INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 17, 2012 through July 19, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Bgi of Brandywine Inc 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, and a review of the Staffing Requirements Facility Summary Report, the facility failed to ensure that each counselor met the qualification for the position of counselor.
The findings include:
On July 17, 2012, nine personnel records were reviewed for documentation of the qualifications for the position of counselor. The facility failed to ensure that each counselor met the qualifications for the position of counselor, specifically employee # 10.
Employee # 10 was hired as a counselor on 6/12/12.
Employee # 10 has a qualifying Bachelor's degree; however, the reviewed documentation did not indicate 1 year of clinical experience.
During the inspection and at the exit interview on July 19, 2012 a conversation was held with the Human Resource Director. The Human Resource Director did not dispute the findings.
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Plan of Correction
Employeoe # 10 was reclassified as a Counselor Assistant as of 7/19/2012.
HR Coordinator will be responsible for properly classifying new hires. As of 10/1/2012, ongoing compliance will be assured by the HR Coordinator who will pull all Counselors/Counselor Assistants HR files on a quarterly basis and review for accuracy.
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the facility failed to document close and direct supervision of counselor assistants.
The findings include:
On July 17, 2012, two counselor assistants personnel records were reviewed for documentation of supervision. The facility failed to ensure that direct and close supervision were documented, specifically employee # 11 and 12.
Employee # 11 was hired as a counselor assistant on 11/13/11. Employee # 11 has a high school diploma; therefore was required to counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first three months. The facility failed to document weekly notes and/or verify that direct observation occurred.
Employee # 12 was hired as counselor assistant on 2/13/12. Employee # 12 has a qualifying Bachelor's degree; however did not have 1 year of clinical experience; therefore was required to counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment. The facility failed to document weekly notes and/or verify that direct observation occurred.
During the inspection and at the exit interview on July 19, 2012 a conversation was held with the clinical supervisor/lead counselor. The clinical supervisor/lead counselor confirmed the findings.
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Plan of Correction
Executive Director held in-service with Clinical Director 7/20/2012 to assure proper understanding of this standard and associated documentation.
As of 8/6/2012, Clinical Director is responsible for proper documentation related to Counselor Assistant Supervision. A schedule has been set up that preplans all required supervision to assure it is completed.
The Executive Director will review said notes on a quarterly basis to assure compliance. |
705.10 (a) (1) (ii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on observation during a physical plant inspection, the facility failed to maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
The findings include:
On July 19, 2012 at approximately 9:30 AM a physical plant inspection was conducted.
It was observed that the facility did not have a minimum of two exits on every floor, in particular the attic. The facility was utilizing the attic for storage and is therefore required to have a minimum of two exits that are separated by a minimum distance of 15 feet.
Based on a conversation with the Director of Maintenance and observation, the facility was storing bags and boxes of holiday decorations, such as Halloween and Christmas decorations. In addition, it was observed that the facility was storing, administrative records, financial records, and old client records in the attic.
The Director of Maintenance confirmed the findings.
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Plan of Correction
All charts that are housed in the Attic will be archived and moved to Iron Mountain for storage.
When this is completed, this area will be closed and not used for any purposes.
Plant operations Supervisor will be resonsible for this task. Target date for completion 11/1/2012. |
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 and a review of the facility's policy and procedures manual, the facility failed to document a psychosocial evaluation in accordance with facility policy and procedures.
The findings include:
The facility policy states: "After the Psychosocial Assessment is completed, the Primary Counselor will complete the Diagnostic Summary, as well, by 5th treatment episode. The Diagnostic Summary is designed to be an evaluative document rather than a repeat of client history."
On July 17, 2012, seven client records requiring documentation of a psychosocial evaluation were reviewed. The facility failed to document an evaluative psychosocial in accordance with facility policy in five of seven records reviewed, # 4, 6, 7, 8, and 11.
Client # 4 was admitted to the program on 7/10/12. The facility documented a psychosocial evaluation on 7/6/12; however, the "Diagnostic Summary" was not evaluative and was a repeat of the client history.
Client # 6 was admitted to the program on 5/31/12 and discharged on 6/7/12.
A psychosocial evaluation was due by the 5th treatment episode, or by 6/5/12. However, the facility failed to document a psychosocial evaluation at the time of review on 7/17/12.
