INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 24, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Creative Health 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:
|
Plan of Correction
|
709.22(e)(3) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
|
Observations
Based on a review of the 2011 annual report, the governing body failed to make available to the public an annual report which included a statement disclosing the names of officers, directors and principal shareholders, as required by regulation.The findings include:The 2011 annual report was reviewed on April 24, 2012. The facility made the 2011 annual report available to the public the on March 2, 2012. The 2011 annual report did not include a statement disclosing the names of officers, directors and principal shareholders. The Facility Director did not dispute the findings.
|
Plan of Correction
The governing body has published and made available the 2012 annual report on 5/29/12. The 2012 annual report included a statement of officers, directors and principal shareholders. Moving forward, to ensure this deficiency does not reoccur the Facility Director will preview the annual report to ensure the statement of officers, directors and principal shareholders will be included on the annual report before publication. The Project Director along with the Facility Director will ensure compliance. |
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 a review of client records and a review of the facility's policy and procedures manual, the facility failed to document case consultations in two of three records reviewed.The findings include:The facility policy titled "Case Consultations" states:"A case consultation offers the client and primary counselor benefits of the treatment team's suggestions and recommendations. Each case consultation form will include the following: name of client reviewed, date of consultation, names of persons attending and their disciplines, summary of the discussion, and disposition of the case reviewed. The frequency of case consultations for each client will be a minimum of every three months. For clients in treatment longer than one year, case consultations will be conducted a minimum of once annually."On April 25, 2012, three client records requiring documentation of a case consultation were reviewed. The facility failed to document a case consultation note per policy in two of three records reviewed, client records # 1 and 2.Client # 1 was admitted to the program on 8/17/11, and is still an active client. A case consultation was due by 11/17/11 and 2/17/12. The facility documented one case consultation on 12/22/11.Client # 2 was admitted to the program on 11/21/11, and is still an active client. A case consultation was due by 2/21/12; however, the facility failed to document a case consultation as of the time of review on 4/25/12 .The Facility Director confirmed the findings.
|
Plan of Correction
By 05/29/2012 Facility Director/Clinical Supervisor(#2) will orient clinical staff (#3),(#5) to DOH client record standards, and will review client record #1 and client record #2 (case consultations) during individual clinical supervision. Facility Director/Clinical Supervisor (#2) has reviewed charts of client #1 and client #2, and has addressed these case consultations in a staff mulitidisciplinary team meeting,ensuring that these case consultations have been completed.
By 05/29/2012 Facility Director/Clinical Supervisor (#2)will review client records completed by clinical staff (#3 and (#5)to ensure compliance with the DOH and frequency of case consultations.
By 06/062012 Facility Director/ Clinical Supervisor will hold a staff training with all staff on the multidisciplinary team as to accurate frequency of case consultations, staff and Facility Director will review facilitys policy and procedure manual. |