INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 6 and 7, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Caron Treatment 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 and a plan of correction is due on February 29, 2008.
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Plan of Correction
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709.81(b)(3)(i) LICENSURE Intake and admission
709.81. 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 on February 6 and 7, 2008, the facility failed to document a completed medical history. Several questions in the personal medical history and symptoms/illnesses were answered "yes" by the client and were not further clarified in five of five records reviewed, #1, 4, 8, 11 and 12.
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Plan of Correction
Action Plan - The Director will train all clinical staff on the state standard for the completion of medical history during the intake and admission process. If a patient answers yes to a medical history question, the clinical staff will document this information in the Comments Section of our electronic database. Our IMS staff also added a promt in Sigmund which states "PLEASE EXPLAIN YES ANSWERS IN THE COMMENT SECTION". The Team Leader will monitor this during monthly chart reviews.
Complete Date 2/18/08
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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 on February 6 and 7, 2008, the facility failed to document a complete psychosocial evaluation in five of five records reviewed, #1, 4, 8, 11 and 12. Psychosocial evaluations did not include a clinical assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment or the client's attitude toward treatment. Psychosocial evaluations were historical with client stated/reported comments rather than the clinician's analysis of the collected information.
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Plan of Correction
Action Plan - The Director will train all clinical staff on the state standard for the completion of the psychosocial evaluation to include a clinical assessment of the client's problems/needs, assets, strengths, support systems, coping mechanisms, negative factors that may inhibit treatment or the client's attitude toward treatment. The clinical staff will also provide their analysis of the collected information. The Team Leader will monitor this during monthly chart reviews.
Complete date 2/18/08
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709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records on February 6 and 7, 2008, the facility failed to document treatment plan updates that included an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in four of five client records, #4, 8, 11 and 12. In addition, when goals were resolve no new goals were added.
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Plan of Correction
Action Plan - The Director will train all clinical staff on the state standard for the completion of Treatment Plan Updates. The Treatment Plan Updates will include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan. Also, add new goals when previous goals were resolved. The Team Leader will monitor this during monthly chart reviews.
Complete date 2/18/08
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709.83(a)(6) LICENSURE Client records
709.83. 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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records on February 6 and 7, 2008, the facility failed to document a complete aftercare plans in one of two client records reviewed, #11. The goals stated in the aftercare plan were not measurable and contained no specific time frame for completion.
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Plan of Correction
Action Plan - The Director will train all clinical staff on the state standard for the completion of Aftercare plans. The goals in the aftercare plan will be measurable and contain specific time frames for completion. The Team Leader will monitor this during monthly chart reviews.
Complete date 2/18/08
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709.83(a)(9) LICENSURE Client records
709.83. 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:
(9) Progress notes.
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Observations
Based on a review of client records on February 6 and 7, 2008, the facility failed to document completed progress notes in five of five client records, #1, 4, 8, 11 and 12. Individual progress notes failed to include an assessment based on the clinician's analysis of and conclusions regarding the client's current situation or status nor a specific plan indicating the direction of treatment, which may include an assignment or topic for the next session.
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Plan of Correction
Action Plan - The Director will train all clinical staff on the state standard for the completion of Individual Progress notes. The individual progress notes will include an assessment based on the clinician's analysis of and conclusions regarding the clients current situation or status with a specific plan indicating the direction of treatment which may include an assignment or topic for the next session. The Team Leader will monitor this during monthly chart reviews.
Complete date 2/18/08
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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 on February 6 and 7, 2008, the facility failed to document a completed medical history in four of five client records, #2, 3, 5 and 9. Medical histories contained questions answered "yes" by the client regarding their personal medical history and symptoms/illnesses. No further clarification was provided.
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Plan of Correction
Action Plan - The Director will train all clinical staff on the state standard for the completion of medical history during the intake and admission process. If a patient answers yes to a medical history question, the clinical staff will document this information in the Comments Section of our electronic database. IMS staf also added a prompt in Sigmund which states "PLEASE EXPLAIN YES ANSWERS IN THE COMMENT SECTION". The Team Leader will monitor this during monthly chart reviews.
Complete Date 2/18/08
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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 on February 6 and 7, 2008, the facility failed to document a complete psychosocial evaluation in four of four client records reviewed, #3, 5, 9 and 10. Psychosocial evaluations did not include a clinical analysis of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and the client's attitude toward treatment. Psychosocial evaluations were historical with client stated/reported comments rather than the clinician's analysis of the collected historical information. In addition, in client record #2 the facility used an old evaluation from the client's previous admission to the program.
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Plan of Correction
Action Plan - The Director will train all clinical staff on the state standard for the completion of the psychosocial evaluation to include a clinical assessment of the client's problems/needs, assets, strengths, support systems, coping mechanisms, negative factors that may inhibit treatment or the client's attitude toward treatment. The clinical staff will also provide their analysis of the collected information. The Team Leader will monitor this during monthly chart reviews.
Complete date 2/18/08
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records on February 6 and 7, 2008, the facility failed to document complete aftercare plans in two of two client records, #3 and 5. Aftercare plans did not include goals stated in terms of measurable criteria or with times frames for the client.
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Plan of Correction
Action Plan - The Director will train all clinical staff on the state standard for the completion of Aftercare plans. The goals in the aftercare plan will be measurable and contain specific time frames for completion. The Team Leader will monitor this during monthly chart reviews.
Complete date 2/18/08
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