INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 18, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHD Lower Merion Counseling Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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 the review of client records, the facility failed to obtain informed and voluntary consents to release information and/or a consent that adhered to 4 PA Code. 255.5 in five of eight client records reviewed.
The findings include:
4 PA Code. 255.5 subpart (b) stipulates the following:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4), (7), (3) of subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following: (1) Whether the client is or is not in treatment, (2) Client's prognosis, (3) The nature of the Project, (4) A brief description of the client's progress and (5) A short statement as the whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Eight client records were reviewed on July 18, 2013. Eight client records were required to have informed and voluntary consent forms. The facility released information that exceeded what was permissible to be released per 4 PA Code. 255.5 subpart (b) in five out of eight records reviewed.
Client #1 had a consent to release form dated May 30, 2013 documenting that they will give the probation/parole officer the following information:
1. Treatment/Aftercare plan
2. Treatment Summary
3. Discharge Summary
Client #2 had a consent to release form dated May 30, 2013 documenting that the facility will give the probation/parole officer the following information:
1. Psychological Evaluation
2. Psychiatric Evaluation
3. Treatment/Aftercare plan
4. Assessment/Evaluation summary
5. Neurological Evaluation
6. Treatment Summary
7. Discharge Summary
8. Biopsychosocial
9. Medical History/Evaluation
10. Social Worker Report
11. Court Records
12. Academic Records
13. Billing Information.
Client #3 had a consent to release form dated June 5, 2013 documenting that the facility will give the probation/parole officer the following information:
1. Psychological Evaluation
2. Treatment/Aftercare plan
3. Assessment/Evaluation summary
4. Treatment Summary
5. Medical History/Evaluation
6. Court Records
7. Academic Records
8. Billing Information.
In client record #4 there was a fax transmittal sheet that showed that a fax went out on March 13, 2013 to a government agency. Client record #4 didn't contain a consent to release information form for the government agency.
In client record #6 there was a fax transmittal sheet that showed that a fax went out on April 29, 2013 to a government agency. Client record #6 didn't contain a consent to release information form for the government agency.
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An interview with the facility director on July 18, 2013 confirmed the findings.
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Plan of Correction
A new release of information (ROI) form has been created for D&A clients that are specific to the five areas outlines under 4 PA Code. 255.5 subpart (b). This new form allows participants to clearly define what information is to be released and for what purpose. All staff will be trained, during supervision with the Acting Director and assistant director, in the month of August on how to properly complete a ROI for D&A clients. It will be stressed to each staff member, that there are only five agencies that are held to the 5 points under 4 PA Code. 255.5 subpart (b) and that these agencies are: Judges, Probation and Parole, Insurance agencies, health and or hospital plans and government agencies. It will further be explained that anybody else can get whatever the client deems appropriate to send out with the exception of employers that can only be told whether the client is or is not in treatment. This training will be documented in the August supervision notes by the Acting Director/Assistant Director and signed by both the staff member and Acting Director/Assistant Director.
New clients will begin using this form immediately. All current clients will complete the new releases at their next session and all staff will be trained in this procedure by 08/31/13.
It is the responsibility of the Director, Assistant Director, and Quality Control Specialist to ensure that this procedure is being followed |
709.91(b)(6) LICENSURE Intake and admission
709.91. 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, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in six of eight client records.
The findings include:
Eight client records were reviewed on July 18, 2013. Six of the eight were reviewed for psychosocial evaluations, #1, 2, 3, 4, 5 and 6.
The psychosocial evaluations in client records #1, 2, 3, 4, 5 and 6 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records #1, 2, 3, 4, 5 and 6 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluations in client records #1, 2, 3, 4, 5 and 6 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records #1, 2, 3, 4, 5 and 6 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluations in client records #1, 2, 3, 4, 5 and 6 did not include an evaluation of the counselor conclusions/impressions of the client.
An interview with the facility director on July 18, 2013, confirmed the findings.
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Plan of Correction
It was noted during the exit interview that the Assessment document contained questions about the client's assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment. However, the therapists are not conveying these points when completing the Assessment Summary. The Director/assistant director will discuss with all staff, during supervision, the proper way to complete the Assessment Summary to include their clinical impressions of the client's assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment.
All staff will be trained by 08/30/13.
It is the responsibility of the Director, Assistant Director, and Quality Control Specialist to ensure that all staff are including clinical impressions and are not simply copying the client's history to the Assessment Summary. The Director/assistant director and the staff member will sign the supervision note outlining this process. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to document individualized treatment and rehabilitation plan in five of eight client records.
The findings include:
Eight client records were reviewed on July 18, 2013. Individualized treatment and rehabilitation plans were required in six client records. The treatment and rehabilitation plans documented in client records # 1, 2, 3, 4 and 5 were identical. An interview with the facility director on July 18, 2013 confirmed the findings.
