INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 6 - 7, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Axiom Family Counseling 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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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:
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Observations
Based on a review of client records, the facility failed to obtain a written, informed and voluntary consent from the client for the disclosure of information contained in the client record in nine of nine client records, In addition, the facility exceeded the limitations imposed at 4 Pa. Code 255.5 regarding the specific client information to be released to an insurance company in two of twelve client records.
The findings include:
Twelve client records were reviewed for written consents to release information from the client on January 6 - 7, 2014. . The facility failed to obtain a written consent to release information from the client prior to releasing information contained in the client record to a funding entity in client records # 1, 2, 3, 6, 8, 9, 10, 11 and 12. The facility exceeded the limitations imposed at 4 Pa. Code 255.5 regarding the specific client information to be released to an insurance company in client records # 3 and 9.
Client # 3 was admitted into treatment on December 4, 2013. A consent to release information to an insurance company, dated December 4, 2013, indicated the client's psychiatric evaluation would be released to the insurance company. This exceeded the limitations imposed at 4 Pa. Code 255.5.
Client # 9 was admitted into treatment on November 6, 2013. A consent to release information to an insurance company, dated November 6, 2013, indicated the client's psychiatric evaluation and psychological exam would be released to the insurance company. This exceeded the limitations imposed at 4 Pa. Code 255.5.
The project/facility director was interviewed throughout the inspection and confirmed the findings.
This is a repeat citation from the March 1, 2013 and August 7 - 8, 2013 inspections.
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Plan of Correction
The Facility Director held a staff training on Confidentiality and appropriate disclosure of client information. New updated releases were also discussed and disclosure of appropriate information to be released and limitations imposed at 4 PA Code 255.5.
Consents will be completed for all clients that did not have one for their funding entity.
Facility Director and Lead Counselor will complete chart audits to ensure staff is releasing appropriate information and does not exceed limitations imposed at 4 Pa Code 255.5 |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility failed to verify the patient's emergency contact prior to the administration of a narcotic agent in nine of nine patient records.
The findings include:
Twelve patient records were reviewed on January 6 - 7, 2014. Nine patient records were reviewed for documentation of an emergency contact. The facility failed to verify the patient's emergency contact prior to the administration of an agent in patient records # 1, 2, 3, 6, 8, 9, 10 ,11 and 12.
Patient # 1 was admitted into treatment on October 30, 2013. Patient # 1 was prescribed 8 mg Subutex BID on November 9, 2013, prior to verifying the patient's emergency contact.
Patient # 2 was admitted into treatment on September 10, 2013. Patient # 2 was prescribed 8 mg/2 mg Suboxone BID on September 13, 2013, prior to verifying the patient's emergency contact.
Patient # 3 was admitted into treatment on December 4, 2013. Patient # 3 was prescribed 8 mg/2 mg Suboxone BID on December 13, 2013, prior to verifying the patient's emergency contact.
Patient # 6 was admitted into treatment on November 6, 2013 and discharged on January 3, 2014. Patient # 6 was prescribed 8 mg/2 mg Suboxone BID on November 9, 2013, prior to verifying the patient's emergency contact.
Patient # 8 was admitted into treatment on October 30, 2013 and discharged on December 6, 2013. Patient # 8 was prescribed 8 mg/2 mg Suboxone BID on November 9, 2013, prior to verifying the patient's emergency contact.
Patient # 9 was admitted into treatment on November 6, 2013. Patient # 9 was prescribed 8 mg/2 mg Suboxone BID on November 8, 2013, prior to verifying the patient's emergency contact.
Patient # 10 was admitted into treatment on November 8, 2013. Patient # 10 was prescribed 8 mg Subutex BID on November 8, 2013, prior to verifying the patient's emergency contact.
Patient # 11 was admitted into treatment on November 11, 2013. Patient # 11 was prescribed 8 mg Subutex BID on November 15, 2013, prior to verifying the patient's emergency contact.
Patient # 12 was admitted into treatment on September 11, 2013 and discharged on October 22, 2013. Patient # 12 was prescribed 8 mg/2 mg Suboxone BID on September 20, 2013, prior to verifying the patient's emergency contact.
The findings were confirmed by the project/facility director on January 7, 2014.
This is a repeat citation from the March 1, 2013 and August 7 - 8, 2013 inspections.
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Plan of Correction
All current patients will sign a consent to release information so Axiom can call the emergency contact if a situation arises.
