INITIAL COMMENTS
|
This report is a result of an on-site follow-up inspection to the initial on-site licensure inspection conducted on February 1 - 2, 2010 by staff from the Division of Drug and Alcohol Program Licensure.
The follow-up inspection was conducted on June 18, 2010 by staff from the Division of Drug and Alcohol Program Licensure.
Based on the findings of the on-site follow-up 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 July 22, 2010.
|
Plan of Correction
|
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Due to the original completion date to be in compliance regarding this deficiency it can not be re-evaluated until the next licensing inspection.
Please resubmit the original plan of correction date, for the date of completion.
|
Plan of Correction
The therapist will receive the required 25 hours of training. She will receive trainings @ BHTEN as well as the WES Institute to insure that she receives the required # of hours for the training year. A higher priority will be placed on insuring that the clinicians receive training during the first 6 months of the year. The WES Institute which is held in August for one week should adequately address any additional training hours that are needed. The Program Director of designee will monitor for compliance. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation in one of one client records.
The findings include:
Fifteen client records were reviewed on June 18, 2010.
One client record required documentation of a psychosocial evaluation.
The facility did not document a psychosocial evaluation in client record # 11.
The facility's policy titled "Comprehensive Bio-Psychosocial History" states:
" WES will ensure that a comprehensive biopsychosocial evaluation is developed on each consumer. The evaluation must provide a composite picture of the individual in relation to the data collected and must identify possible causes leading to the consumer ' s current situation. The consumer ' s assigned program therapist must complete the biopsychosocial evaluation within 30 days following the consumer ' s admission and registration process. "
Client # 11 was admitted to the program on 3/18/10.
The comprehensive treatment plan was documented on 3/18/10.
Client # 11 was an active client at the time of review on 6/18/10.
A treatment plan update was not documented for client # 11 at the time of review on 6/18/10.
|
Plan of Correction
Weekly chart reviews will occur during individual clinical supervision to insure that all client records are complete with psycho social assessments and treatment plans. Peer chart reviews will also occur during weekly treatment team meetings to insure compliance. All staff will be re-trained on policies and procedures for psycho social assessments and treatment plans. The program director or designee will monitor for compliance. |
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.
|
Observations
Based on the review of client records, the facility failed to document a treatment plan update in one of one client records.
The findings include:
Fifteen client records were reviewed on June 18, 2010.
One client record required documentation of a treatment plan update.
The facility did not document a treatment plan update in client record # 11.
The facility's policy titled "Treatment and Rehabilitation Plan" states:
" The Preliminary treatment plan will be completed within fifteen (15) days of admission; The Comprehensive Treatment plan will be completed within thirty (30) days of admission; Treatment plan updates occur every (60) days thereafter. "
Client # 11 was admitted to the program on 3/18/10.
The comprehensive treatment plan was documented on 3/18/10.
At the time of review on 6/18/10 client # 11 was an active client in the program; however, to date the treatment plan update had not been documented.
|
Plan of Correction
All treatment plans will be updated at least every 60 days. Staff will be counseled and retrained on treatment plan policies and procedures to insure compliance. Chart reviews will occur during individual clinical supervision as well as peer chart reviews during weekly treatment team meetings. Facility Director or designee will monitor for 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
Due to the original completion date to be in compliance regarding this deficiency it can not be re-evaluated until the next licensing inspection.
Please resubmit the original plan of correction date, for the date of completion.
|
Plan of Correction
The system will not allow me to put in a date prior to this inspection; therefore I am submitting the date above date as our completion date. |
709.93(a)(11) 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:
(11) Follow-up information.
|
Observations
Based on the review of client records, the facility failed to document follow-up information in one of one record as required.
The findings include:
Fifteen client records were reviewed on June 18, 2010.
One client record required documentation of follow-up information.
The facility did not document follow-up information within 7 days from the date of discharge, as stated in their policy manual, in client record # 3.
The facility's policy titled "Follow-Up" states:
Follow-up will occur on clients who successfully complete treatment within 7 days.
Clients terminated and not referred will be followed up in 30 days.
Client # 3 was admitted to the program on 8/13/09 and "successfully discharged" on 6/3/10.
Follow-up was not documented at the time of review on 6/18/10.
|
Plan of Correction
A follow up contact will be documented on all clients upon discharge. Staff will receive training on documentation protocol. The Facility Director or designee will monitor for compliance. |