INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 15 and 16, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Jefferson Outreach Drug and Alcohol Program Central 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 January 15, 2009.
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Plan of Correction
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704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of administrative documents, the facility failed to document an annual evaluation of the overall training plan for the 2007 training year.
Findings:
The administrative documents were reviewed on December 15, 2008. The facility failed to document an annual evaluation of the overall training plan for the 2007 training year.
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Plan of Correction
In December 2008 and continuing annually thereafter the meeting in which the annual training plan is reviewed will be more clearly documented. This review will not only go over what needs have/have not been addressed, but also the overall quality of the training year. The Division Director will be responsible for documenting this review.. Each year the Division's Coordinator of Treatment and Training will update the policy and procedure manual for the division; it will contain the current year's overall training plan and a review of the previous year's training plan. This will be done at the start of each year (January 15th). |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on the physical plant inspection, the facility failed to ensure that all facility heaters were permanently mounted or installed.
Findings:
The physical plant inspection was conducted on December 16, 2008. A space heater that was not permanently mounted or installed was located in the facility director's office.
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Plan of Correction
The offending space heater was removed from the office immediately. The Division Director notified all Outreach staff of the Department of Health policy that no space heaters are to be used in the facility. The facility director inspected all Outreach offices. It was suggested that if office temperature is an issue in the future, staff store additional clothing in their offices or contact the building maintenance director to have the thermostat adjusted. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of eight client records, the facility failed to document a psychosocial evaluation for each client.
Findings:
Eight client records were reviewed on December 16, 2008. A psychosocial evaluation was required in five client records. The facility failed to document a psychosocial evaluation in four of five client records reviewed, #1, 2, 3 and 5. There was no psychosocial evaluation document in client record #1. Two psychosocial evaluations were undated so it could not be determined if the evaluations were completed per agency policy of within 30 days of admission, #3 and 5. The facility failed to document a clinical assessment of the client's potential support systems in two client records, #2 and 5. The facility failed to document a clinical assessment of the negative factors which may impact treatment in client record #2.
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Plan of Correction
The division director, facility director and senior therapist will work together to train the new employee, emphasizing the importance of 1) timely completion of all required paperwork, 2) the need to sign and date all documents in the record, and 3) thorough completion of the biopsychosocial in a timely fashion. During the first three months of this counselor's employment at Outreach, all paperwork will be inspected by the senior therapist before being filed. After this time, the senior therapist will regularly monitor biopsychosocial evaluations during weekly administrative supervision for completeness, timeliness, and thoroughness. In addition, a new "chart log" will be used to monitor the contents of all client records, deadlines and the presence of signatures. This chart content log is being prepared by the Facility Director and will be in place by 2/2/09. |
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 client records, the facility failed to document that counseling services were provided according to the individual treatment plan.
Findings:
Eight client records were reviewed on December 16, 2008. Documentation that counseling services were provided according to the individual treatment plan was required in five client records. The facility failed to document that counseling services were provided according to the individual treatment plan in four of five client records, #1,2, 3 and 4. The treatment plan for client record #1 prescribed one individual treatment session per week. The record of services and progress notes documented individual treatment sessions scheduled on 10/9, 10/16, 10/20, 11/5, 11/12 and the last session documented was on 11/19/08. The treatment plan for client record #2 prescribed one individual treatment session per week. The record of services and progress notes documented individual treatment sessions scheduled for 9/16 and 9/25/08. The treatment plan for client record #3 prescribed one individual treatment session per week. The record of services and progress notes documented individual treatment sessions scheduled for 8/7, 8/14, 8/28, 9/4, 9/11, 9/18, 11/6, 11/13 and 11/20/08. The treatment plan for client record #4 prescribed one individual treatment session per week. The record of services and progress notes documented individual treatment sessions scheduled for 10/8, 10/16, 10/27, 11/3, 11/17, 11/24, 12/1, 12/8 and 12/15/08.