ED (therapist) will complete chart audits to ensure an emergency contact release has been obtained at intake appointment. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the facility failed to document a physical examination of the patient prior to the administration of a narcotic agent in five of nine patient records.
The findings include:
Twelve patient records were reviewed on January 6 - 7, 2014. Nine patient records were reviewed for physical examinations. The facility failed to document a physical examination of the patient prior to the administration of a narcotic agent in patient records # 1, 2, 8, 11 and 12.
Patient # 1 was admitted into treatment on October 30, 2013. Patient # 1 was prescribed 8 mg Subutex BID on November 9, 2013. A physical examination of patient # 1 was not completed until November 22, 2013.
Patient # 2 was admitted into treatment on September 10, 2013. Patient # 2 was prescribed 8 mg/2 mg Suboxone BID on September 13, 2013. A physical examination of patient # 2 was not completed until October 21, 2013.
Patient # 8 was admitted into treatment on October 30, 2013 and discharged on December 6, 2013. Patient # 8 was prescribed 8 mg/2 mg Suboxone BID on November 9, 2013. A physical examination of patient # 8 was not completed until November 14, 2013.
Patient # 11 was admitted into treatment on November 11, 2013. Patient # 11 was prescribed 8 mg Subutex BID on November 15, 2013. A physical examination of patient # 11 was not completed until November 22, 2013.
Patient # 12 was admitted into treatment on September 11, 2013 and discharged on October 22, 2013. Patient # 12 was prescribed 8 mg/2 mg Suboxone BID on September 20, 2013. There was no documentation of a physical examination of patient # 12 as of January 7, 2014.
The findings were confirmed by the project/facility director.
This is a repeat citation from the March 1, 2013 and August 7 - 8, 2013 inspections.
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Plan of Correction
The physical examination requirement has been added to the initial intake checklist by the Lead Counselor.
Physical examinations will be scheduled on the date of the initial intake appointment and will be completed prior to the physician writing a prescription for Suboxone.
Facility Director and Lead Counselor will monitor intake appointments and scheduling of physicals to ensure they are completed on the initial date of intake. ED (therapist) will complete chart audits to ensure a physical was documented in the patient's chart on the initial date of intake. |
715.10(c) LICENSURE Pregnant patients
(c) Counseling records and other appropriate patients records shall reflect the nature of prenatal support provided by the narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document the nature of prenatal support provided to pregnant patients by the treatment program in three of three patient records.
The findings include:
Twelve patient records were reviewed on January 6 - 7, 2014. Three records pertained to pregnant patients. The facility failed to document the nature of prenatal support provided to pregnant patients in patient records # 1, 10 and 11.
Patient # 1 was admitted into treatment on October 30, 2013. Patient # 1 is pregnant and was prescribed 8 mg Subutex BID on November 9, 2013. The counseling records for patient # 1 did not reflect the nature of prenatal support provided by the treatment program.
Patient # 10 was admitted into treatment on November 8, 2013. Patient # 10 is pregnant and was prescribed 8 mg Subutex BID on November 8, 2013. The counseling records for patient # 10 did not reflect the nature of prenatal support provided by the treatment program.
Patient # 11 was admitted into treatment on November 11, 2013. Patient # 11 is pregnant and was prescribed 8 mg Subutex BID on November 15, 2013. The counseling records for patient # 11 did not reflect the nature of prenatal support provided by the treatment program.
The findings were confirmed by the project/facility director.
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Plan of Correction
Treatment plan has been updated to include a section to document the nature of prenatal support provided to pregnant patients. Treatment plans will be reviewed to ensure prenatal support is documented by each therapist. New Treatment plan form utilization was also discussed at staff training. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
Based on a review of patient records, the facility failed to ensure that each female patient was fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of or withdrawal from a narcotic drug administered by the program in comprehensive maintenance or detoxification treatment in three of three patient records.
The findings include:
Twelve patient records were reviewed on January 6 - 7, 2014. Three records pertained to pregnant patients. The facility failed to ensure that each female patient was fully informed of the possible risk to her or her unborn child in patient records # 1, 10 and 11.
Patient # 1 was admitted into treatment on October 30, 2013. Patient # 1 is pregnant and was prescribed 8 mg Subutex BID on November 9, 2013. There was no documentation that patient # 1 was fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of or withdrawal form a narcotic drug administered by the program in comprehensive maintenance or detoxification treatment.
