INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 16-17, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Perspectives at White Deer Run 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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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project.
The findings include:
One client record was reviewed for documentation of a termination letter on April 16, 2013. One of one client record reviewed failed to include notification to the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in a timely manner, specifically client record # 14.
Client # 14 was admitted to the program on November 1, 2012 and was involuntarily terminated from the program on January 7, 2013. The client did not receive notification of the decision to involuntarily terminate treatment until February 22, 2013.
The findings were reviewed with the site director during the exit interview.
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Plan of Correction
Clinical Supervisor will provide onsite training to review policy and procedure regarding notification of termination during weekly OP meeting to be held on May 10, 2013. Ongoing, Outpatient Counselors will review termination letters with Clinical Supervisor during regularly scheduled meetings prior to mailing out to patients. |
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 the review of outpatient client records and the facility's policies and procedures, the facility failed to document biopsychosocial evaluations in accordance to the facility's policies and procedures.
The findings include:
In reference to biopsychosocial evaluations, the facility's policy states:
Biopsychosocial evaluations are to be completed within 14 days of admission for Intensive Outpatient and 21 days of admission for Outpatient clients.
Seven outpatient client records were reviewed on April 16, 2013 for documentation of biopsychosocial evaluations. The facility failed to document biopsychosocial evaluations within 21 days of admission in five out of seven outpatient client records, specifically client records # 8, 9, 11, 12, and 13.
Client #8 was admitted on October 18, 2012. The biopsychosocial evaluation was completed but undated for client #8.
Client #9 was admitted on January 24, 2013. The biopsychosocial evaluation was signed on April 3, 2013 for client #9.
Client #11 was admitted on November 12, 2012 and discharged on January 28, 2013. As of the date of inspection, there was no documentation of a biopsychosocial evaluation for client #11.
Client #12 was admitted on September 25, 2012 and discharged on January 24, 2012. As of the date of inspection, there was no documentation of a biopsychosocial evaluation for client #12.
Client #13 was admitted on September 13, 2012 and discharged on February 20, 2013. The biopsychosocial evaluation was completed on January 9, 2013 for client #13.
The findings were confirmed with the regional director and facility director during the exit interview.
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Plan of Correction
Training with the outpatient clinical staff will be conducted by the Clinical Supervisor on or before May 17, 2013 to ensure understanding of the intake/admission standard regarding documentation of the Bio-Psychosocial evaluations and legibility, with a focus on time frames in accordance with the White Deer Run policy. In addition to their signature, outpatient clinical staff are required to note the date that documentation was completed. The Clinical Supervisor will conduct random monthly chart audits as well as monthly supervision to ensure ongoing compliance of this standard. Documentation of chart audits will be sent to the White Deer Run Quality Improvement Department and included in the quarterly supervision of each clinician. An EIP (Employee Improvement Plan) will be initiated for clinicians not compliant with the Policy and legibility of the Bio-Psychosocial evaluation, with progressive disciplinary action to be taken as needed. This process will be an on-going effort. |
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 outpatient client records and the facility's policies and procedures, the facility failed to document treatment plans in accordance with the facility's policies and procedures.
The findings include:
In reference to the comprehensive treatment plan for outpatient clients, the project's policy states:
The comprehensive treatment plan is to be completed within 14 days of admission for intensive outpatient clients and within 21 days of admission for outpatient clients.
Seven outpatient client records were reviewed for comprehensive treatment plans on April 16, 2013. Three out of seven outpatient client records lacked a treatment plan that was documented within 14 or 21 days, specifically records # 11, 12, and 13.
Client #11 was admitted into outpatient treatment on November 12, 2012 and discharged on January 28, 2013. As of the date of inspection, a treatment plan had not been documented for client #11.
Client #12 was admitted into outpatient treatment on September 25, 2012 and discharged on January 24, 2013. The comprehensive treatment plan had not been documented until November 11, 2012 for client #12.
Client #13 was admitted into outpatient treatment on September 13, 2012 and discharged on February 20, 2013. The comprehensive treatment plan had not been documented until January 8, 2013 for client #13.
The findings were confirmed with the regional director and facility director during the exit interview.
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Plan of Correction
Training with the outpatient clinical staff will be conducted by the Clinical Supervisor on or before May 17, 2013 to ensure comprehension of the standard regarding documentation of an individual treatment and rehabilitation plan, with a focus on time frames in accordance with the White Deer Run policy. The Clinical Supervisor will conduct random monthly chart audits as well as monthly supervision to ensure ongoing compliance; findings will be documented in the quarterly supervision of each clinician. An EIP (Employee Improvement Plan) will be initiated for clinicians not compliant with the Policy, with progressive disciplinary action to be taken as needed. This will be an on-going process. |
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.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document case consultations according to the facility's policies and procedures.
The findings include:
The project's policy in reference to case consultations states:
Every patient will have a minimum of one case consult during the course of treatment. For patients in treatment longer than 90 days, their case will be reviewed a minimum of every 90 days.
Six client records were reviewed for a case consultation on April 16, 2013. Two out of six client record lacked documentation of a case consultation within 90 days, specifically client records # 12 and 13.
Client #12 was admitted on September 25, 2012 and discharged on January 24, 2012. The case consult was documented on January 24, 2013 for client #12.
Client #13 was admitted on September 13, 2012 and discharged on February 20, 2013. The case consult was documented on February 20, 2013 for client #13.
The findings were discussed with the regional director and facility director during the exit interview.
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Plan of Correction
Clinical Supervisor will provide onsite training on case consults, to include policy review on or before May 17, 2013. Clinical Supervisor will audit 10 percent for each clinician for 3 months, effective immediately to monitor compliance and provide supervision as needed. An EIP (Employee Improvement Plan) will be initiated for clinicians not compliant with the Policy, with progressive disciplinary action to be taken as needed. This will be an on-going process. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on the review of outpatient client records and the facility's policies and procedures, the facility failed to document follow-ups in accordance with the facility's policies and procedures.
The findings include:
The facility's policy regarding follow-ups states:
If no referral is made (including AMA clients), a contact call will be attempted within 30 business days after discharge.
Four outpatient client records were reviewed on April 16, 2013 for documentation of a follow-up. The facility failed to document follow-ups in accordance with the facility's policy in two out of four inpatient client records, specifically client records # 12 and 13.
Client #12 was admitted on September 25, 2012 and discharged on January 24, 2013. The client was not referred to another agency. The follow-up was documented on January 24, 2013, which was the date of discharge for client #12.
Client #13 was admitted on September 13, 2012 and discharged on February 20, 2013. The client was not referred to another agency. The follow-up was documented on February 20, 2013, which was the date of discharge for client #13.
The findings were confirmed with the regional director and facility director during the exit interview.
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Plan of Correction
Campus Director will review policies and procedures regarding completing follow up information in the next weekly outpatient counselor meeting on June 3, 2013. Regional Clinical Supervisor will also review a minimum of 25% of all charts over the next 3 months for compliance. |