INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 8, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Little Creek Outpatient Services LLC, 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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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to document an annual written individual staff performance evaluation in 2 of 3 applicable personnel records.
Employee #2 was hired on 7/22/2015 as the Clinical Supervisor and was still in that position. There was no annual written individual staff performance evaluation documented for the employee since the previous licensing inspection.
Employee #5 was hired 6/17/2015 as a Counselor Assistant and was still in that position. There was no annual written individual staff performance evaluation documented for the employee since the previous licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Annual Performance Evaluations are typically performed at least once per year for any and all staff, and are accompanied by a performance-based pay increase. Ongoing performance monitoring of Clinical Staff was reflected in supervision notes. Moving forward, all employee performance evaluations will be performed on all Staff at least once per year. A written, objective evaluation that assesses 10 performance areas will be utilized. Each staff member will meet with their direct supervisor and the Clinical Director to review this evaluation.
These changes were put in place, effective 10/2/17. Annual Performance Evaluations for Employee #2 and Employee #5, occurred on 10/10/17.
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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 client records, the facility failed to include the type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan in six of seven applicable records reviewed.
Client #1 was admitted on 1/21/17 and was discharged on 8/31/17.
Client #3 was admitted on 5/4/17 and was discharged on 7/14/17.
Client #4 was admitted on 4/6/17 and was discharged on 8/19/17.
Client #5 was admitted on 4/11/17 and was still active at the time of the inspection.
Client #6 was admitted on 5/6/17 and was still active at the time of the inspection.
Client #7 was admitted on 3/23/17 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plan formats were reviewed and edited on 10/2/17 to include the specific type and frequency of interventions used as part of clients' individualized treatment plans. Instead of notating just the assignment, objective, or method of service being used, the specific type and frequency of each service is not documented to provide an objective measure for progress in achieving the stated treatment goal.
Clinical Director discussed these changes were discussed with Counselors at a Staff Meeting 9/28/17, and the edits to electronic treatment plan formats were made by the lead Clinician at LCOPS on 10/2/17. |
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.
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Observations
Based on a review of client records, the facility failed to provied a complete client record in three of seven records reviewed.
Client #1 was admitted to treatment on 1/21/2017 and was discharged on 8/31/2017. There was no case consultation notes documented in the record.
Client #2 was admitted to treatment on 7/27/2017 and was discharged on 8/7/2017. There was no case consultation notes documented in the record.
Client #4 was admitted to treatment on 4/6/2017 and was discharged on 8/19/2017. There was no case consultation notes documented in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 10/2/17, Little Creek Outpatient Services implemented a policy requiring all client charts to have at least one case consultation note during the duration of their treatment. This policy was amended by the Clinical Director and reviewed with all clinical staff on 9/28/17. It is the responsibility of the Clinical Director to review charts on a monthly basis to ensure all cases are receiving a case consultation by the treatment team . |