INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 12-13, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Philadelphia Health management Corporation/Chances 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 the review of client records, the facility failed to notify a client, in writing, of a decision to involuntarily terminate the client's treatment.
The findings include:
On September 13, 2011, one client record requiring documentation of a termination letter notifying the client of a decision to involuntarily terminate their treatment was reviewed. There was no documentation that the facility notified the client in writing of the decision to involuntarily terminate treatment.
Client # 4 was admitted on 7/14/10 and discharged on 6/27/11. The discharge summary in client record # 4 stated the client was administratively discharged, but the client record did not contain a termination letter.
An interview with the facility director on September 13, 2011 confirmed the findings.
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Plan of Correction
By October 15th, Program Director will revise the policy that describes the documentation requirements for involuntary discharges. Program Director will also develop a form letter that will be mailed to clients to provide them with written notification of their discharge. This letter will include instructions on how to appeal the facility's decision to terminate their treatment if/when they want to return to the program. During the October 17th clinical team meeting, Program Director will review the policy and the form with the therapists. PHMC's Quality Management team will look for this letter when they conduct their quarterly chart audits, to ensure that the policy is being implemented. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to inform a client of the right to request reconsideration of the decision to terminate treatment.
The findings include:
On September 13, 2011, one client record requiring documentation of the client being given the opportunity to request reconsideration of the facility's decision to terminate treatment was reviewed, specifically, client record # 4. There was no documentation that the facility provided the client the opportunity to request reconsideration of the facility's decision to terminate treatment in client record # 4.
Client # 4 was admitted on 7/14/10 and discharged on 6/27/11. Client record # 4 did not include documentation of the right to request reconsideration.
An interview with the facility director on September 13, 2011 confirmed the findings.
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Plan of Correction
By October 15th, Program Director will revise the policy that describes the documentation requirements for involuntary discharges. Program Director will also develop a form letter that will be mailed to clients to provide them with written notification of their discharge. This letter will include instructions on how to appeal the facility's decision to terminate their treatment if/when they want to return to the program. During the October 17th clinical team meeting, Program Director will review the policy and the form with the therapists. PHMC's Quality Management team will look for this letter when they conduct their quarterly chart audits, to ensure that the policy is being implemented. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the review of client records, the facility failed to document treatment plan updates to include an assessment of the client's progress in five of five records.
The findings include:
On September 13, 2011, treatment plans updates in five client records were reviewed, specifically records # 1, 2, 6, 7 and 8. The facility did not document treatment plan updates to include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in records # 1, 2, 6, 7 and 8.
Client # 1 was admitted on 10/11/10. The treatment plan updates in client record # 1 dated 1/10/11, 2/9/11, 3/9/11, 4/8/11, 5/11/11 and 6/13/11 did not include an assessment of the client's progress.
Client # 2 was admitted on 11/15/10. The treatment plan updates in client record # 2 dated 1/15/11, 2/14/11, 3/14/11 and 4/8/11 did not include an assessment of the client's progress.
Client # 6 was admitted on 3/8/11. The treatment plan updates in client record # 6 dated 5/2/11, 6/2/11, 6/29/11 and 8/1/11 did not include an assessment of the client's progress.
Client # 7 was admitted on 2/17/11. The treatment plan updates in client record # 7 dated, 4/16/11, 5/16/11, 6/16/11 and 7/12/11 did not include an assessment of the client's progress.
Client # 8 was admitted on 4/11/11. The treatment plan updates in client record # 8 dated 2/11/11, 3/11, 4/8/11, 6/9/11 and 8/5/11 did not include an assessment of the client's progress.
An interview with the facility director on September 13, 2011 confirmed the findings.
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Plan of Correction
By November 15th, Program Director will meet with PHMC's Quality Management team to improve and expand the section of the treatment plan that prompts the therapists for their assessment of the client's progress. After the form has been revised, the Clinical Director will conduct a training with the staff to review the form and discuss how to effectively document client progress. Going forward, Clinical Director will also ensure that progress is properly documented prior to signing off on treatment plans. Finally, PHMC's Quality Management team will monitor that an assessment of client progress is included in every treatment plan when they conduct their quarterly chart audits, and any noted deficiency will be reported back to the Program and Clinical Directors so that they can address the problem with specific staff. |