INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 25, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Jefferson Outreach Drug and Alcohol Program 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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704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 12 clock hours of annual training required for Project Director in employee #1's employee record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the responsibility of the Facility Director to ensure that all staff members attend the requisite number of trainings annually. The Project Director's employee record was not reviewed at Jefferson Outreach; however, the Facility Director will ensure that the Project Director's training documentation is in his personnel file and is available to inspection staff at the time of the site visit. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of 14 client records, the facility failed to document treatment plan updates within the regulatory timeframe in 4 client records reviewed.Client #3 was admitted on 12/7/15 and was still active at the time of the inspection. A treatment plan update was completed on 1/31/17 and the next update was due not later than 3/31/17 however, there was no update documented in the record at the time of the inspection.Client #8 was admitted on 9/22/16 and was still active at the time of the inspection. A treatment plan update was completed on 6/5/17 and the next update was due no later than 8/5/17 ; however, there was no update documented in the record at the time of the inspection.Client #10 was admitted on 10/16/17 and was discharged 3/12/18. A treatment plan update was completed on 11/13/17 and the next update was due no later than 12/16/17 however, there was no update documented in the record at the time of the inspection.Client #11 was admitted on 11/2/15 and was discharged on 4/20/18. A treatment plan update was completed on 12/18/17 and the next update was due no later than 2/18/18; however, there was no update documented in the record at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It shall be the responsibility of the Facility Director to ensure that treatment plan updates are being updated every 60 days. The Facility Director will instruct the counselor to complete treatment plans at 45 days so that in the event of a missed appointment, time will still be available to complete the treatment plan update with the patient. Client #3's treatment plan was updated 3/13/18; Client #8 will receive a new treatment plan update immediately. |
711.92(e) LICENSURE Provision of TX RE: TX Plan
711.92. Treatment and rehabilitation services.
(e) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of 14 outpatient client records, there was no documentation that the clients received counseling services according to their individual comprehensive treatment plan in 3 charts reviewed.Client #5 was admitted on 3/29/13 and was discharged on 11/10/17. The treatment plan, dated 5/23/17, indicated 2 individual sessions a month. The chart's record of service and progress notes indicated that the client had received a total of 5 individual sessions between the months of January 2017 and August 2017. Client #11 was admitted on 11/02/15 and was discharged on 04/20/18. The treatment plan, dated 9/26/17, indicated 2 individual sessions a month. The chart's record of service and progress notes indicated that the client had received a total of 4 individual sessions between the months of August 2017 and December 2017. Client #12 was admitted on 10/11/16 and was discharged on 4/4/17. The treatment plan, dated 1/10/17 , indicated 3 individual session a month. The chart's record of service and progress notes indicated that the client only received 3 session a month for the month October 2016. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It shall be the responsibility of the Facility Director to ensure that services are being delivered in accordance with the individual comprehensive treatment plan. The Facility Director will instruct the counselor to develop treatment plans that reflect the services that are expected to be delivered for each patient, based on what is collaboratively agreed upon between patient and counselor during sessions. |
711.93(a) LICENSURE Complete Client Record
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a Consent to treatment, Record of Service, Referral Contact, Progress notes, Aftercare plan and/or follow-up information in client record #'s 1, 2, 3, 4,5 6, 7, 8, 9, 10, 11, 12, 13 and 14.Client #1 was admitted on 10/7/16. The client record did not contain documentation of Referral Contact and Case Consultations.Client #2 was admitted on 2/17/17. The client record did not contain documentation of referral contact and Case Consultations.Client #3 was admitted on 12/7/15. The client record did not contain documentation of referral contact. Client #4 was admitted on 3/29/16 and discharged on 1/17/17. The client record did not contain documentation of a follow up.Client #5 was admitted on 3/29/13 and discharged on 11/10/17. The client record did not contain documentation of Consent to treatment, Referral contact, Case consultations, progress notes, and follow up. Client #6 was admitted on 5/5/17 and was discharged on 10/13/17. The client record did not contain documentation of Referral contact, Case consultation, aftercare plan or follow up. Client #7 was admitted 5/15/17 and was discharged 9/8/17. The client record did not contain referral contact, case consultations and follow up. Client#8 was admitted 9/22/16. The client record did not contain Record of Service and Referral contact. Client#9 was admitted 11/1/16. The client record did not contain, record of service and Referral contact. Client #10 was admitted 10/16/17 and was discharged 3/12/18. The client record did not contain Referral contact, case consultations and follow up. Client #11 was admitted 11/2/15 and was discharged 4/20/18. The client record did not contain Referral contact, Case consultations, progress notes and follow up. Client #12 was admitted on 10/11/16 and was discharged on 4/4/17. The client record did not contain referral contact, case consultations, progress notes and follow up. Client #13 was admitted on 8/11/10 and was discharged on 1/31/17. The client record did not contain referral contact, case consultations and follow up. Client #14 was admitted 4/22/13 and was discharged 5/2/17. The client record did not contain referral contact, case consultation, progress notes and follow up. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the responsibility of the Facility Director to ensure that each client record is complete. The Facility Director will instruct the counselor to complete a Consent to Treatment, Record of Service, Referral Contact, Progress Notes, Aftercare plan and follow-up information for each patient who is admitted. For existing patients, the appropriate documentation (minus case consultations for non-medication assisted treatment patients) will be completed for each individual by 8/31/18. |
711.93(c)(2)(i) LICENSURE Name of person/agency/organization
711.93. Client records.
(c) Confidentiality.
(2) 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:
(i) The name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, client record #'s 1, 2, 3, 5 and 6 were missing specific information to be released or the name of the person/organization to whom the disclosure was made to.#1 was admitted on 10/7/16 and was an active client as of the date of the inspection. A consent to release information form was signed and dated on 3/17/17 to the funding source/government agency that allowed for the release of a limited employment schedule. Additionally, there was a consent to release information form signed and dated on 3/17/17 to a family member with no specific information to be released.#2 was admitted on 2/7/17 and was an active client as of the date of the inspection. A consent to release information form was signed and dated on 3/9/18 to the funding source/government agency that allowed for the release of a limited employment schedule. Additionally, there was a consent to release information form signed and dated on 3/9/18 to a family member with no specific information to be released.#3 was admitted on 12/7/15 and was an active client as of the date of the inspection. A consent to release information form was signed and dated on 3/13/18 to the funding source/government agency that allowed for the release of a limited employment schedule. Additionally, there was a consent to release form signed and dated on 3/13/18 for a boyfriend and 3/7/17 to client's daughter with no specific information to be released.Client 5# was admitted on 3/29/13 and was discharged 11/10/17. A consent to release information form for a funding source/government agency and the primary care physician was not dated. Client 6 # was admitted on 5/5/17 and was discharged 10/13/17. There was documentation of a correspondence with the County assistance office; however, there was no proper consent to release information form signed by the client prior to disclosure.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It shall be the responsibility of the Facility Director to ensure that consent to release information forms include complete information that is in accordance with all regulations. The Facility Director will update all consent to release information forms so that they are in accordance with all regulations and train the counselor in how to ensure that they are completed with no missing information. At 3 and 6 months after staff members begin completing these new forms, the Facility Director will conduct random chart checks to ensure that the updated forms are being used and completed in accordance with no missing information. Clients #2, 3, and 6 will sign updated forms immediately. |