(4) The client has the right to appeal a decision limiting access to his records to the project director.
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Observations
Based on the review of seven client records on September 25-26, 2008, the facility failed to document that the client was informed of the right to appeal a decision limiting access to his records to the project director in seven of seven client records where required.
Findings:
The facility did not document that the client was informed of this right in client records # 1, 2, 3, 4, 5, 6 and 7.
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Plan of Correction
Plan of Correction:
1. The Clinical Director will review the current client orientation handbook according to the regulations and ensure that all information regarding client rights is included by October 31, 2008.
2. A statement of correction to the client rights information will be given to the 7 clients that were not informed of the information contained in 709.30(3)
3. Updated client orientation handbooks will be implemented on November 3, 2008 (the first business day following approval of the update.
The agency will be in full compliance by November 3, 2008.
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709.30(6) LICENSURE Client Rights
709.30. Client rights.
(6) The client has the right to submit rebuttal data or memoranda to his own records.
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Observations
Based on the review of seven client records on September 25-26, 2008, the facility failed to document that the client was informed of the right to submit rebuttal data or memoranda to his own records in seven of seven client records where required.
Findings:
The facility did not document that the clients were informed of this right in client records # 1, 2, 3, 4, 5, 6 and 7.
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Plan of Correction
1. The Clinical Director will review the current client orientation handbook according to the regulations and ensure that all information regarding client rights is included by October 31, 2008.
2. A statement of correction to the client rights information will be given to the 7 clients that were not informed of the information contained in 709.30(3)
3. Updated client orientation handbooks will be implemented on November 3, 2008 (the first business day following approval of the update.
The agency will be in full compliance by November 3, 2008.
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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 the review of seven client records on September 25-26, 2008, the facility failed to document a psychosocial evaluation in two of seven client records where required.
Findings:
There was no documentation of a psychosocial evaluation being completed in client records # 2 and 4.
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Plan of Correction
1. The clinical director will develop an outline for completion of psychosocial evaluations by October 31, 2008.
2. The clinical director will establish the standard for the development and documentation of psychosocial evaluations with all clinicians in group supervision on November 3, 2008.
3. The clinical director will provide individual feedback and training to therapists responsible for records #2 and #4 by October 31, 2008.
4. All psychosocial evaluations will be reviewed by the clinical supervisor in the individual supervision immediately following each intake assessment to ensure that the psycho social evaluation includes all the information required by the standards and that it is documented in a timely and professional manner. If the psycho social assessment if found to be deficient in the supervisory session, the intake therapist will make corrections to the summary before the client's first individual therapy session.
The agency will be in full compliance by November 15, 2008.
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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 seven client records on September 25-26, 2008, the facility failed to update treatment and rehabilitation plans at least every 60 days in two of four client records where required.
Findings:
The facility did not complete treatment plan updates for March and May, 2008 and July 2008 was completed late, more than 60 days from the last treatment plan, in client record # 3.
In client record # 5 there was no documentation of the progress or lack of progress made on the treatment plan goals on the treatment plan update. The update consisted of new goals only.
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Plan of Correction
Plan of Correction:
1. The clinical director will review the requirements for treatment planning; evaluating and documenting progress; and treatment plan updates with the therapist responsible for record #3 by November 15, 2008.
2. The clinical director will review the standards for treatment planning; evaluating and documenting progress; treatment plan updates and requirements around content and time frames will the clinical staff in group supervision on December 1, 2008.
3. The clinical director will ensure that the standards for treatment planning; evaluating and documenting progress; and treatment plan updates are met by reviewing documentation in clinical supervision (occurring on a weekly basis).
The agency will be in full compliance by December 31, 2008.
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709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on the review of seven client records, the facility failed to document a record of services provided in two of seven client records where required.
Findings:
The facility did not provide documentation of a record of services provided in client records #2 and 4.
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Plan of Correction
Plan of Correction:
1. The clinical director will review the agency's account tracking form procedure (that is designed to meet the standards set forth in 703.93(a) (3) for keeping record of services provided) with therapists responsible for client records #2 and #4, in individual supervision by November 15, 2008.
2. The clinical director will review the standard and the agency's procedure for meeting this standard in group supervision on December 1, 2008.
3. The clinical director will ensure that account tracking procedure is followed by including monthly checks on the process in individual supervision.
The agency will be in full compliance by December 15, 2008.
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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 the review of seven client records on September 25-26, 2008, the facility failed to document a complete discharge summary in one of two client records where required.
Findings:
The discharge summary in client record # 6 was incomplete, failing to document the reason for treatment, services offered and the client's response to treatment.
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Plan of Correction
Plan of Correction:
1. The clinical director will provide individual training and supervision to the therapist responsible for the deficient client record.
2. In group supervision on December 1, 2008, the clinical director will review the standards set for in 709.93(a)(10) regarding discharge summaries e.g.,
'Within one week after discharge, there should be entered into the client's case
record a discharge summary describing the reasons for treatment, services
offered, response to treatment and client's status or condition upon discharge.'
3. In group supervision on December 1, 2008 the clinical director will review the
Agency's outline for completion of the discharge summary; provide examples of acceptable discharge summaries and implement timely completion and review of discharge summaries.
The agency will be in full compliance by December 15, 2008
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