INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 14 - 15, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Conemaugh Valley Memorial Hospital 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 February 15, 2008.
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Plan of Correction
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on review of personnel records, the facility failed to document first aid training for sufficient staff to cover all hours of operation.
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Plan of Correction
1) As the program is loacted within a 24 hour acute care hospital setting, staff members in this program have never been trained in the provision of first aid. Any and all injuries or situations requiring medical attention were either referred to the emergency department, to the client's PCP office or the Nursing Supervisor was called.
2)First Aid training will be provided to all NVCDP staff from this point forward.
3) Responsible party: Christina Bargdill |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the "Staffing Requirements Facility Summary Report" the facility is out of compliance with the staff to client caseload requirements. Employee # 2 has a caseload of 52/1 and employee # 3 has a caseload of 48/1. The overall caseload size is 46/1, well in excess of the 35/1 caseload limit.
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Plan of Correction
1) Several clients were transferred from the partial level of care to the outpatient level of care between the date the survey was originally scheduled to occur and the date that it actually occurred. While the census was updated on the Staffing Requirements Facility Summary Form, the staff hours were not reallocated to cover the change in patient load. While the outpatient case loads were 52:1; 48:1; 33:1 the partial case loads were all below the 1:6 ratio required (1:4, 1:4, 1:2).
2)At this point we are working to promote the Prevention Specialist, to a counselor role to provide flexibility in case load distribution. A resume and transcripts for the candidate were faxed to the Department for review on 2/11/08. Pending approval, THE PREVENTION SPECIALIST will be promoted and will assume a small case load. In addition I will work to ensure staffing and census information is updated to reflect current conditions on a daily basis.
3)Responsible Party: Program Director |
711.81(b)(3)(i) LICENSURE Medical History
711.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records on January 15, 2008, the facility failed to document the date of completion on the medical history form. In accordance with project policy the medical history is to be completed at intake, but since no date of completion was documented it was not possible to determine when the medical history was completed.
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Plan of Correction
1) Medical histories, although completed upon orientation, were not dated by the person that completed them during orientation.
2) The Medical History form has been revised to include a signature and date completed line to trigger the counselor to sign and date the form. The form was reviewed with staff during treatment team meeting Thursday 2/7/2008. The form will be put in place this week.
3) Program Director |
711.81(b)(3)(ii) LICENSURE D & A History
711.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records on January 15, 2008, the facility failed to document the date of completion on the drug and alcohol history in two out of two client records, specifically # 2 and #5. In accordance with the project policy the drug and alcohol history was to be completed at intake, but since no date was documented, it was not possible to substantiate when the history was completed.
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Plan of Correction
1) The drug and alcohol chemical history is completed upon orientation, however there is no designated area for the counselor to sign off and date the form when completed.
2) The chemical history form has been revised and reviewed with the staff on Thursday 2/7/08. The form will be put into use this week.
3) Responsible party: Program Director |
711.81(b)(3)(iii) LICENSURE Personal History
711.81. 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 client records on January 15, 2008, it was determined that the facility failed to document a complete personal history in two out of two client records reviewed, specifically # 2 and # 5. Personal histories failed to include a complete family history, legal, educational, recreational and sexual history in client records #2 and 5.
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Plan of Correction
1)Staff did not document a complete personnel history. The form utilized does not provide adequate cues to trigger the information and the space to document the history obtained is not large enough to provide for the complete documentation of this information.
2)The psychosocial history form was revised and put into draft format a few weeks preceeding the inspection. This form is much more extensive,providing more cues for the counselor and allowing more space for documentation. Based upon counselor feedback and survey results, the form was again revised and is to be implemented this week (2/11/2008). We will review again in 1 month and adjust format as necessary.
3)Program Director |
711.81(b)(6) LICENSURE Psychosocial Evaluation
711.81. 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 on January 15, 2008 it was determined that the facility failed to ensure that the psychosocial evaluation contained a complete composite picture, a clinical analysis of the client's problems/needs, assets/strengths, coping mechanisms, and negative factors. This was evident in two out of two client records reviewed, specifically # 2 and 5.