Client # 7 was admitted to the program on 5/16/12. The facility documented a psychosocial evaluation on 5/16/12; however, the "Diagnostic Summary" was not evaluative and was a repeat of the client history. In addition, the counselor failed to include the client's attitude toward treatment and provide a clinical conclusion/impression.
Client # 8 was admitted to the program on 5/9/12. The facility documented a psychosocial evaluation on 5/14/12; however, the "Diagnostic Summary" was not evaluative and was a repeat of the client history.
Client # 11 was admitted to the program on 7/9/12.
A psychosocial evaluation was due by the 5th treatment episode, or by 7/14/12. However, the facility failed to document a psychosocial evaluation at the time of review on 7/17/12.
The facility did not dispute the findings.
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Plan of Correction
An in-service was held 9/6/2012 by the Clinical Director retraining staff on a proper Biopsychosocial Assessment. As of 10/1/2012, compliance of this standard will be done by the Clinical Director doing random quarterly audits of each counselor or counselor assistant. Feedback will be documented in supervision and/or an EIP (Employee Improvement Plan) where applicable. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. 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:
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Observations
Based on a review of client records, the facility failed to document individualized treatment and rehabilitation plans in seven out of seven records reviewed.
The findings include:
On July 18, 2012, seven client records requiring documentation of individualized treatment plans were reviewed. The facility failed to individualize the treatment and rehabilitation plans, as they were nearly identical in seven of seven records, # 4, 6, 7, 8, 9, 10, and 11.
The treatment plans of client # 4, 7, 8, 9, 10, and 11 documented the following:
Action Steps:
1. (Client) will review his past relapse cycles. Identify the events, feelings, and behaviors that lead up to the relapse. What contributed to the relapse and what did you learn to prevent future relapse?
2. (Client) will make a list of goals he has for himself that he was not able to do while active in his addiction.
3. (Client) will review Step 1. Discuss the powerlessness and unmanageability of addiction.
4. (Client) will make a list of 20 consequences of his addiction, and then write/express what they plan on doing differently this time around to promote your recovery and stay clean. Have you begun to make those changes yet?.....
In addition, client # 4 and 10's treatment plans were not signed and dated by the primary counselor nor were they countersigned and dated by the supervisory counselor.
Furthermore, the facility failed to document an individual treatment plan for client # 6.
Client # 6 was admitted to the program on 5/31/12 and discharged on 6/12/12.
According to facility policy treatment plans are to be documented within 5 days, or by 6/5/12 for client # 6.
The facility did not dispute the findings.
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Plan of Correction
An in-service was held 9/6/2012 by the Clinical Director retraining staff on a proper Individualized Treatment Plans. As of 10/1/2012, compliance of this standard will be done by the Clinical Director doing random quarterly audits of each counselor or counselor assistant. Feedback will be documented in supervision and/or an EIP (Employee Improvement Plan) where applicable. |
709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan.
The findings include:
On July 18, 2012, seven client records were reviewed to ensure that counseling services were provided according to plan.
The facility failed to ensure and provide counseling services as prescribed in five of seven, client records # 4, 8, 9, 10, and 11.
Client # 4 was admitted to the program on 7/10/12.
The individual treatment plan in client record # 4 dated 7/10/12 prescribed individual sessions 1-2 times per week; however the facility failed to assure and document individual counseling sessions in accordance with the prescribed treatment plan.
Client # 8 was admitted to the program on 5/9/12.
The individual treatment plan in client record # 8 dated 5/18/12 prescribed individual sessions 1-2 times per week; however the facility failed to assure and document individual counseling sessions in accordance with the prescribed treatment plan.
Client # 9 was admitted to the program on 6/21/12.
The individual treatment plan in client record # 9 dated 6/21/12 prescribed individual sessions 1-2 times per week; however the facility failed to assure and document individual counseling sessions in accordance with the prescribed treatment plan.
Client # 10 was admitted to the program on 7/2/12.
The individual treatment plan in client record # 10 was not dated; however the treatment plan documented individual sessions 1-2 times per week. The facility failed to assure and document individual counseling sessions in accordance with the prescribed treatment plan.
Client # 11 was admitted to the program on 7/9/12.
The individual treatment plan in client record # 11 dated 7/9/12 prescribed individual sessions 1-2 times per week; however the facility failed to assure and document individual counseling sessions in accordance with the prescribed treatment plan.
The facility did not dispute the findings.
