INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the January 6 - 7, 2014 licensure renewal inspection. The follow-up inspection was conducted on April 7, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to offer to the client a copy of a consent to release information in four of four client records.
The findings include:
Four client records were reviewed for informed and voluntary consent to release client information forms on April 7, 2014. There was no documentation in the client record verifying that the client was offered a copy of the consent to release information in client records # 1, 2, 4 and 5.
Client # 1 was admitted into treatment on March 21, 2014. The client signed a consent to release information to an emergency contact on March 21, 2014. There was no documentation that the client was offered a copy of the consent.
Client # 2 was admitted into treatment on March 25, 2014. The client signed a consent to release information to an emergency contact on March 25, 2014. There was no documentation that the client was offered a copy of the consent.
Client # 4 was admitted into treatment on March 26, 2014. The client signed a consent to release information to an emergency contact on March 26, 2014. There was no documentation that the client was offered a copy of the consent.
Client # 5 was admitted into treatment on March 21, 2014. The client signed a consent to release information to an emergency contact on March 21, 2014. There was no documentation that the client was offered a copy of the consent.
The lead counselor confirmed the findings on April 7, 2014.
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Plan of Correction
All releases have been updated to include whether or not the client has accepted or rejected a copy of the release.
Staff meeting was held to discuss the importance of documenting client response. Axiom's drug and alcohol handbook was also updated to include relevant policies regarding releases that all clients will be offered a copy of release.
(ED), therapist, will complete audit audits to ensure therapists are filling out releases appropriately and all information is checked on the release to document whether client has accepted or rejected a copy of the release.
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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 one of one patient records.
The findings include:
Six patient records were reviewed on April 7, 2014. One patient record pertained to a pregnant patient. The facility failed to document the nature of prenatal support provided to pregnant patients in patient record # 1.
Patient # 1 was admitted into treatment on March 21, 2014. Patient # 1 is pregnant and was prescribed 8 mg Subutex BID on March 21, 2014. The counseling records for patient # 1 did not reflect the nature of prenatal support provided by the treatment program.
The findings were confirmed by the lead counselor on April 7, 2014.
This is a repeat citation from the January 6 - 7, 2014 licensing inspection.
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Plan of Correction
Staff training was held by Project Director to discuss utilization of new treatment plan. Treatment plan requirements and progress note documentation of prenatal support were reviewed.
ED, therapist, and Lead Counselor will complete chart audits to ensure treatment plan requirements are documented on each individual treatment plan. Records will be reviewed to ensure the nature of prenatal support is documented. |
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 to include a family medical history and failed to document a drug or alcohol history to include the length and patterns of use, in four of four client records.
The findings include:
Four client records were reviewed for medical and drug or alcohol histories on April 7, 2014. The facility failed to document a medical history, to include a family medical history, and failed to document a drug or alcohol history, to include the length and patterns of use, in client records # 1, 2, 4 and 5.
Client # 1 was admitted into treatment on March 21, 2014. The medical, drug and alcohol histories for client # 1 were completed on March 21, 2014. The facility failed to document a medical history including a family medical history. The facility failed to document a drug and alcohol history including the length and patterns of use.
Client # 2 was admitted into treatment on March 25, 2014. The medical, drug and alcohol histories for client # 2 were completed on March 25, 2014. The facility failed to document a medical history including a family medical history. The facility failed to document a drug and alcohol history including the length and patterns of use.
Client # 4 was admitted into treatment on March 26, 2014. The drug and alcohol history for client # 4 was completed on March 31, 2014. The facility failed to document a drug and alcohol history including the length and patterns of use. The intake process was completed on March 31, 2014. The facility failed to document a medical history for client # 4 as of April 7, 2014.
Client # 5 was admitted into treatment on March 21, 2014. The medical, drug and alcohol histories for client # 5 were completed on March 21, 2014. The facility failed to document a medical history including a family medical history. The facility failed to document a drug and alcohol history including the length and patterns of use.
The findings were confirmed by the lead counselor on April 7, 2014.
This is a repeat citation from the January 6 - 7, 2014 licensing inspection.
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Plan of Correction
The intake form has been updated to include the family medical history as well as a drug and alcohol history including length and patterns of use.
Staff training was held to discuss proper utilization of intake by the Project Director.
Chart audits will be completed by ED, therapist, and Lead Counselor to ensure compliance with family/medical history as well as drug and alcohol history length/use patterns. |
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 provided a composite picture of the individual in relationship to the collected historical information in three of four client records.