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Plan of Correction
1) Staff was unclear on the differences between the history and the psychosocial evaluation. Prior to the survey the process was discussed with staff and new history and evaluation forms were created and put into use in draft format. The Evaluation form includes specific prompts to address the areas identified. Staff was educated on the form, the process and the Program Director is randomly reviewing records and providing feedback directly to the counselors to improve documentation and confidence.
2)Revised psychosocial evaluation form in place; will continue to review and provide feedback to counselors.
3) Program Director |
711.82(c) LICENSURE Individualized Tx Plan
711.82. 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 on January 15, 2008, the facility failed to document individualized treatment plans in two out of two client records reviewed, specifically # 2 and 5. Treatment plans reviewed in the records documented identical goals and objectives.
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Plan of Correction
1) Staff members utilize treatment plan templates but failed to individualize the templates to the clients indvidualized needs.
2) Discussed individualization of treatment plans with staff. 2 employees attended a BDAP sponsored training on developing and implementing treatment plans. These staff members are working on re-designing the treatment plan format to increase opportunities to individualize the plans, balancing the need to keep documentation streamlined, but information as specific to the individual client as possible.
3) Program Director |
711.82(c)(3) LICENSURE Support Service - Tx Plan
711.82. 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records on January 15, 2008, the facility failed to document support services on the treatment and rehabilitation plan. A review of two client records revealed that in one client record, specifically #1, support services specific to the client's needs were not identified.
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Plan of Correction
1)The particular client whose chart was reviewed declined to attend AA meetings for support and the counselor failed to document alternative support services available to the client.
2) Reviewed the issue of support systems with counselors during treatment team 2/7/2008. Discussed alternatives to AA/NA if clients refuse to attend. Discussed importance of helping clients identify and utilize support systems as they are able to promote recovery and resiliency. Revised treatment plans to include support services.
3) Program Director |
711.83(a)(4) LICENSURE Progress Notes
711.83. 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 contained in 115.32 (relating to contents), the client record shall include the following:
(4) Progress notes.
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Observations
Based on a review of client records on January 15, 2008, the facility failed to document the data, assessment and plan on group therapy notes on two out of two client records reviewed, client records # 2 and 5. Group notes lacked any association to the treatment plan goals and objectives in client records # 2 and 5 representing two out of two client records reviewed.
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Plan of Correction
1) The progress note format did not contain clear triggers to document in DAP format. The notes were extremely descriptive of the content of group, but did not address process, assessment and planning for future treatment interventions.
2) Both the indvidual and group progress note forms were revised to include areas to document specific information in a DAP format. Staff was educated on process of therapy and on how to document in terms of process themes and treatment issues and strategies. The forms are in draft use as of February 11, 2008. I will continue to review records for documentation and provide direct supervision to counselors related to both the treatment process and the documentation of that process.
3) Program Director |
711.91(b)(3)(i) LICENSURE Medical History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on review of client records on January 15, 2008, the facility failed to document when the medical history was completed. In accordance with the facility's policy, the medical history is to be completed upon initial orientation/intake, but since no date was documented on the medical history it was impossible to determine if the material was timely in three out of three client records reviewed, specifically client records # 1, 3, and 4.
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Plan of Correction
1) Medical histories, although completed upon orientation, were not dated by the person that completed them during orientation.
2) The Medical History form has been revised to include a signature and date completed line to trigger the counselor to sign and date the form. The form was reviewed with staff during treatment team meeting Thursday 2/7/2008. The form will be put in place this week.
3) Program Director
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711.91(b)(3(ii) LICENSURE D & A History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document when the drug and alcohol history was completed. In accordance with the facility's policy, drug and alcohol histories are to be completed at the initial orientation/intake. Since the drug and alcohol histories were not dated it is not possible to determine whether they were completed by the end of the initial orientation/ intake session. Histories were missing dates in three out of three client records reviewed, specifically client records # 1, 3 and 4.