Patient # 10 was admitted into treatment on November 8, 2013. Patient # 10 is pregnant and was prescribed 8 mg Subutex BID on November 8, 2013. There was no documentation that patient # 10 was fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of or withdrawal form a narcotic drug administered by the program in comprehensive maintenance or detoxification treatment.
Patient # 11 was admitted into treatment on November 11, 2013. Patient # 11 is pregnant and was prescribed 8 mg Subutex BID on November 15, 2013. There was no documentation that patient # 11 was fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of or withdrawal form a narcotic drug administered by the program in comprehensive maintenance or detoxification treatment.
The findings were confirmed by the project/facility director.
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Plan of Correction
The Lead Counselor has created a document that the therapist and patient will discuss during the intake process. The patient will sign this document stating they have received this information. This document details the risks to her or her unborn child from continued use of illicit drugs and from the use of or withdrawal from a narcotic drug administered by the program in maintenance or detoxification.
Chart audits will be completed by therapist (ED) to ensure each female patient was fully informed of these risks during the intake process. |
715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
Based on a review of patient records, the facility failed the restrict the involuntary termination of a patient from the treatment program to the reasons permitted by regulation in two of four patient records.
The findings include:
Twelve patient records were reviewed on January 6 - 7, 2014. Four patients were involuntarily terminated from treatment. The facility failed to restrict the involuntary termination of a patient from the treatment program to the reasons permitted by regulation in patient records # 4 and 5.
Patient # 4 was admitted into treatment on July 27, 2013 and involuntarily terminated from treatment on September 7, 2013. The involuntary termination letter, dated September 7, 2013, stated the patient was involuntarily terminated from treatment due to "failure to maintain sobriety and failure to follow program rules and regulations". The facility failed to restrict the involuntary termination of patient # 4 to the reasons permitted by regulation.
Patient # 5 was admitted into treatment on September 5, 2013 and involuntarily terminated from treatment on November 15, 2013. The involuntary termination letter, dated November 15, 2013, stated the patient was involuntarily terminated from treatment due to "failure to follow program rules and regulations". The facility failed to restrict the involuntary termination of patient # 5 to the reasons permitted by regulation.
The findings were confirmed by the project/facility director and lead counselor.
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Plan of Correction
A new termination of services letter was created by Facility Director to match regulations regarding reasons for involuntary termination.
Patients will only be terminated for the reasons allowed by the regulation.
Facility Director will complete chart audits of discharges to ensure new termination of services letter was completed. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document a medical history including a history of illness and symptoms in nine of nine client records. The facility failed to document a drug or alcohol history including the length and patterns of use and the client's perception of their effect on his/her social, physical and mental state in nine of nine client records. In addition, the facility failed to document a personal history including a recreational and sexual history in nine of nine client records.
The findings include:
Twelve client records were reviewed on January 6 - 7, 2014. Nine client records were reviewed for medical, drug and alcohol and personal histories. The facility failed to document a medical history including a history of illness and symptoms in client records # 1, 2, 3, 6, 8, 9, 10, 11 and 12. The facility failed to document a drug or alcohol history including the length and patterns of use and the client's perception of their effect in client records # 1, 2, 3, 6, 8, 9, 10, 11 and 12. The facility failed to document a personal history including a recreational and sexual history in client records # 1, 2, 3, 6, 8, 9, 10, 11 and 12.
Client # 1 was admitted into treatment on October 30, 2013. The medical, drug and alcohol histories for client # 1 were completed on October 30, 2013. The facility failed to document a medical history including a history of illness and symptoms. The facility failed to document a drug and alcohol history including the length and patterns of use. The facility failed to document a personal history including a sexual history.
Client # 2 was admitted into treatment on September 10, 2013. The medical, drug and alcohol histories for client # 2 were completed on September 10, 2013. The facility failed to document a medical history including a history of illness and symptoms. The facility failed to document a drug and alcohol history including the length and patterns of use. The facility failed to document a personal history including a recreational and sexual history.
Client # 3 was admitted into treatment on December 4, 2013. The medical, drug and alcohol histories for client # 3 were completed on December 4, 2013. The facility failed to document a medical history including a history of illness and symptoms. The facility failed to document a drug and alcohol history including the length and patterns of use. The facility failed to document a personal history including a recreational and sexual history.
Client # 6 was admitted into treatment on November 6, 2013 and discharged on January 3, 2014. The medical, drug and alcohol histories for client # 6 were completed on November 6, 2013. The facility failed to document a medical history including a history of illness and symptoms. The facility failed to document a drug and alcohol history including the length and patterns of use. The facility failed to document a personal history including a recreational and sexual history.