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Plan of Correction
LMCS will no longer use an initial/preliminary treatment plan for D&A clients. These plans were very basic templates that did not contain a lot of individualizations. Therefore, since treatment plans are completed at every Assessment, a comprehensive, individualized treatment plan will be used at Assessment for D&A clients which will be updated every 60 days. All staff will be informed of this policy change and trained by 08/30/13
It is the responsibility of the Director and Assistant Director to train each staff person on how to write a comprehensive treatment plan at Assessment. The Director, Assistant Director, and Quality Control Specialist will ensure that this policy is being followed through supervision and chart audits. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document a treatment and rehabilitation plan update at least every 60 days in three of eight records.
The findings include:
Eight client records were reviewed on July 18, 2013. Three of the eight were reviewed for treatment plans updates, #4, 5 and 6. Treatment plans updates are to be updated every 60 days after the documentation of the client's comprehensive treatment plan.
Client #4's comprehensive treatment plan was documented on April 25, 2013. The treatment update was to be documented by June 25, 2013. At the time of the licensing inspection client #4's treatment update was not documented for review.
Client #5's comprehensive treatment plan was documented on January 21, 2013. The treatment update was to be documented by March 21, 2013. At the time of the licensing inspection client #5's treatment update was not documented for review.
Client #6's comprehensive treatment plan was documented on January 22, 2013. The treatment update was to be documented by March 22, 2013. At the time of the licensing inspection client #6's treatment update was documented on April 11, 2013.
An interview with the facility director on July 18, 2013 confirmed the findings.
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Plan of Correction
LMCS will no longer use an initial/preliminary treatment plan for D&A clients. Treatment plans are completed at every Assessment. A comprehensive, individualized treatment plan will be completed at Assessment for all D&A clients. These plans will be updated every 60 days. All staff will be informed of this policy change and trained by 08/30/13.
It is the responsibility of the Director and Assistant Director to train each staff person on how to write a comprehensive treatment plan at Assessment and when to update them. The Director, Assistant Director, and Quality Control Specialist will ensure that this policy is being followed through supervision and chart audits.
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in four of four client records.
The findings include:
Eight client records were reviewed on July 18, 2013. Four of the eight were discharge records, #5, 6, 7 and 8.
Client #5 was admitted on January 21, 2013 and discharged on March 6, 2013. At the time of the licensing inspection client record #5 lacked a documented aftercare plan.
Client #6 was admitted on January 22, 2013 and discharged on April 22, 2013. At the time of the licensing inspection client record #6 lacked an aftercare plan that included time frames and support services.
Client #7 was admitted on July 17, 2012 and discharged on December 5, 2012. At the time of the licensing inspection client record #7 lacked a documented aftercare plan.
Client #8 was admitted on June 28, 2012 and discharged on January 17, 2013. At the time of the licensing inspection client record #8 lacked a documented aftercare plan.
An interview with the facility director on July 18, 2013 confirmed the findings.
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Plan of Correction
LMCS has an Aftercare plan in use that meets all the requirements set forth by DDAP. Staff will be trained to understand that aftercare plans must be completed with all clients who are successfully discharged from LMCS as long as these clients agree to complete the plan. Staff will be trained to understand that a client can decline to complete an Aftercare Plan, but this refusal must be documents in the session note. They will be further trained to understand that Aftercare Plans are not needed for clients who are discharged for non-complaisance, against medical advice, or who just stop attending treatment sessions. All staff will be informed of this procedure and trained by 08/30/13.
It is the responsibility of the Director and Assistant Director to train each staff person on how and when to complete an Aftercare Plan. The Director, Assistant Director, and Quality Control Specialist will ensure that these procedures are being followed through supervision and chart audits.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, an interview with the facility director and a review of facility policy and procedures, the facility failed to document a follow up attempt in two of four discharged client records.
The findings include:
Facility policy states that follow up will be attempted within seven days for referrals, and 7 days for all others. An interview with the facility director on July 18, 2013 confirmed the policy.
Eight client records were reviewed on July 18, 2013. Four of the eight client records were for discharged clients, #5, 6, 7 and 8. A follow up attempt is required in four of the client records. .
Client #6 was admitted on January 22, 2013 and discharged on April 22, 2013. The follow-up should have been documented by April 29, 2013. The follow-up attempt took place on May 5, 2013.
Client #8 was admitted on June 28, 2012 and discharged on January 17, 2013. The follow-up should have been documented by January 24, 2013. The follow-up attempt took place on January 26, 2013.
An interview with the facility director on July 18, 2013 confirmed the findings.
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Plan of Correction
LMCS has a 7-Day Follow up form in use that meets all the requirements set forth by DDAP. Staff will be trained to understand that follow ups must be completed within 7 days of discharge for all D&A clients regardless of the reason they are discharged. All staff will be informed of this procedure and trained by 08/30/13.
It is the responsibility of the Director and Assistant Director to train each staff person on how and when to complete the follow up calls and how to document the calls on the form. The Director, Assistant Director, and Quality Control Specialist will ensure that follow up calls are being made in the allotted amount of time through supervision and chart audits.
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