INITIAL COMMENTS
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This report is a result of an on-site inspection to this newly licensed facility following the admission of its first client. The inspection was conducted on December 16, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of this on-site inspection, Mercy House of Meadville 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 January 1, 2010.
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Plan of Correction
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of the client records, the facility failed to provide a personal history in one of three records, and failed to provide a personal history that included detail in the areas of family history, legal history, employment/vocational history, education history and sexual history in one of three records. The findings include: Three client records were reviewed on December 16, 2009. Two of the three records did not include complete personal histories. Record #1 - The client was admitted on 12-10-09. The personal history was completed by the client but failed to include detail in the areas of family history, legal history, employment/vocational history, education history, sexual history. Questions included in each of these sections were completed with one or two word answers or were left blank resulting in an incomplete personal history.Record #2 - Client was admitted on 10-15-09. Per the agency policy, the personal history is to be completed at the intake. The intake occurred on 10-15-09. The personal history was not documented for this client. Progress notes were documented for individual sessions on 10-15-09, 10-22-09, 11-11-09, and 11-18-09. This confirms the client was involved with treatment sessions without a personal history. The client was discharged on 12-8-09. There is a progress note from the counselor dated on 12-15-09 confirming the client did not return the personal history form.The director confirmed, during an interview on December 16, 2009, that the personal history in client record # 1 did not include all required information and that the personal history was not completed in client record # 2.
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Plan of Correction
The facility director conducted a meeting with the staff on December 28, 2010 to discuss the personal history deficiency issue. It was agreed that comprehensive histories are a crucial component of treatment planning. In order to correct deficiencies several issues were addressed:
Plan of correction for record # 1
1). A signature line for was added to the history form on Dec 28, 2009. Signature will confirm that a staff member has reviewed the form in entirety. Any responses that are found to be inadequate will be discussed with the client and will be added to the history form to insure an adequate amount of information has been secured to insure an effective treatment protocol.
Plan of correction for Record # 2
2). Since the personal history form is lengthy, and may require several sessions for full information gathering, and mutual planning of interventions, the facility manual was amended to reflect that the history form must be completed and signed by therapist no later than the clients third visit, and that in the event that in the event that enough data can't be gathered to formulate a treatment plan, a preliminary treatment plan can be used. Staff members were advised of this change on December 28, 2009.
Ongoing compliance will be guaranteed by regular chart review of history forms by facility director or clinical supervisor.
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709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of the client records, the facility failed to provide group progress notes that included the data and the plan sections in two of three client records. The findings include: Three client records were reviewed on December 16, 2009. Three client records were required to include documentation of progress notes. Two of the three records did not include complete progress notes. Facility policy requires that the progress notes include data, assessment and plans relative to treatment. Record #1 - Client was admitted on 12-10-09. The group therapy progress notes dated 12-10-09, 12-14-09, and 12-15-09 did not include the data or the plan for those group sessions. Record #3 - Client was admitted on 10-8-09. The client was discharged on 11-24-09. The group therapy progress notes dated 10-12-09, 10-13-09, and 10-20-09 did not include the data or the plan for those group sessions. The director confirmed on December 16, 2009 that the group progress notes did not include the data and the plan sections.
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Plan of Correction
12/28/2009
The facility director conducted a meeting with the staff on December 28, 2009 to discuss the deficiency for progress notes that did not include topic, data, assessment and plan. Good progress notes insure treatment delivery and therapeutic direction. To correct the deficiency, a new form for progress group notes was made that includes space for group topic, data, assessment and plan. Staff was trained in the use of the new form.
Ongoing compliance will be guaranteed by regular chart review of history forms by facility director or clinical supervisor
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