INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the April 27, 2011 licensure renewal inspection. The follow-up inspection was conducted on November 14, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Home Nursing Agency Community Services 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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709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial assessment and/or failed to document a psychosocial assessment that included the client's composite picture, assets and strengths, and negative factors that could interfere with treatment.
The findings include:
On November 14, 2011, three Partial Hospitalization (P.H.) client records were reviewed for psychosocial evaluations. Two out of three client records lacked documentation of a clinical assessment, specifically client records # 9 and 11.
Client # 9 was admitted on June 7, 2011 and discharged on August 11, 2011. The psychosocial evaluation was completed on June 7, 2011 and did not include a clinical assessment of the client's composite picture, assets and strengths, and negative factors that could interfere with treatment.
Client # 11 was admitted on July 11, 2011 and discharged on July 28, 2011, as of the date of inspection, there was no documentation of a psychosocial evaluation.
On November 14, 2011 an interview was conducted with the clinical supervisor, which confirmed the psychosocial assessments were non-evaluative or missing.
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Plan of Correction
All intake counselors will complete a Clinical Assessment on all individuals that are admitted into the D&A program effective 12-1-11. The Clinical Services Manager and staff will complete monthly internal random chart audits that relect that Clincial Assessments are completed on everyone admitted. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document a medical history in accordance with facility policy.
The findings include:
On November 14, 2011, eight outpatient (O.P.) client records were reviewed for a medical history. Four out of eight client records lacked documentation of a medical history, specifically client records #3, 4, 5, and 6.
Facility policy titled Referral, Assessment & Intake Process: Clinical Number: 8020; states:
At the time of admission The scheduler will request individual (sic) to fill out the Family Medical History.
O.P. Client #4 was admitted on August 30, 2011, as of the date of inspection, there is no documentation of a medical history.
O.P. Client #3 was admitted on August 1, 2011, Client #3 was assessed on August 1, 2011. A medical history was completed; however it did not include documentation of the client's family medical history.
O.P. Client #5 was admitted on September 2, 2011, Client #5 was assessed on September 2, 2011. A medical history was completed; however it did not include documentation of the client's personal medical history and symptoms and illnesses.
O.P. Client #6 was admitted on September 8,2011, Client #6 was assessed on September 7, 2011. A medical history was completed; however it did not include documentation of the client's personal medical history and and family medical history.
On November 14, 2011 an interview was conducted with the clinical supervisor, which confirmed the medical histories were incomplete or missing.
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Plan of Correction
All Intake Counselors will ensure that a complete Medical History is completed at the time of admisson on everyone entering the D&A program by 12-1-11. The Clinical Services Manager will conduct a training on
11-28-11 to staff to ensure that this is completed completely and correctly.
Monthly random chart audits will be completed to ensure compliance with completion of the Medical History. |
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 a review of client records, the facility failed to document a psychosocial assessment and/or failed to document a psychosocial assessment that included the client's composite picture, problems and needs that could not be resolved through treatment, assets and strengths, support systems, preferred coping mechanisms, negative factors that could interfere with treatment, attitude towards treatment, and the counselors' conclusions/impressions.
The findings include:
On November 14, 2011, eight Outpatient (O.P.) client records were reviewed for psychosocial evaluations. Two of eight O.P. client records lacked documentation of a clinical assessment, specifically client records # 2 and 4. Four out of eight O.P. client records failed to document a psychosocial assessment that included the client's composite picture, problems and needs that could not be resolved through treatment, assets and strengths, support systems, preferred coping mechanisms, negative factors that could interfere with treatment, attitude towards treatment, and the counselors' conclusions/impressions, specifically records # 1, 6, 7, and 8.
Client # 1 was admitted on July 25, 2011. The psychosocial evaluation was completed on July 25, 2011 and did not include a clinical assessment of the client's support systems and the negative factors that can affect treatment.
Client # 2 was admitted on June 13, 2011. As of the date of inspection, there was no documentation of a psychosocial evaluation from the facility. Instead there was documentation of an clinical evaluation documented from another agency prior to the client entering treatment.
Client # 4 was admitted on August 30, 2011. As of the date of inspection, there was no documentation of a psychosocial evaluation from the facility. Instead there was documentation of an clinical evaluation documented from another agency prior to the client entering treatment.
Client # 6 was admitted on September 8, 2011. The psychosocial evaluation was completed on September 8, 2011 and did not include a composite picture of the client, a clinical assessment of the client's assets and strengths, support systems, coping mechanism, the negative factors that can affect treatment, and the counselor's conclusions and impressions.
Client # 7 was admitted on September 28, 2011. The psychosocial evaluation was completed on September 28, 2011 and did not include a clinical assessment of the client's assets and strengths, support systems, coping mechanism, the negative factors that can affect treatment, and the counselor's conclusions and impressions.
Client # 8 was admitted on September 23, 2011. The psychosocial evaluation was completed on September 23, 2011 and did not include a clinical assessment of the client's support systems, coping mechanism, the negative factors that can affect treatment, attitude towards treatment, and the counselor's conclusions and impressions.
On November 14, 2011 an interview was conducted with the clinical supervisor, which confirmed the psychosocial assessments were non-evaluative or missing.
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Plan of Correction
All Intake Counselors will complete a Psychosocial Assessment on all individauls that are admitted into the D&A program by 12-1-11. The Clinical Services Manager and D&A staff will complete mnthly internal random chart audits that reflect that Assessments that include a composite picture of the individual needs and problems is included in these assessments.
We no longer accept outside biopsychosocials as assessments and complete our own paperwork on everyone coming into the D&A program. |