INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 16, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on May 18, 2007.
|
Plan of Correction
|
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
|
Observations
The written procedures for the confidentiality of client identity and records contained a document designed by CODAAP titled "Confidentiality Regulations and the Drug and Alcohol Treatment Programs." This document contained incorrect language regarding disclosure to parents of a minor without the client's consent and wording "with or without the client's consent" to judges and probation/parole. In addition, written procedures stated that "a client may revoke a consent to release information, in writing, to the clinic or project manager. The facility must honor a client's verbal revocation of a consent and the facility must document the verbal revocation in writing.
|
Plan of Correction
The Director of Quality Improvment has removed the CODAPP document from the policy and procedure manual. This was replaced with copies of 255.5 and 42CFR regulations. The Project Director will oversee that the company's confidentiality policy is revised to allow for verbal revocation of consents. The Facility Director will oversee the distribution and review of this revised policy to all staff in staff meeting. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
|
Observations
Consent to release information forms stated that clients must revoke their consent in writing in ten of ten records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10. Clients may revoke their consent verbally and the facility staff can document this in writing.
|
Plan of Correction
The Quality Improvement Department is currently overseeing the revision of our consent forms to allow for written or verbal revocation. The Facility Director will oversee that all staff receive the revised consent forms and are educated on how to document verbal revocation.
|
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
|
Observations
Drug and alcohol histories did not address the client's lengths and patterns of use in their addiction in ten of ten records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
|
Plan of Correction
The Facility Director will oversee that all clinical staff are educated in staff meeting to provide detailed information regarding the client's lengths and patterns of use in each drug and alcohol history. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
The personal histories failed to address family relations, significant events/problems related to the family history and recreation interests in ten of ten client records reviewed, specifically # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10. In addition, one word answers were indicated without any additional information to clarify these responses from the client.
|
Plan of Correction
The Facility Director will oversee that all clinical staff receive training in staff meeting to educate the therapists on gathering more detailed information regarding family relations, significant events/problems related to the family history and recreation history in each client's personal history. Therapists will also be reminded to avoid one word answers and to clarify responses from the clients. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
The psychosocial evaluation was historical rather than evaluative and failed to include clinical impressions, client's problems/needs, assets/strengths, support systems and coping mechanisms in ten of ten client records reviewed, specifically # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
|
Plan of Correction
The Facility Director will oversee that all clinical staff are reminded in staff meeting to give clinical impressions and opinions regarding client's problems/needs, assets/strengths, support systems and coping mechanisms in each client's psychosocial evaluation. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
|
Observations
Goals did not include measurable action steps in three of six records reviewed, #1, 2 and 3.
|
Plan of Correction
The Facility Director will oversee that all clinical staff are educated in staff meeting in regards to the completion of the individual treatment plan and how to create individualized goals with measurable action steps. |
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.
|
Observations
Treatment plans updates did not include an assessment of the client's progress in relationship to previously stated goals in five of five records reviewed, #2, 3, 4, 9 and 10.
|
Plan of Correction
The Facility Director will oversee that all clinical staff receive training in staff meeting to educate staff on completing a thorough treatment plan update which addresses the client's progress in the past 60 days as it relates to the previously stated goals from the individual treatment plan. |
709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
|
Observations
Clients went several weeks without treatment before contact was made by the therapist in 5 of 10 records reviewed, # 1, 2, 7, 9 and 10.
|
Plan of Correction
The Facility Director will oversee that all staff are educated in staff meeting in regards to contacting clients in a timely manner for unattended treatment sessions, highlighting how to document all attempts to contact. |
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.
|
Observations
Progress notes for individual sessions did not address the data and assessment portion of the note in eight of ten records reviewed, #1, 2, 3, 6, 7, 8, 9 and 10.
|
Plan of Correction
The Facility Director will oversee that all staff are educated in staff meeting to thoroughly complete the data and assessment portions of the progress notes. The Quality Improvement department will oversee that progress notes are monitored for thorough completion. |
709.93(a)(8) 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:
(8) Case consultation notes.
|
Observations
Case consultations did not indicate who was in attendance, the summary of the discussion or disposition in six of ten records reviewed, #1, 2, 3, 4, 9 and 10.
|
Plan of Correction
The Quality Improvement Department will oversee the revision of the case consultation format to include the purpose of the consultation, a summary of the discussion that was held or a disposition and an accurate account of which staff attended the consultation. The Facility Director will oversee the distribution and review of the revised case consultation note to all clinical staff in staff meeting. Clinical staff will also be educated in completing the note thoroughly. |
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.
|
Observations
Aftercare plans were missing in two of three client records reviewed, #4 and 9. Also, the aftercare plan failed to include realistic and measurable goals and support services in one of three client records reviewed, specifically #7.
|
Plan of Correction
The aftercare plan has been revised to prompt therapists to give more realistic and measurable goals and support services. The Facility Director will oversee the distribution and review of the revised aftercare plan to all clinical staff in staff meeting, highlighting the importance of creating realistic/measurable goals and support services. |