INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the July 18, 2014 licensure renewal inspection. The follow-up inspection was conducted on January 10, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, RHD Lower Marion Counseling Services 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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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 seven of eleven client records.
The findings include:
Eleven client records were reviewed on January 10, 2014. Eight of the eleven were reviewed for psychosocial evaluations, 1, 2, 3, 4, 5, 6, 7 and 8.
The psychosocial evaluations in client records #3, 4, 5, 6 and 8 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records #2, 3, 4, 5, 6 and 8 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluations in client records #2, 3, 4, 5, 6, 7 and 8 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 #2, 3, 4, 5 and 8 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluations in client records #3, 4 and 6 did not include an evaluation of the client's attitude towards treatment and how it would impact treatment.
The psychosocial evaluations in client records #3 and 4 did not include an evaluation of the counselor conclusions/impressions of the client.
An interview with facility staff on January 10, 2014, confirmed the findings.
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Plan of Correction
The psychosocial evaluation will be completed by a therapist and reviewed by the Assistant Director or Director prior to being signed and put into the chart. Staff will be trained on the proper way to gather information from the client and record it on the form. These areas include but are not limited to:
Client's assets and strengths and HOW they will impact treatment
Client's support systems and how they can impact treatment
Client's Coping mechanisms and how they may impact treatment
Client's negative factors and how they may impact treatment
Client's attitude toward treatment and its impact on treatment
Counselor's evaluation/conclusions and impressions
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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 seven of eleven client records.
The findings include:
Eleven client records were reviewed on January 10, 2014. Individualized treatment and rehabilitation plans were required in eight client records. The treatment and rehabilitation plans documented in client records # 1, 2, 3, 4, 5, 6 and 7 were identical. An interview with facility staff on January 10, 2014 confirmed the findings.
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Plan of Correction
The therapists will develop a treatment plan with the individual that is unique to their therapeutic needs. The Psychosocial Assessment (see above) will be used for the Service Plan: Strengthening negatives, utilization of support systems, development of coping mechanisms are examples of area for treatment planning.
Training will be conducted on the proper way of developing a plan. Plans will be reviewed by the Assistant Director or Director.
Treatment plans will be updated every 60 days after the initial treatment plan is developed. These plans will focus on progress made by the client for their goals and objectives and reflect changes as treatment progresses.
This process will be monitored by the UR worker, Assistant Director and the therapist.
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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 five of eleven records.
The findings include:
Eleven client records were reviewed on January 10, 2014. Eight of the eleven were reviewed for treatment plans updates, #1, 2, 3, 4, 5, 6, 7 and 8. Treatment plans updates are to be updated every 60 days after the documentation of the client's comprehensive treatment plan.
Client #1's comprehensive treatment plan was documented on September 6, 2013. The treatment update was to be documented by November 6, 2013. At the time of the licensing inspection client #1's treatment update was documented late, November 14, 2013.
Client #3,'s comprehensive treatment plan was documented on August 23, 2013. The treatment update was to be documented by October 23, 2013. The first treatment plan update was documented on November 4, 2013, which was late. The next treatment plan update was due by January 4, 2014. At the time of the licensing inspection, it was not documented.
Client #6's comprehensive treatment plan was documented on October 3, 2013. The treatment update was to be documented by December 3, 2013. At the time of the licensing inspection client #6's treatment update was documented on December 12, 2013.
Client #7's comprehensive treatment plan was documented on October 23, 2013. The treatment update was to be documented by December 23, 2013. At the time of the licensing inspection client #7's treatment update was documented on January 8, 2014.
Client #8's comprehensive treatment plan was documented on October 14, 2013. The treatment update was to be documented by December 14, 2013. At the time of the licensing inspection client #8's treatment update was not documented for review.
An interview with facility staff on January 10, 2014 confirmed the findings.
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Plan of Correction
Treatment plans will be updated every 60 days after the initial treatment plan is developed. These plans will focus on progress made by the client for their goals and objectives and reflect changes as treatment progresses.
This process will be monitored by the UR worker, Assistant Director and the therapist.
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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 two of eleven client records.
The findings include:
Eleven client records were reviewed on January 10, 2 014. Four of the eleven were discharge records, #2, 9, 10 and 11.
Client #2 was admitted on August 22, 2013 and discharged on December 5, 2013. At the time of the licensing inspection client record #2 lacked a documented aftercare plan.
Client #9 was admitted on July 9, 2013 and discharged on December 6, 2013. At the time of the licensing inspection client record #9 lacked a documented aftercare plan.
An interview with facility staff on January 10, 2014 confirmed the findings.
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Plan of Correction
After Care Plans will be developed prior to discharge by the therapist and individual being served jointly. In the event that the client refuses to develop an aftercare plan, or leaves against medical advice, the aftercare form will reflect this on its face. For example "Client left AMA. Attempts to contact client have failed. An aftercare plan has not been able to be developed with the client."
Staff will be trained on this procedure and it will be monitored by the Asssistant Program Director and Utilization Review Staff. |
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 three of four discharged client records.
The findings include:
Eleven client records were reviewed on January 10, 2014. Four of the eleven client records were for discharged clients, #2, 9, 10 and 11. A follow-up attempt was required in four of the client records. The facility failed to documented a follow-up attempt in client records, #9, 10 and 11.
An interview with facility staff on January 10, 2014 confirmed the findings.
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Plan of Correction
When Clients leave AMA a contact(s)or attempts to contact the client must occur with in 7 days of discharge and be documented.
When referrals are made for a client the therapist must document attempts to contact the referral to verify if they have had contact with the individual. This must occur within 7 days of the referral.
Therapist will be trained on this procedure and it will be monitored by the Assistant Program Director and UR staff. |