The findings include:
Six client records were reviewed on April 7, 2014. Four client records were reviewed for psychosocial evaluations. The facility failed to document a psychosocial evaluation that provided a composite picture of the individual in relationship to the collected historical information in client records # 2, 4 and 5.
Client # 2 was admitted into treatment on March 25, 2014. The intake process was completed on March 25, 2014. There was no documentation of a psychosocial evaluation for client # 2 as of April 7, 2014.
Client # 4 was admitted into treatment on March 26, 2014. The intake process was completed on March 26, 2014. There was no documentation of a psychosocial evaluation for client # 4 as of April 7, 2014.
Client # 5 was admitted into treatment on March 21, 2014. The psychosocial evaluation was completed on March 21, 2014. The facility failed to document a psychosocial evaluation for client # 5 that provided a composite picture of the individual in relationship to the collected historical information.
The lead counselor confirmed the findings.
This is a repeat citation from the July 9 - 10, 2012, March 1, 2013, August 7 - 8, 2013 and January 6 - 7, 2014 inspections.
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Plan of Correction
A staff meeting was held by Project Director to discuss importance of completing psychosocial on appropriate day. Future disciplinary action was discussed regarding timely completing of evaluations. ED, therapist, also discussed appropriate way to develop psychosocial evaluations.
Project Director will monitor timely completeness of evaluations and ED, therapist will monitor charts to ensure compliancy as well. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan was developed with the client in 2 of 4 client records.
The findings include:
Six client records were reviewed on April 7, 2014. Individual comprehensive treatment plans were due to be completed in four client records. The facility failed to document an individual treatment and rehabilitation plan developed with the client in client records #1 and 4.
Client # 1 was admitted into treatment on March 21, 2014. An individual treatment and rehabilitation plan was completed by the counselor on March 26, 2014. This treatment plan was not signed by the client as of April 7, 2014. The progress notes did not include documentation of the development of an individual treatment plan with client # 1.
Client # 4 was admitted into treatment on March 26, 2014. An individual treatment and rehabilitation plan was completed by the counselor. This treatment plan was not signed by the client as of April 7, 2014. The progress notes did not include documentation of the development of an individual treatment plan with client # 4.
The lead counselor confirmed the findings on April 7, 2014.
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Plan of Correction
Staff training was held by Project Director and Lead Counselor to discuss utilization of new treatment plan and future disciplinary for treatment plans not completed in timely manner and/or those lacking client signatures. .
ED, therapist, and Lead Counselor will complete chart audits to ensure treatment plan requirements are documented on each treatment plan.
Project Director will monitor treatment plans to ensure signatures are being obtained and treatment planning is completed in a timely manner. Client records will be reviewed to ensure the treatment plan is developed with the client. |
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.
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan, including long and short term goals for treatment, was developed with the client in 2 of 4 client records.
The findings include:
Six client records were reviewed on April 7, 2014. Individual comprehensive treatment plans were due to be completed in four client records. The facility failed to document an individual treatment and rehabilitation plan developed with the client, which included short and long term goals for treatment in client records # 1 and 4.
Client # 1 was admitted into treatment on March 21, 2014. An individual treatment and rehabilitation plan was completed by the counselor on March 26, 2014. This treatment plan was not signed by the client as of April 7, 2014. The progress notes did not include documentation of the development of a treatment plan, including long and short term treatment goals, with client # 1.
Client # 4 was admitted into treatment on March 26, 2014. An individual treatment and rehabilitation plan was completed by the counselor. This treatment plan was not signed by the client as of April 7, 2014. The progress notes did not include documentation of the development of a treatment plan, including long and short term treatment goals, with client # 4.
The lead counselor confirmed the findings on April 7, 2014.
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Plan of Correction
A staff training was held on all required documentation of treatment plan by Project Director. This included proposed support services, prenatal services, frequency/type of treatment, and short and long term goals. Timeliness of treatment plans were discussed and future disciplinary action if documentation is not done correctly was addressed.
ED, Therapist, and Lead Counselor in conjunction with Project Director will complete chart audits and monitor timeliness of all treatment plans. Chart audits and record reviews will be completed to ensure individual treatment plans including long/short term goals were developed with the client. |
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, was developed with the client in 2 of 4 client records.
The findings include:
Six client records were reviewed on April 7, 2014. Individual comprehensive treatment plans were due to be completed in four client records. The facility failed to document an individual treatment and rehabilitation plan developed with the client, which included the type and frequency of treatment and rehabilitation services in client records #1 and 4.