Client # 8 was admitted into treatment on October 30, 2013 and discharged on December 6, 2013. The medical, drug and alcohol histories for client # 8 were completed on October 30, 2013. The facility failed to document a medical history including a history of illness and symptoms. The facility failed to document a drug and alcohol history including the length and patterns of use. The facility failed to document a personal history including a recreational and sexual history.
Client # 9 was admitted into treatment on November 6, 2013. The medical, drug and alcohol histories for client # 9 were completed on November 6, 2013. The facility failed to document a medical history including a history of illness and symptoms. The facility failed to document a drug and alcohol history including the length and patterns of use and the client's perception of their effect. The facility failed to document a personal history including a recreational and sexual history.
Client # 10 was admitted into treatment on November 8, 2013. The medical, drug and alcohol histories for client # 10 were completed on November 8, 2013. The facility failed to document a medical history including a history of illness and symptoms. The facility failed to document a drug and alcohol history including the length and patterns of use and the client's perception of their effect. The facility failed to document a personal history including a recreational and sexual history.
Client # 11 was admitted into treatment on November 11, 2013. The medical, drug and alcohol histories for client # 11 were completed on November 11, 2013. The facility failed to document a medical history including a history of illness and symptoms. The facility failed to document a drug and alcohol history including the length and patterns of use and the client's perception of their effect. The facility failed to document a personal history including a recreational and sexual history.
Client # 12 was admitted into treatment on September 11, 2013 and discharged on October 22, 2013. The medical, drug and alcohol histories for client # 12 were completed on September 11, 2013. The facility failed to document a medical history including a history of illness and symptoms. The facility failed to document a drug and alcohol history including the length and patterns of use and the client's perception of their effect. The facility failed to document a personal history including an employment, military, recreational and sexual history.
The findings were confirmed by the project/facility director and the lead counselor.
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Plan of Correction
A new medical history checklist has been created and will be completed as part of the intake process.
A new intake packet was created with an extensive drug and alcohol history as well as recreational/sexual histories.
A staff training was held to discuss proper documentation of these histories and utilization of new forms by Facility Director and Lead Counselor.
Therapist (ED) will complete chart audits to ensure intake paperwork is being documented appropriately and that drug/alcohol history, recreational/sexual history are documented appropriately. |
709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based on a review of client records, the facility failed to complete a physical examination during the intake process in five of nine client records.
The findings include:
Twelve client records were reviewed on January 6 - 7, 2014. Nine client records were reviewed for physical examinations. Nine clients were prescribed Subutex or Suboxone and were required to receive physical examinations as a part of the intake process. The facility failed to complete a physical examination during the intake process in client records # 1, 2, 8, 11 and 12.
Client # 1 was admitted into treatment on October 30, 2013. The intake process was completed on October 30, 2013. The physical examination for client # 1 was not completed until November 22, 2013.
Client # 2 was admitted into treatment on September 10, 2013. The intake process was completed on September 10, 2013. The physical examination for client # 2 was not completed until October 21, 2013.
Client # 8 was admitted into treatment on October 30, 2013 and discharged on December 6, 2013. The intake process was completed on October 30, 2013. The physical examination for client # 1 was not completed until November 14, 2013.
Client # 11 was admitted into treatment on November 11, 2013. The intake process was completed on November 11, 2013. The physical examination for client # 11 was not completed until November 22, 2013.
Client # 12 was admitted into treatment on September 11, 2013 and discharged on October 22, 2013. The intake process was completed on September 11, 2013. There was no documentation of a physical examination for client # 12, as of January 7, 2014.
The findings were confirmed by the project/facility director and lead counselor.
This is a repeat citation from the August 7 - 8, 2013 licensing inspection.
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Plan of Correction
Certified Registered Nurse Practitioner (TS) will complete all physical examinations on initial date of intake as part of the intake process. This will ensure that a physical examination of the patient will be completed prior to the
administration of a narcotic agent. ED (Therapist) will complete
chart audits to ensure there is documentation of a physical
examination completed on the date of intake. Facility Director and
Lead Counselor will monitor intake appointments and schedule to ensure
physicals have been completed on the initial intake appointment. |
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 a review of client records, the facility failed to document a psychosocial evaluation that included a clinical assessment of the client's assets/strengths, support systems, coping mechanisms, negative factors and conclusions regarding the client's attitude toward and ability to participate in the treatment process in seven of nine client records.