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Plan of Correction
An in-service was held 9/6/2012 by the Clinical Director retraining staff the importance of following treatment plan action items, specifically frequency of individual sessions. As of 10/1/2012, compliance of this standard will be done by the Clinical Director doing random quarterly audits of each counselor or counselor assistant. Feedback will be documented in supervision and/or an EIP (Employee Improvement Plan) where applicable. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to ensure and document that individual counseling was provided at least twice weekly.
The findings include:
On July 18, 2012, seven client records requiring documentation of individual counseling at least twice weekly were reviewed. The facility failed to ensure and document individual counseling at least twice weekly, in six of eight client records, # 4, 6, 8, 9, 10, and 11.
Client # 4 was admitted to the program on 7/10/12.
Individual counseling is required at least twice weekly; however at the time of review on 7/18/12 the facility failed to ensure that client # 4 received individual counseling at least twice weekly.
Client # 6 was admitted to the program on 5/31/12.
Individual counseling is required at least twice weekly; however at the time of review on 7/18/12 the facility failed to ensure that client # 6 received individual counseling at least twice weekly.
Client # 8 was admitted to the program on 5/9/12.
Individual counseling is required at least twice weekly; however at the time of review on 7/18/12 the facility failed to ensure that client # 8 received individual counseling at least twice weekly.
Client # 9 was admitted to the program on 6/21/12.
Individual counseling is required at least twice weekly; however at the time of review on 7/18/12 the facility failed to ensure that client # 9 received individual counseling at least twice weekly.
Client # 10 was admitted to the program on 7/2/12.
Individual counseling is required at least twice weekly; however at the time of review on 7/18/12 the facility failed to ensure that client # 10 received individual counseling at least twice weekly.
Client # 11 was admitted to the program on 7/9/12.
Individual counseling is required at least twice weekly; however at the time of review on 7/18/12 the facility failed to ensure that client # 11 received individual counseling at least twice weekly.
The facility did not dispute the findings.
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Plan of Correction
An in-service was held 9/6/2012 by the Clinical Director retraining partial hospitalization staff on the standard related to each partial patient requiring 2 individuals per week. As of 10/1/2012, compliance of this standard will be done by the Clinical Director doing random quarterly audits of each partial hospitalization counselor or counselor assistant. Feedback will be documented in supervision and/or an EIP (Employee Improvement Plan) where applicable. |
709.83(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary in two of three client records.
The findings include:
On July 17, 2012, three client records requiring documentation of a discharge summary were reviewed. Within one week after discharge, there should be entered into the client's case record a discharge summary describing the reasons for treatment, services offered, response to treatment and client's status or condition upon discharge The facility failed to document a discharge summary in two of three records reviewed, specifically # 6, and 7.
Client # 6 was admitted to the program on 5/31/12 and discharged on 6/7/12.
There was no documented discharge summary in client record # 6 at the time of review on 7/17/12.
Client # 7 was admitted to the program on 5/16/12 and discharged on 6/7/12.
There was no documented discharge summary in client record # 7 at the time of review on 7/17/12.
The facility did not dispute the findings.
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Plan of Correction
An in-service was held 9/6/2012 by the Clinical Director retraining staff on the standard related to the timeliness of a Discharge Summary. As of 10/1/2012, compliance of this standard will be done by the Medical Records Director and Clinical Director. All discharged charts are reviewed by Medical Records and information related to deficiencies will be communicated to the Clinical Director on a daily basis. Clinical Director will address all issues timely and will be reflective in supervision notes and/or an EIP (Employee Improvement Plan) where applicable. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records and clinical documentation, the facility failed to obtain an informed and voluntary consent in client record # 14.
The findings include:
On July 19, 2012, twenty-one client records requiring documentation of an informed and voluntary consent were reviewed to ensure compliance with 28 Pa. Code 709.28 and 42 CFR Part II subpart C subsection 2.31 (b). The facility failed to adhere to the requirements specified at 4 Pa. Code in one of twenty-one records, specifically client record # 14.
28 Pa. Code 709.28 states:
The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
(2) Specific information disclosed.
(3) Purpose of disclosure.
(4) Dated signature of client or guardian.
(5) Dated signature of witness.
(6) Expiration date of the consent.
Client # 14 was admitted to the program on 7/5/12.
Client # 14 signed but did not date three "Authorization for Release of Information" forms.
Form # 1 signed by the client was documented to a government agency. The form failed to document the specific information disclosed, the purpose of the disclosure, a dated signature of the client, and a dated witness signature.