Client # 1 was admitted into treatment on March 21, 2014. An individual treatment and rehabilitation plan was completed by the counselor on March 26, 2014. This treatment plan was not signed by the client as of April 7, 2014. The progress notes did not include documentation of the development of an individual treatment plan, including the type and frequency of treatment services, with client # 1.
Client # 4 was admitted into treatment on March 26, 2014. An individual treatment and rehabilitation plan was completed by the counselor. This treatment plan was not signed by the client as of April 7, 2014. The progress notes did not include documentation of the development of an individual treatment plan, including the type and frequency of treatment services, with client # 4.
The lead counselor confirmed the findings on April 7, 2014.
This is a repeat citation from the January 6 - 7, 2014 licensing inspection.
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Plan of Correction
A treatment planning staff training was held by the project director. Treatment plans were discussed including the importance of documenting the patient's type and frequency of treatment. The PD also discussed the importance of documentation of the treatment plan in the progress notes. Missing client signatures were discussed.
ED, therapist, will monitor all treatment plans by completing of chart audits to ensure compliance with all aspects of treatment plan. Lead Counselor and Project Director will also complete chart audits to ensure compliancy. Chart audits and record reviews will be completed to ensure individual treatment plans including type and frequence of treatment services were developed with the client. |
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, was developed with the client in 4 of 4 client records.
The findings include:
Six client records were reviewed on April 7, 2014. Individual comprehensive treatment plans were due to be completed in four client records. The facility failed to document an individual treatment and rehabilitation plan developed with the client, to include the proposed type of support service, in client records # 1, 2, 4 and 5.
Client # 1 was admitted into treatment on March 21, 2014. An individual treatment and rehabilitation plan was completed by the counselor on March 26, 2014. This treatment plan was not signed by the client as of April 7, 2014. The progress notes did not include documentation of the development of an individual treatment plan, including the proposed type of support service, with client # 1.
Client # 2 was admitted into treatment on March 25, 2014. An individual treatment plan was developed with the client on March 25, 2014. The facility failed to document an individual treatment plan for client # 2 that included the proposed type of support service.
Client # 4 was admitted into treatment on March 26, 2014. An individual treatment and rehabilitation plan was completed by the counselor. This treatment plan was not signed by the client as of April 7, 2014. The progress notes did not include documentation of the development of an individual treatment plan, including the proposed type of support service, with client # 4.
Client # 5 was admitted into treatment on March 21, 2014. An individual treatment plan was developed with the client on March 21, 2014. The facility failed to document an individual treatment plan for client # 5 that included the proposed type of support service.
The lead counselor confirmed the findings.
This is a repeat citation from the August 7 - 8, 2013 and January 6 - 7, 2014 inspections.
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Plan of Correction
Staff training was held on utilization of new treatment plan to include proposed support services. The development of the individual treatment plan by the therapist and client was discussed and the importance of completing it on time. PD also discussed the importance of obtaining all client signatures on treatment plans.
ED, therapist, and Lead Counselor will monitor all treatment plans in conjunction with the Project Director to ensure treatment plans are completed in a timely manner with all required components. Chart audits and record reviews will be completed to ensure individual treatment plans including proposed support services were developed with the client. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to document a medication record including the name of the drug, dosage and frequency of use in three of four client records.
The findings include:
Six client records were reviewed on April 7, 2014. Four client records were reviewed for medication records. The facility failed to document a medication record including the name of the drug, dosage and frequency of use in client records # 1, 2 and 4.
Client # 1 was admitted into treatment on March 21, 2014. Per the assessment completed on March 21, 2014, the client was prescribed Phernergan. There was no documentation of the dosage and frequency of use of this medication.
Client # 2 was admitted into treatment on March 25, 2014. An assessment for client # 2 was documented on March 25, 2014. The medication section of the assessment was not completed. The facility failed to document a medication record for client # 2 including the name of the drug, dosage and frequency of use.
Client # 4 was admitted into treatment on March 26, 2014. Per the assessment completed on March 31, 2014, the client was prescribed Keppra and Vimpat. There was no documentation of the dosage and frequency of use of this medication.
The findings were confirmed by the lead counselor on April 7, 2014.
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Plan of Correction
A staff training was held by Project Director to review intake policies and procedures including appropriate documentation during intake assessment. Staff will be trained to collect the frequency of use of medications. Project Director discussed documentation and completeness of intake assessments.
Project Director reviewed medication record with physicians.
(ED), therapist and Lead Counselor will complete chart audits to ensure completeness of documentation. Records will be reviewed for documentation of the dosage and frequency of use of medications. |