The finding include:
Twelve client records were reviewed on January 6 - 7, 2014. Nine client records were reviewed for psychosocial evaluations that included a clinical assessment of the client. The facility failed to document a psychosocial evaluation that included a clinical assessment of the client's assets/strengths, support systems, coping mechanisms, negative factors and conclusions regarding the client's attitude toward and ability to participate in the treatment process in client records # 1, 3, 6, 8, 9, 10 and 11.
Client # 1 was admitted into treatment on October 30, 2013. A psychosocial evaluation was completed on October 30, 2013. The psychosocial evaluation for client # 1 did not include a clinical assessment of the client's assets/strengths, support systems, coping mechanisms and negative factors and only included client reported historical information.
Client # 3 was admitted into treatment on December 4, 2013. A psychosocial evaluation was completed on December 4, 2013. The psychosocial evaluation for client # 3 did not include a clinical assessment of the client's coping mechanisms, negative factors and conclusions regarding the client's attitude toward and ability to participate in the treatment process and only included client reported historical information.
Client # 6 was admitted into treatment on November 6, 2013 and discharged on January 3, 2014. A psychosocial evaluation was completed on November 6, 2013. The psychosocial evaluation for client # 6 did not include a clinical assessment of the client's assets/strengths, support systems, coping mechanisms and negative factors and only included client reported historical information.
Client # 8 was admitted into treatment on October 30, 2013 and discharged on December 6, 2013. A psychosocial evaluation was completed on October 30, 2013. The psychosocial evaluation for client # 8 did not include a clinical assessment of the client's assets/strengths, coping mechanisms and conclusions regarding the client's attitude toward and ability to participate in the treatment process and only included client reported historical information.
Client # 9 was admitted into treatment on November 6, 2013. A psychosocial evaluation was completed on November 6, 2013. The psychosocial evaluation for client # 9 did not include a clinical assessment of the client's strengths/assets, support systems, coping mechanisms and negative factors and only included client reported historical information.
Client # 10 was admitted into treatment on November 8, 2013. A psychosocial evaluation was completed on November 8, 2013. The psychosocial evaluation for client # 10 did not include a clinical assessment of the client's strengths/assets, support systems, coping mechanisms, negative factors and conclusions regarding the client's attitude toward and ability to participate in the treatment process and only included client reported historical information.
Client # 11 was admitted into treatment on November 11, 2013. A psychosocial evaluation was completed on November 11, 2013. The psychosocial evaluation for client # 11 did not include a clinical assessment of the client's strengths/assets, support systems, coping mechanisms and negative factors and only included client reported historical information.
The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the July 9 - 10, 2012, March 1, 2013 and August 7 - 8, 2013 inspections.
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Plan of Correction
A training was held by the Facility Director and Lead Counselor with clinical staff to discuss the appropriate documentation of the psychosocial evaluation including a clinical assessment of the client's assets/strengths/support systems/coping mechanisms/negative factors and conclusions regarding the client's attitude toward and ability to participate in treatment process.
Facility Director and Lead Counselor will audit psychosocial evaluations to ensure clinical staff are completing all required components and not only including client reported information. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan including the type and frequency of treatment and rehabilitation services in eight of ten client records.
The findings include:
Twelve client records were reviewed on January 6 - 7, 2014. Ten client records were reviewed for individual treatment plans including the type and frequency of treatment and rehabilitation services. The facility failed to document an individual treatment plan including the type and frequency of treatment and rehabilitation services in client records # 1, 2, 3, 6, 9, 10, 11 and 12.
Client # 1 was admitted into treatment on October 30, 2013. An individual treatment and rehabilitation plan was developed with the client on November 11, 2013. Per review of the record of services provided and progress notes, the client was participating in weekly group counseling sessions. The treatment plan for client # 1 did not include written documentation of the type and frequency of group counseling sessions.
Client # 2 was admitted into treatment on September 10, 2013. An individual treatment and rehabilitation plan was developed with the client on September 10, 2013. Per review of the record of services provided and progress notes, the client was participating in weekly group counseling sessions. The treatment plan for client # 2 did not include written documentation of the type and frequency of group counseling sessions.
Client # 3 was admitted into treatment on December 4, 2013. An individual treatment and rehabilitation plan was developed with the client on December 4, 2013. Per review of the record of services provided and progress notes, the client was participating in weekly group counseling sessions. The treatment plan for client # 3 did not include written documentation of the type and frequency of group counseling sessions.
