Observations
Based on a review of client records and clinical documentation, the facility failed to document an evaluative psychosocial assessment in twelve of twelve records reviewed.The findings include:Twelve client records were reviewed for an evaluative psychosocial assessment on September 4 -5, 2013. The facility failed to document an evaluative psychosocial assessment in twelve of twelve records reviewed, client record # 1, 2, 3, 4, 6, 7, 9, 10, 13, 14, 15, and 16.Client # 1 was admitted to the program on 7/2/13. The psychosocial evaluation was documented on 7/15/13 but did not include an assessment of the client's assets/strengths, support systems, and coping mechanisms. Client # 2 was admitted to the program on 7/23/13. The psychosocial evaluation was documented on 8/20/13 but did not include an assessment of the client's assets/strengths, support systems, problems/needs, and negative factors. Client # 3 was admitted to the program on 7/16/13. The psychosocial evaluation was documented on 7/29/13 but did not include an assessment of the client's attitude toward treatment, assets/strengths, support systems, and coping mechanisms. Client # 4 was admitted to the program on 7/25/13. The psychosocial evaluation was documented on 8/5/13 but did not include an assessment of the client's assets/strengths, support systems, and coping mechanisms. Client # 6 was admitted to the program on 7/19/13. The psychosocial evaluation was documented on 8/5/13 but did not include an assessment of the client's assets/strengths, support systems, and coping mechanisms, problems/needs, and negative factors. Client # 7 was admitted to the program on 7/24/13. The psychosocial evaluation was documented on 8/12/13 but did not include an assessment of the client's coping mechanisms.Client # 9 was admitted to the program on 5/24/13. The psychosocial evaluation was documented on 6/10/13 but did not include an assessment of the client's assets/strengths, support systems, and coping mechanisms. Client # 10 was admitted to the program on 5/17/13. The psychosocial evaluation was documented on 5/28/13 but did not include an assessment of the client's assets/strengths, support systems, and coping mechanisms, problems/needs, and negative factors. Client # 13 was admitted to the program on 7/24/13. The psychosocial evaluation was documented on 6/10/13 but did not include an assessment of the client's assets/strengths, support systems, and coping mechanisms, problems/needs, and negative factors. In addition, the evaluation failed to include the client's attitude toward treatment and the counselors conclusion and impressions.Client # 14 was admitted to the program on 4/25/13. The psychosocial evaluation was documented on 5/23/13 but did not include an assessment of the client's assets/strengths, support systems, and coping mechanisms, problems/needs, and negative factors. In addition, the evaluation failed to include the client's attitude toward treatment and the counselors conclusion and impressions.Client # 15 was admitted to the program on 4/24/13. The psychosocial evaluation was documented on 5/20/13 but did not include an assessment of the client's assets/strengths, support systems, and coping mechanisms, problems/needs, and negative factors. Client # 16 was admitted to the program on 4/22/13. The psychosocial evaluation was documented on 5/14/13 but did not include an assessment of the client's assets/strengths, support systems, and coping mechanisms, problems/needs, and negative factors. The Facility Director confirmed the findings.
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Plan of Correction
The facility director will hold-in-service trainings to continue to address the need for comprehensive, individualized and strength based assessments. The trainings will be concentrated on staff development, and the need to provide clear descriptions or assessment of the necessity of treatment. The comprehensive assessment process should reflect engagement with the client, while building a relaxed rapport with him or her and address any immediate problems or crises that may present. It should individualize treatment-based factors known to have an effect on service outcomes (spirituality, culture, gender, strengths, experience of trauma, co-occurring conditions). It should promote hope and strengths, abilities, preferences, needs, and challenges that impact the client's hopes and dreams (goals). In addition, CBH and state OP/IOP standards will guide the trainings. The program director will also follow-up with clinicians' progress during weekly or bi-weekly individual supervisions in order to ensure assessment correction and that training's information is being implemented. The facility director is also revising intake and assessment forms in order to better reflect intake and assessment forms. These new forms are expected to launch by 10/31/2013.
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Observations
Based on an interview with the Facility Director, the facility failed to obtain a current, signed provider agreement with the Department of Public Welfare.The findings include:A copy of the Department of Public Welfare provider agreement was requested on September 4, 2013, as the facility receives reimbursement from medical assistance for drug and alcohol treatment services. The Facility Director confirmed during an interview that the facility did not currently have a provider agreement with the Department of Public Welfare. However, the facility did apply for the provider agreement and is currently awaiting a response from the Department of Public Welfare. Eleven client records requiring the physician's signature were reviewed as per 55 Pa. Code Part III. Although the facility did not have the provider agreement the facility documented the physician's signature in eleven of eleven client records reviewed as per 55 Pa. Code.The Facility Director confirmed the findings.
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Plan of Correction
The facility director submitted the provider enrollment application to DPW with all necessary attachments effective June 14 in order to obtain the provider agreement. On September 20, 2013 DPW issued a new provider agreement and number. |