Form # 2 signed by the client did not indicate the name of the person, agency or organization to whom the disclosure was made, the specific information disclosed, the purpose of the disclosure, a dated signature of the client, and a dated witness signature.
Form # 3 signed by the client did not indicate the name of the person, agency or organization to whom the disclosure was made, the specific information disclosed, the purpose of the disclosure, a dated signature of the client, and a dated witness signature.
The facility did not dispute the findings.
Based on a review of client records and clinical documentation, the facility failed to obtain an informed and voluntary consent in client record # 10.
The findings include:
On July 19, 2012, one client record requiring documentation of an informed and voluntary consent to an employer were reviewed to ensure compliance with 4 Pa. Code 255.5. The facility failed to adhere to the requirements specified at 4 Pa. Code in one of one record reviewed, specifically client record # 10.
4 Pa. Code 255.5 (a)(6) states: Projects may disclose with clients consent, in writing, the information to employers of a client to further the client ' s rehabilitation ...Such information shall be limited to whether the client has or is receiving treatment with the project.
Client # 10 was admitted to the program on 7/2/12.
On 7/9/12 client # 10 and a witness signed and dated an "Authorization for Release of Information" to client # 10's employer. The Authorization for Release of Information documented the "reason for disclosure includes diagnosis, prognosis, return to work date."
The "Authorization for Release of Information" form did not comply with 4 Pa. Code 255.5(a)(6).
In addition, on July 6, 2012 the Physician Assistant faxed a letter to the client's employer.
The letter stated: I am writing this letter to serve as documentation that your employee, is currently sill admitted to our inpatient facility. While inpatient, from 5/29/12 to 8/2/12, patient is unable to work at all due to admission into 24 hour level of care at an inpatient, residential facility. The following information was requested from us:
1.Date Treatment Began : 5/29/12
2.Diagnosis: Alcohol Dependence (303.00)
3.Prognosis: Excellent (Fully compliant with treatment)
4.Exact Date Can Return to Work: Discharging from our facility on 8/2/12, may return to work full time, without any restrictions or limitations, on 8/3/12.
Please let out facility know if any additional information is required.
The facility did not dispute findings.
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Plan of Correction
By 910/2012, An in-service will be held by all Leadership Staff who supervise staff who have responsibilities of completing and executing Voluntary Consent forms will conduct and in-service to retrain on proper completion of this form. As of 10/1/2012, compliance of this standard will be done by each corresponding Department Director doing random weekly audits Feedback will be documented in supervision and/or an EIP (Employee Improvement Plan) where applicable.
All active charts will be reviewed by department supervisors by 9/14/2012 to assure corrections are made to any deficient consents that exist on current clients. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation.
The findings include:
On July 17, 2012, seven client records requiring documentation of a psychosocial evaluation were reviewed. The facility failed to document a psychosocial evaluation in five of seven records reviewed, # 1, 2, 3, 11, and 12.
Client # 1 was admitted to the program on 7/15/12. A psychosocial evaluation was due within 72 hours; however at the time of review on 7/17/12 the facility failed to document a psychosocial evaluation
Client # 2 was admitted to the program on 7/13/12. A psychosocial evaluation was due within 72 hours; however at the time of review on 7/17/12 the facility failed to document a psychosocial evaluation.
Client # 3 was admitted to the program on 7/14/12. A psychosocial evaluation was due within 72 hours; however at the time of review on 7/17/12 the facility failed to document a psychosocial evaluation.
Client # 11 was admitted to the program on 7/9/12. A psychosocial evaluation was due within 72 hours; however at the time of review on 7/17/12 the facility failed to document a psychosocial evaluation.
Client # 12 was admitted to the program on 6/25/12 and discharged on 6/29/12. A psychosocial evaluation was due within 72 hours; however the facility failed to document a psychosocial evaluation for client # 12.
The facility did not dispute the findings.
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Plan of Correction
An in-service was held 9/6/2012 by the Clinical Director retraining staff on a proper Biopsychosocial Assessment. As of 10/1/2012, compliance of this standard will be done by the Clinical Director doing random quarterly audits of each counselor or counselor assistant. Feedback will be documented in supervision and/or an EIP (Employee Improvement Plan) where applicable. |
709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary describing the client's reasons for treatment, the client's response to treatment and status or condition upon discharge.
