INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 27-28,2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Dolminis 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 November 24, 2008.
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Plan of Correction
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on the review of the agency fire drill log on October 27-28, 2008, the facility failed to ensure that fire drills were held and documented each month. One month of twelve months in the past year did not have a documented fire drill.FINDING: The facility failed to document a fire drill for August , 2008.
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Plan of Correction
The fire drill log will be monitored by the risk management leader who will ensure that fire drills are completed monthly and all drills are documented. To begin immediately. |
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 review of twelve client records on October 27-28, 2008, the facility failed to ensure that information to be released was specifically listed on the consent to release information forms in eleven of twelve client records where required. Consent to release information forms listed information that exceeded the limitations imposed at 4 Pa. Code Subsection 255.5(b) in releases made to third party payers and/or government agencies in two of twelve client records where required.FINDING: The "Other" option was checked off on the consent to release information forms without any further explanation of what would be released in client records # 1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 12. The information listed on the consent to release information forms in client records #5 and 7 was being sent to third party payers and government agencies and exceeded the limitations imposed at 4 Pa. Code Subsection 255.5(b).
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Plan of Correction
The "Other" option is being removed from the release forms and will only be added to the form if needed. If the "Other" option needs to be added, counselor will be required to document what information has been released. This will be monitored by the program director during monthly chart reviews and by clinical staff during monthly peer chart reviews. All staff will be required to attend a training on confidentiality and completion of release forms by 11-28-2008. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of twelve client records on October 27-28, 2008, the facility failed to document the type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plans in five of twelve client records where required.FINDING: The type and frequency of the treatment that was to be provided was not documented on the treatment plans in client records # 2, 3, 4, 7 and 12.
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Plan of Correction
The type and frequency of services was added to the new treatment plan that was implemented in early August. This section must be completed by the counselor and reviewed by the lead counselor when submitted for signature.
The documentation of type and frequency is monitored by the lead counselor when submitted for signature.
This issue was addressed and a POC implemented prior to receiving this citation
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of twelve client records on October 27 & 28, 2008, the facility failed to ensure that clients received the required counseling hours for each client in five of twelve client records where required. FINDING: Documentation did not support that clients consistently received a minimum of 2 and 1/2 hours of counseling per month, on average, in client records # 1, 2, 3, 5 and 12.
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Plan of Correction
Client #2
February=1 hours
March=1.75 hours
April=1.25
May=2.25 hours
Chart documents that client refused to attend all therapy and group sessions, sign treatment plans and behavioral contract. Client was involuntarily discharged on June 3, 2008 due to non-compliance with treatment.
Client #3
February=30 minutes
March=3.5 hours
April=2. 5
May=2.75 hours
June=1.75 hours
July=2.0 hours
Client left treatment AMA on July 23, 2008 after having privileges rescinded in early July.
Client #5
February=3.25 hours
March=3.25 hours
April=1.2 Chart documents Ct's child was in hospital in Pittsburgh which made it difficult for ct. to attend therapy during this month.
May=3.25 hours
June=3.25 hours
July=3.25 hours
August=3.25 hours
September=3.25 hours
October=3.25 hours
Client #12
February=2 hours
March=2.5 hours
April=3.75
May=2.75 hours
June=2.75 hours
July=2.75 hours
August=2.5 hours
September=2.5 hours
October=2.75 hours
As evidenced by the data above, client hours have increased and continue to increase as a result of the POC's that were implemented previously such as:
Counselors have increased their documentation of attempts at engaging clients in treatment, consistency with communicating expectations to clients regarding attendance, holding clients accountable for missing sessions and implementing treatment plans for clients who attendance has become a treatment issue. Program director continues to monitor client hours weekly by counselor.
This issue has been addressed and continues to be addressed. Results have been achieved.
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709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on the review of twelve client records on October 27-28, 2008, the facility failed to consistently comply with 55 Pa. Code Part III ( relating to the Medical Assistance Manual). The facility failed to document the physician's signature on treatment plans and/or treatment plan updates in three of nine client records where required.FINDING: The treatment plans and treatment plan updates were not signed in client records # 3, 4 and 12.
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Plan of Correction
During the audit at Foundations in June 2008, we were made aware that Medical Assistance regulations require treatment plans and treatment plan updates to be reviewed and signed by the physician.
This issue was addressed and a POC implemented at that time. All treatment plans and treatment plan updates have been reviewed and signed by the physician since.
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