INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 31 - September 1, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, WPIC Narcotic Addiction Treatment Program 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 September 30, 2010.
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Plan of Correction
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711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, administrative policies, and staff interviews, the facility failed to document an individual treatment and rehabilitation plan was developed with the client within 30 days of admission, as required per agency policy, in four out of seven client records.
The findings include:
Thirteen client records were reviewed on August 31 - September 1, 2010. Seven client records were reviewed for the individual treatment plan. Six client records were outside of the current review time frame. Per regulation, an individual treatment and rehabilitation plan shall be developed with a client. Per agency policy, an individual treatment plan will be developed with the client within 30 days of admission. The facility failed to document the completion of an individual treatment plan with the client within 30 days of admission in client records # 1, 2, 5 and 6.
Client # 1 was admitted into treatment on June 3, 2010. An individual treatment and rehabilitation plan was due to be completed no later than July 3, 2010. An individual treatment plan was completed with the client on August 3, 2010. The facility failed to document the completion of the treatment plan within 30 days of admission.
Client # 2 was admitted into treatment on August 17, 2009. An individual treatment and rehabilitation plan was due to be completed no later than September 16, 2009. An individual treatment plan was completed by the counselor on October 5, 2009. The treatment plan was not signed by the client. The facility failed to document the completion of the treatment plan within 30 days of admission.
Client # 5 was admitted into treatment on March 5, 2010. An individual treatment and rehabilitation plan was due to be completed no later than April 4, 2010. An individual treatment plan was completed with the client on August 17, 2010. The facility failed to document the completion of the treatment plan within 30 days of admission.
Client # 6 was admitted into treatment on March 8, 2010. An individual treatment and rehabilitation plan was due to be completed no later than April 7, 2010. An individual treatment plan was completed with the client on May 12, 2010. The facility failed to document the completion of the treatment plan within 30 days of admission.
The facility director and clinical supervisor were interviewed on September 1, 2010. Both confirmed that the agency policy requires the completion of a treatment plan within 30 days of admission. The clinical supervisor reviewed client records # 1, 2, 5 and 6 and confirmed the treatment plans were not completed within 30 days of admission.
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Plan of Correction
The Clinical Supervisor, during a clinical treatment meeting to be held by 10/1/2010, will review with clinical staff the necessity of documenting the completion of an individual treatment plan for each client within 30 days of their admission. Monitoring of completion will be conducted through quality assurance chart audits completed by the Clinical Supervisor. |
711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based on a review of client records, administrative policies and staff interviews, the facility failed to document follow up information within 7 days of discharge, per agency policy, in three of six client records.
The findings include:
Thirteen client records were reviewed on August 31 - September 1, 2010. Six client records were closed and required follow up information. Per regulation, there shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 28 Pa. Code Subsection 715.23 (relating to contents), the client record shall include follow-up information. Per agency policy, a follow up will be conducted with all clients within 7 days of discharge. The facility failed to document follow up information within 7 days of discharge in client records # 8, 9 and 11.
Client # 8 was admitted into treatment on May 27, 2009 and discharged on August 17, 2010. Follow up was due to be completed no later than August 24, 2010. The client record included a follow up consent form. The follow up consent form indicated a follow up occurred on August 5, 2010. The client record was still open on this date. Follow up is conducted after a client's record is closed. The facility failed to document a follow up with the client within 7 days of discharge, per agency policy.
Client # 9 was admitted into treatment on February 16, 2008 and discharged on June 9, 2010. Follow up was due to be completed no later than June 16, 2010. The client record included a follow up consent form. The follow up consent form indicated a follow up occurred on June 1, 2010. The client record was still open on this date. Follow up is conducted after a client's record is closed. The facility failed to document a follow up with the client within 7 days of discharge, per agency policy.
Client # 11 was admitted into treatment on June 28, 2006 and discharged on April 26, 2010. Follow up was due to be completed no later than May 3, 2010. The client record included a follow up consent form. The follow up consent form indicated a follow up occurred on April 23, 2010. The client record was still open on this date. Follow up is conducted after a client's record is closed. The facility failed to document a follow up with the client within 7 days of discharge, per agency policy.
The facility director and clinical supervisor were interviewed on September 1, 2010. Both confirmed the agency follow up policy is within 7 days of discharge for all clients. The clinical supervisor reviewed client records # 8, 9 and 11 and confirmed that follow ups were not conducted within 7 days of discharge.
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Plan of Correction
The Clinical Supervisor will conduct an in-service training, to include all clinical staff, to review the requirements of documenting follow up information within 7 days of discharge. The Clinical Supervisor will continue to enforce requirement during supervision sessions and will monitor compliance through quality assurance chart audits. The in-service will occur before October 1, 2010 |