INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 20, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Clear Concepts Counseling 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 May 14, 2011.
|
Plan of Correction
|
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
Based on review of the policy and procedure manual and client records the facility failed to document a case consultation in three of five records.The findings include:The policy and procedure manual was reviewed on April 18, 2011. According to the facility policy and procedure manual, "Case consultations will be done at least every 90 days or more often if needed." Eight client records were reviewed on April 20, 2011. Five records required case consultations. The facility failed to document a case consultation in three of five client records reviewed, specifically records # 3, 4, and 7.Client #3 was admitted on January 10, 2011. A case consultation was due by April 10, 2011. The facility failed to document a case consultation in the record as of the date of the inspection.Client # 4 was admitted on October 8, 2010 and discharged on April 19, 2011. A case consultation was due by January 9, 2011 and April 9, 2011. The facility failed to document any case consultations in this client record. Client #7 was admitted on October 19, 2010 and discharged on January 20, 2011. A case consultation was due by January 19, 2011. The facility failed to document a case consultation in the client record.
|
Plan of Correction
Our facility will be in full compliance with this standard by 5/12/11. This standard and our agency policy relative to this standard will be reviewed with all counselors at our next staff meeting on 5/12/11. The proper completion and timing of completion of the case consultation notes will begin immediately. This standard and policy will also be reviewed with all therapists by the Clinical Supervisor in individual supervision to assure compliance. In the future all therapists will bring active charts to supervision and the Clinical Supervisor will verify that the therapist has the completed case consultation note. |
709.94(d) LICENSURE Project management services
709.94. Project management services.
(d) The project shall develop a written client aftercare policy.
|
Observations
Based on a review of the policy and procedure manual and staff interview, the facility failed to follow their aftercare policy. The facility failed to provide documentation in the client record when an aftercare could not be completed in three of four records, as required by the policy. Additionally, the aftercare policy did not include aftercare for clients involved in the Student Assistance Program. The findings include:The policy and procedure manual was reviewed on April 18, 2011. The aftercare policy failed to address aftercare for the clients involved in the Student Assistant Program. There were two policies that addressed aftercare.The first policy stated, "Aftercare Plans will be developed for all clients. This will be a treatment plan for the individual to follow after they leave treatment. the Aftercare Plan will be signed and dated by the client and the therapist. A copy of an Aftercare Plan can be found in this policy and procedure manual. In some cases it will not be possible to complete an Aftercare Plan with the client, for example when the client leaves treatment abruptly without prior notification. In these situations, this should be noted in the progress notes."The second policy stated, "Clear Concepts believes that the goals of treatment extend beyond the termination of treatment and the therapist should assist the client to develop a plan for the future....1. When termination of services is imminent, either with or without the therapist's agreement- it will be the primary therapist's responsibility to assist the client in completing an Aftercare Plan using the Clear Concepts Counseling form. This plan will outline the client's goals for the future after their treatment ceases.2. This plan states the client's goals for the future in terms of measurable criteria and the action steps necessary to achieve these goals. It also lists support services to be used in attaining these goals. Both the therapist and client will sign and date this form. In signing this form, the client also consents to participate in follow-up in regards to this plan. A copy of the Aftercare Plan will be given to the client and the original will be kept in the client's chart. An example of the Aftercare Plan form will be included in this section of the Policy and Procedure Manual.3. In those instances where the client has given no forewarning of their desire to terminate treatment (e.g. the client drops out of treatment) the completion of an Aftercare Plan will not be possible. The instances will be recorded on a progress note."Four discharge records were reviewed. Three clients abruptly left treatment and required documentation by the therapist that indicated they were unable to complete an aftercare plan. The therapists failed to document that an aftercare could not be completed in the progress notes for client records # 4 and 7.Client # 5 received treatment through the student assistant program. The therapist failed to complete an aftercare plan for this client. An interview with the Clinical Supervisor was conducted on April 20 and 21, 2011 and confirmed that the facility did not complete aftercare plans on the clients involved in the school-based Student Assistant Programs.
|
Plan of Correction
Our facility will be in full compliance with this standard and our agency policy by 5/12/11. The agency's aftercare policy will be changed to address aftercare for the clients involved in the Student Assistance Program. The proper completion of the aftercare plan with successful discharged clients will begin immediately. This standard and our agency policy will be reviewed at our next staff meeting on 5/12/2011. The Clinical Supervisor will review therapists charts monthly during supervision to ensure that the aftercare plans are being completed. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
|
Observations
Based on a review of the policy and procedure manual and staff interview, the facility failed to follow their policy and procedure for all clients involved in treatment. The follow-up policy did not address follow-up procedures for clients involved in the Student Assistance Program. The findings include: The policy and procedure manual was reviewed on April 18, 2011. The follow-up policy failed to address follow-up for the clients involved in the Student Assistant Program. There were two policies that addressed follow-up.The first policy stated, " Follow-up attempts will be made 60 days after discharge so long as the client has consented to participate in follow-up by signing the aftercare plan. Efforts will initially be made by phone but when that is unsuccessful, the attempt will be made by mail. A copy of the follow-up form and the follow-up letter will be included in the Policy and Procedure Manual. When a client has been referred to an outside resource, the primary therapist will (with the client's written consent) attempt to determine from the resource the outcome of the referral. This will occur within one week from the day of the referral."The second policy stated, "It is the position of Clear Concepts Counseling that efforts should be made to determine if former clients are continuing to make progress with their lives....1. At time of a closing, the primary therapist will complete the Aftercare Plan with the client which includes the client's consent to participate in follow-up efforts. If the client refused to sign the Aftercare Plan or was not available for the completion of the Aftercare Plan, then follow-up shall be made in the form of the Closing Letter. 2. After completing the Aftercare Plan with the client, the primary therapist is responsible for completing the upper portion of the Follow-up Questionnaire and giving the questionnaire to a support staff person. An example of this Follow-up Questionnaire can be found in this Policy and Procedure Manual. 3. The support staff person is then responsible for making the follow-up call to the client 60 days after the termination of services allowing for weekends and/or holidays). The support staff person will document the results of the follow-up call on the questionnaire and then file it in the client's chart.4. If the support staff person is unable to reach the client by phone, the Follow-up letter will be sent to the client. Upon return of the letter, it will be filed in the client's chart. An example of the Follow-up letter can be found in this Policy and Procedure Manual. 5. If the client has been referred to an outside resource, the primary therapist is responsible for contacting the resource within one week to determine the outcome of the referral. This contact should be documented on the Progress Notes form."Based on the review of the policy and procedure manual and an interview with the clinical supervisor, the facility failed to document follow-up for clients involved in the student assistant program. Client # 5 was involved in the student assistance program. The client was discharged on 12/16/2010. According to the policy and procedure the client should have obtained follow-up services by 2/16/2010. The therapist failed to document follow-up for this client as of the time of the licensing visit. An interview with the clinical supervisor on April 20 and 21, 2011 confirmed that the facility did not follow their follow-up policy for the clients involved in the student assistant program and did not document follow-up for those clients.
|
Plan of Correction
Our facility will be in full compliance with this standard and our agency policy by 5/12/11. The agency's follow-up policy will be changed to address follow-up for the clients involved in the Student Assistance Program. The clients involved in the Student Assistance Program will be given a letter they have to sign with the agency's information listed. The client will be given the original and a copy will be kept in the client chart. The Clinical Supervisor will review charts monthly during supervision to ensure that follow up procedures are being completed. This standard and our agency policy will be reviewed at our next staff meeting on 5/12/2011. |