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Plan of Correction
In an effort to assure greater congruence between patient appointment/service expectations cited in the Treatment Plan, and the reality of "no-shows," cancellations, emergencies etc. it is necessary for counseling staff to document in the Progress Note when any of the above (or other untoward events) occur. The division director will review the policy that Outreach staff must document all appointment cancellations, no-shows, and rescheduling. Staff will be reminded of the importance of following through on the counseling recommendations made in treatment plans and, when not doing so, they are expected to document why. If the patient is being non-compliant with prescribed treatment, they must address this issue and provide documentation. If services are to be formally reduced/increased or modified (group or family therapy added) the Treatment Plan should be modified to reflect those changes. The division director, facility director and senior therapist will use the newly designed "chart log" (see above) when monitoring treatment provision, ensuring that psychotherapy is offered as prescribed in treatment plans. |
711.93(a)(7) LICENSURE Follow-up Information
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:
(7) Follow-up information.
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Observations
Based on a review of eight client records, the facility failed to document follow-up on discharged clients in one of two client records reviewed.
Findings:
Eight client records were reviewed on December 16, 2008. Follow-up was required for two client records. The facility failed to document follow-up for one of two client records, #7.
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Plan of Correction
Both the facility director and senior therapist will work together to train the new employee in the proper follow-up procedure of clients who leave the Outreach program. During the first three months of this counselor's employment at Outreach, all paperwork will be inspected by the senior therapist before being filed. Thereafter, the senior therapist will regularly monitor this counselor's paperwork in weekly administrative supervision. In addition, the division director, facility director and senior therapist will use the newly designed "chart log" when monitoring treatment service provision; all clinical charts will be monitored. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
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:
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Observations
Based on a review of eight client records, the facility failed to include within the informed and voluntary consent forms the right for clients to verbally revoke the consent.
Findings:
Eight client records were reviewed on December 16, 2008. Informed and voluntary consent forms were required in five client records. The consent for release of information form only indicated the client could revoke the consent in writing in four of five client records, #1, 2, 4 and 5.
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Plan of Correction
Changes were made to the most recent versions of the informed and voluntary consent forms to allow for verbal revocation of consent. Upon inspection, the facility director found that a counselor had older versions of consents stored in her office. All older versions will be located and destroyed. The most recent consent forms, which permit verbal revocation, will be given to every Outreach employee by the Facility Director by January 31, 2009. The senior therapist will regularly monitor the new counselor's paperwork in weekly administrative supervision to ensure that the correct consent form is used. The facility director will oversee the senior therapist's paperwork to ensure the correct consent is being used. |
711.93(c)(2)(ii) LICENSURE Specific Info. Disclosed
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:
(ii) The specific information disclosed.
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Observations
Based on a review of eight client records, the facility failed to obtain an informed and voluntary consent from the client in two of five client records.
Findings:
Eight client records were reviewed on December 16, 2008. Informed and voluntary consents were required in five client records. The specific information to be disclosed to the Social Security Administration exceeded that allowed under the limitations imposed by 4 Pa. Code 255.5 in client record #2. The information to be disclosed included "all records regarding my treatment and outpatient care for my impairment." The specific information to be disclosed to the Connecticut Court exceeded that allowed under the limitations imposed by 4 Pa. Code 255.5 in client record #4. The specific information to be disclose included "recommendations".
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Plan of Correction
All Outreach clinical staff will be trained by the division director in the limits of confidentiality when communicating with outside sources. This training will stress the importance of: 1) not providing more information than is permitted by 4 Pa. Code 255.5, 2) communicating the limits of disclosure to the patient, and 3) using Outreach's informed and voluntary consent forms. The senior therapist will monitor the new counselor's paperwork in weekly administrative supervision and the facility director will oversee the senior therapist's paperwork. The new counselor is also expected to attend a formal Confidentiality Training within the first 6 months of her employment. |