The findings include:
On July 17, 2012, three client records requiring documentation of a discharge summary were reviewed. The facility failed to document a discharge summary describing the client's reasons for treatment, the client's response to treatment and status or condition upon discharge in three of three records reviewed, # 3, 12, and 13.
Client # 3 was admitted to the program on 7/14/12 and discharged on 7/18/12.
The facility documented a discharge summary on 7/18/12; however the discharge summary did not describe the client's reasons for treatment.
Client # 12 was admitted to the program on 6/25/12 and discharged on 6/29/12.
The facility documented a discharge summary on 6/29/12; however the discharge summary did not describe the client's status or condition upon discharge.
Client # 13 was admitted to the program on 3/22/12 and discharged on 3/23/12.
The facility documented a discharge summary on 3/23/12; however the discharge summary did not describe the client's status or condition upon discharge.
The facility did not dispute the findings.
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Plan of Correction
An in-service was held 9/6/2012 by the Clinical Director retraining staff on a proper Discharge Summary. As of 10/1/2012, compliance of this standard will be done by the Clinical Director doing random quarterly audits of each counselor or counselor assistant. Feedback will be documented in supervision and/or an EIP (Employee Improvement Plan) where applicable. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. 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 and a review of the facility's policy and procedures manual, the facility failed to document a psychosocial evaluation in accordance with facility policy and procedures.
The findings include:
The facility policy states: "After the Psychosocial Assessment is completed, the Primary Counselor will complete the Diagnostic Summary, as well, by 5th treatment episode. The Diagnostic Summary is designed to be an evaluative document rather than a repeat of client history."
On July 17, 2012, nine client records requiring documentation of a psychosocial evaluation were reviewed. The facility failed to document an evaluative psychosocial per policy in three of nine records reviewed, # 18, 20, and 21.
Client # 18 was admitted to the program on 6/22/12. A psychosocial evaluation was due by the 5th treatment episode; however at the time of review on 7/17/12 the facility failed to document a psychosocial evaluation
Client # 20 was admitted to the program on 7/2/12. A psychosocial evaluation was due by the 5th treatment episode; however at the time of review on 7/17/12 the facility failed to document a psychosocial evaluation.
Client # 21 was admitted to the program on 6/15/12. A psychosocial evaluation was due by the 5th treatment episode. The facility documented a psychosocial evaluation; however it did not have a completion date.
The facility did not dispute the findings.
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Plan of Correction
An in-service was held 9/6/2012 by the Clinical Director retraining staff on a Biopsychosocial Assessment, specifically the timeliness. As of 10/1/2012, compliance of this standard will be done by the Clinical Director doing random quarterly audits of each counselor or counselor assistant. Feedback will be documented in supervision and/or an EIP (Employee Improvement Plan) where applicable. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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 and a review of the facility's policy and procedures manual, the facility failed to document case consultation notes in accordance with facility policy and procedures.
The findings include:
The facility policy states: "For all clients requiring additional counseling during involvement with the program, the counselor will complete the case consultation note documenting the following information: client being reviewed, client number, date of review, staff attending (name, credentials and discipline), reason for review, discussion summary, disposition of the case, assessment/action plan, counselor signature, title and date. Every client will have a minimum of one case consult during the course of treatment. For clients in treatment longer than 90 days, their case will be reviewed a minimum of every 90 days."
On July 17, 2012, five client records requiring documentation of a case consultation were reviewed. The facility did not document a case consultation note in accordance with facility policy in three of five records, specifically # 22, 23, and 24.
Client # 22 was admitted to the program on 3/31/12. A case consultation was documented on 4/12/12; however the case consult was not reviewed with a multi-disciplinary team or one other clinician. The case consult identified the counselor, and did not identify representatives from the various client service components.
Client # 23 was admitted to the program on 3/24/12. A case consultation was documented on 4/13/12; however the case consult was not reviewed with a multi-disciplinary team or one other clinician. The case consult identified the counselor, and did not identify representatives from the various client service components.
Client # 24 was admitted to the program on 3/17/12 and "stepped down" on 4/14/12.
The facility failed to document a case consultation note during the course of treatment in accordance with facility policy.
The facility did not dispute the findings.
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Plan of Correction
An in-service was held 9/6/2012 by the Clinical Director retraining staff on a Case Consult. As of 10/1/2012, compliance of this standard will be done by the Clinical Director doing random quarterly audits of each counselor or counselor assistant. Feedback will be documented in supervision and/or an EIP (Employee Improvement Plan) where applicable. |