INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 4, 5 and 6, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, WES Corporation. 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 and a plan of correction is due on March 11, 2008.
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Plan of Correction
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709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on the random review of 12 client records, the facility failed to ensure adherence to 4 PA Code 255.5 by not clearly identifying what specific information was to be released to the funding source, CBH, in three of six client records reviewed, # 1, 7 and 8. Instead, the statement "all services rendered" was documented on the consent to release information form.
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Plan of Correction
The project shall obtain an informed and voluntary consent from the clients for the disclosure of information contained in the client record. The information released to the funding source, CBH, will not read "all services rendered". It will state specific information to be released. That information will be within the guidelines of 4PA Code Section 255.5. All clinical staff will be trained on the completion of these releases and thr facility director will monitor for compliance. The completion date is 2/29/08. |
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 the random review of 12 client records, the facility failed to provide written notification of involuntary termination in one of two client records reviewed, # 5.
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Plan of Correction
The project will provide written notification of termination to clients. All clinical staff will be trained on the completion of this termination letter. Facility Director will monitor for compliance. The completion date is 03/31/08. |
709.91(a)(3) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(3) Requirements for completion of treatment.
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Observations
Based on the review of the policy and procedure manual presented by the administrative staff, the facility failed to expand the requirements for completion of treatment. The policy stated only that the client was to successfully complete goals and objectives. The policy and procedures need to contain all the criteria the facility applied to determine treatment completion requirements.
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Plan of Correction
The current policy regarding requirements for completion of treatment will be revised to contain all the criteria that was applied to determine treatment completion requirements. Clinical staff will be trained on this procedure. Facility Director will monitor for compliance.
Completion date is 03/31/2008. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the random review of 12 client records, the drug and alcohol history was missing lengths and patterns attributing to the client's progression of use in 5 out of 5 clinical charts reviewed, specifically # 2, 4, 5, 7 and 8. In addition, the client's perception of use was not documented at all. Two other client records, #1 and 3, were missing drug and alcohol histories completely.
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Plan of Correction
All clinical staff will be trained on the completion of the psychosocial history to include the lengths and patterns of substance use as well as the client's perception of use. All clients will receive complete drug and alcohol histories. Facility Director will monitor for compliance. Completion date is 03/31/2008. |
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 random review of 12 client records, the facility failed to ensure the psychosocial evaluation was completed for three of seven client records, # 2, 4, and 10. The psychosocial evaluation for client record # 1 was completed without having had a psychosocial history completed to base it on. In addition, two other client records, # 7 and 8, had evaluations that were more historical then evaluative with client stated/reported comments in place of the clinician's analysis of the collected historical information.
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Plan of Correction
The facility will ensure that all clients receive a complete psychosocial evaluation. The clinical impressions/diagnostic summary will be revised to provide a more clinical evaluation of the client. All clinical staff will be trained on documentation protocol of the revised form. The facility Director will monitor for compliance. Completion date is 03/31/2008. |
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 the random review of 12 client records, the facility failed to ensure the treatment plans were completed in two of five client records reviewed, # 1 and 2.
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Plan of Correction
An individual treatment plan will be developed with each client. In the event the clinician is unable to complete the treatment plan due to client's non-compliance, documentation of this will be completed in the client record. All clinical staff will be trained on this procedure. Facility Director will monitor for compliance. Completion date is 03/31/2008. |
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 the random review of 12 client records, the facility failed to ensure case consultations were completed in two of two client records. Client # 6 had been admitted for treatment in June 2006 and was discharged November 2007, but there were no case consultations in the record. Client # 9 had a case consultation in October 2007 and needed at least one more since then.
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Plan of Correction
The facility will ensure that case consultations are completed on clients every 90 days. All clinical staff will be trained on this documentation protocol and the Facility Director will monitor for compliance. Completion date is 03/31/2008. |