Client # 6 was admitted into treatment on November 6, 2013 and discharged on January 3, 2014. An individual treatment and rehabilitation plan was developed with the client on November 11, 2013. Per review of the record of services provided and progress notes, the client was participating in weekly group counseling sessions. The treatment plan for client # 6 did not include written documentation of the frequency of group counseling sessions.
Client # 9 was admitted into treatment on November 6, 2013. An individual treatment and rehabilitation plan was developed with the client on November 14, 2013. Per review of the record of services provided and progress notes, the client was participating in weekly group counseling sessions. The treatment plan for client # 9 did not include written documentation of the type and frequency of group counseling sessions.
Client # 10 was admitted into treatment on November 8, 2013. An individual treatment and rehabilitation plan was developed with the client on November 8, 2013. Per review of the record of services provided and progress notes, the client was participating in weekly group counseling sessions. The treatment plan for client # 10 did not include written documentation of the type and frequency of group counseling sessions.
Client # 11 was admitted into treatment on November 11, 2013. An individual treatment and rehabilitation plan was developed with the client on November 11, 2013. Per review of the record of services provided and progress notes, the client was participating in weekly group counseling sessions. The treatment plan for client # 11 did not include written documentation of the type and frequency of group counseling sessions.
Client # 12 was admitted into treatment on September 11, 2013 and discharged on October 22, 2013. An individual treatment and rehabilitation plan was developed with the client on September 11, 2013. Per review of the record of services provided and progress notes, the client was participating in weekly group counseling sessions. The treatment plan for client # 12 did not include written documentation of the type and frequency of group counseling sessions.
The project/facility director and lead counselor confirmed the findings.
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Plan of Correction
Training was held by Facility Director on proper use of updated treatment plan including documentation of frequency of treatment and rehabilitation services. ED (Therapist) will audit charts to ensure
there is written documentation of type and frequency of rehabilitation
services on all treatment plans. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan including the proposed type of support service in nine of ten client records.
The findings include:
Twelve client records were reviewed on January 6 - 7, 2014. Ten client records were reviewed for individual treatment plans including the proposed type of support service. The facility failed to document an individual treatment plan including the proposed type of support service in client records # 1, 2, 3, 5, 6, 7, 10, 11 and 12.
Client # 1 was admitted into treatment on October 30, 2013. An individual treatment plan was developed with the client on November 11, 2013. The individual treatment plan for client # 1 did not include written documentation of the proposed type of support service.
Client # 2 was admitted into treatment on September 10, 2013. An individual treatment plan was developed with the client on September 10, 2013. The individual treatment plan for client # 2 did not include written documentation of the proposed type of support service.
Client # 3 was admitted into treatment on December 4, 2013. An individual treatment plan was developed with the client on December 4, 2013. The individual treatment plan for client # 3 did not include written documentation of the proposed type of support service.
Client # 5 was admitted into treatment on September 5, 2013 and discharged on November 15, 2013. An individual treatment plan was developed with the client on September 26, 2013. The individual treatment plan for client # 5 did not include written documentation of the proposed type of support service.
Client # 6 was admitted into treatment on November 6, 2013 and discharged on January 3, 2014. An individual treatment plan was developed with the client on November 11, 2013. The individual treatment plan for client # 6 did not include written documentation of the proposed type of support service.
Client # 7 was admitted into treatment on September 7, 2013 and discharged on October 8, 2013. An individual treatment plan was developed with the client on September 14, 2013. The individual treatment plan for client # 7 did not include written documentation of the proposed type of support service.
Client # 10 was admitted into treatment on November 8, 2013. An individual treatment plan was developed with the client on November 8, 2013. The individual treatment plan for client # 10 did not include written documentation of the proposed type of support service.
Client # 11 was admitted into treatment on November 11, 2013. An individual treatment plan was developed with the client on November 11, 2013. The individual treatment plan for client # 11 did not include written documentation of the proposed type of support service.
Client # 12 was admitted into treatment on September 11, 2013 and discharged on October 22, 2013. An individual treatment plan was developed with the client on September 11, 2013. The individual treatment plan for client # 12 did not include written documentation of the proposed type of support service.
The findings were confirmed by the project/facility director and lead counselor.
This is a repeat citation from the August 7 - 8, 2013 licensing inspection.
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Plan of Correction
A training was conducted by Facility Director on proper use of the
updated treatment plan form which now includes proposed support
services. Treatment plan form has been updated by Facility Director
and ED (therapist) will complete chart audits to ensure there is documentation of proposed support services on all treatment plans.
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