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Plan of Correction
1) The drug and alcohol chemical history is completed upon orientation, however there is no designated area for the counselor to sign off and date the form when completed.
2) The chemical history form has been revised and reviewed with the staff on Thursday 2/7/08. The form will be put into use this week.
3) Responsible party: Program Director |
711.91(b)(3)(iii) LICENSURE Personal History
711.91. 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 review of the client records it was determined that the facility failed to document the clients' complete personal history. Personal histories failed to include a complete family, legal, employment, recreational, and sexual history in three out of three client records reviewed, specifically client records # 1, 3 and 4.
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Plan of Correction
1)Staff did not document a complete personnel history. The form utilized does not provide adequate cues to trigger the information and the space to document the history obtained is not large enough to provide for the complete documentation of this information.
2)The psychosocial history form was revised and put into draft format a few weeks preceeding the inspection. This form is much more extensive,providing more cues for the counselor and allowing more space for documentation. Based upon counselor feedback and survey results, the form was again revised and is to be implemented this week (2/11/2008). We will review again in 1 month and adjust format as necessary.
3)Program Director
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711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on review of the client records on January 15, 2008 the facility failed to document a complete psychosocial evaluation in three out of three client records reviewed, specifically client records # 1, 3 and 4. Psychosocial evaluations did not include a composite picture, a clinical assessment of the clients' problems/needs and negative factors. Assets/strengths were incomplete in client records # 1 and 5.
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Plan of Correction
1) Staff was unclear on the differences between the history and the psychosocial evaluation. Prior to the survey the process was discussed with staff and new history and evaluation forms were created and put into use in draft format. The Evaluation form includes specific prompts to address the areas identified. Staff was educated on the form, the process and the Program Director is randomly reviewing records and providing feedback directly to the counselors to improve documentation and confidence.
2)Revised psychosocial evaluation form in place; will continue to review and provide feedback to counselors.
3) Program Director
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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 review of client records on January 15, 2008, the facility failed to document individualized treatment and rehabilitation plans. The treatment and rehabilitation plans were standardized and identical in client records #1, 3 and 4 , or three out of three client records reviewed.
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Plan of Correction
1) Staff members utilize treatment plan templates but failed to individualize the templates to the clients indvidualized needs.
2) Discussed individualization of treatment plans with staff. 2 employees attended a BDAP sponsored training on developing and implementing treatment plans. These staff members are working on re-designing the treatment plan format to increase opportunities to individualize the plans, balancing the need to keep documentation streamlined, but information as specific to the individual client as possible.
3) Program Director
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711.92(c)(3) LICENSURE Support Service
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:
(3) Proposed type of support service.
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Observations
Based on a review of client records on January 15, 2008, the facility failed to document support services on the individualized treatment rehabilitation plan. In client records # 1, and 3, two out of three client records reviewed, support services were not specific to the client.
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Plan of Correction
1)The particular client whose chart was reviewed declined to attend AA meetings for support and the counselor failed to document alternative support services available to the client.
2) Reviewed the issue of support systems with counselors during treatment team 2/7/2008. Discussed alternatives to AA/NA if clients refuse to attend. Discussed importance of helping clients identify and utilize support systems as they are able to promote recovery and resiliency. Revised treatment plans to include support services.
3) Program Director |
711.93(a)(4) LICENSURE Progress Notes
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:
(4) Progress notes.
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Observations
Based on a review of client records on January 15, 2008, the facility failed to document data, assessment, and plan on group therapy notes in three out of three client records reviewed, # 1, 3, and 4.
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Plan of Correction
1) The progress note format did not contain clear triggers to document in DAP format. The notes were extremely descriptive of the content of group, but did not address process, assessment and planning for future treatment interventions.
2) Both the indvidual and group progress note forms were revised to include areas to document specific information in a DAP format. Staff was educated on process of therapy and on how to document in terms of process themes and treatment issues and strategies. The forms are in draft use as of February 11, 2008. I will continue to review records for documentation and provide direct supervision to counselors related to both the treatment process and the documentation of that process.
3) Program Director |