INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the April 11-12, 2011 licensure renewal inspection. The follow-up inspection was conducted on October 17, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Colonial House 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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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on the review of client records, the facility failed to have treatment plans signed and dated by the primary counselor and countersigned by the supervisory counselor in two of eight client records reviewed.
The findings include:
Eight client records were reviewed on October 17, 2011. Treatment plan updates are to be signed and dated by the primary counselor and countersigned and dated by the supervisory counselor. Treatment plan updates were required in two client records,#2 and 3. An interview with facility staff on October 17, 2011 confirmed the findings.
Client #2 was admitted on August 8, 2011 and their treatment plan update was documented on October 15, 2011 with no signature from the client, primary counselor or by the supervisory counselor.
Client #3 was admitted on July 6, 2011 and their treatment plan updates was documented on September 6, 2011 and October 6, 2011 with no signature from the client, primary counselor or by the supervisory counselor.
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Plan of Correction
The Director of Residential Services met with entire clinical team on 10/26/11. She reviewed the standard 709.52(b)concerning treatment plan updates. Provided instruction on when updates are due, proper completionand documentation of updates, and required signatures.
Colonial House is in the process of hiring a clinical supervisor. Until this person is hired, the Director of Residential Services will be responsible for maintaining compliance with standard through weekly clinical chart reviews. The clinical supervisor will ultimately be responsible for future compliance. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document completed records of service in three of eight client records reviewed.
The findings include:
Eight client records were reviewed on October 17, 2011. A record of service is to be documented on every client documenting the various specific services provided. The following client records did not document every service provided, #1, 2 and 3. An interview with facility staff on October 17, 2011 confirmed the findings.
Client #1 was admitted on September 2, 2011. The client attended on the following dates, as documented in their progress notes, September 7 and 8 for individual sessions; September 6, 8, 12, 23, 28, 30 and October 5, 6, 7, 12 and 14 for group sessions. The record of service only documented September 2, 7 and 8, 2011.
Client #2 was admitted on August 15, 2011. It could not be determined how often the client came in for sessions because there were no progress notes, but the record of service documented only one session on August 8, 2011, an intake note. Client # 2 was an active client at the time of the inspection with a master treatment plan (9/15/11) and treatment plan update (10/15/11) in record reviewed.
Client #3 was admitted on July 6, 2011. Only one progress not dated July 13, 2011, history/evaluation completed on July 6, 2011 and master treatment plan dated July 13, 2011. The record of service only documented the following dates; July 6, 7 and 8. Client was an active client at the time of the inspection with a treatment plan updates for (9/6/11 and 10/6/11) and treatment plan update (10/6/11) in record reviewed
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Plan of Correction
The Director of Residential met with entire clinical team on 10/26/2011. During the meeting she reviewed standard 709.53(a)(3) concerning record of service. She went over how to document on the record of service stressing that it is the expectation that each record of service will be updated as services are provided.
She will review charts on a weekly basis to insure that the record of service is being filled in properly and in a timely manner. Once the clinical supervisor is hired, this person will be responsible to insure future compliance with this standard. |
709.53(a)(5) LICENSURE Progress 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:
(5) Progress notes.
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Observations
Based on the review of client records, the facility failed to document progress notes in three of eight client records.
The findings include:
Eight records were reviewed on October 17, 2011. Progress notes were required in eight client records. Progress notes were either not documented or only had one or two progress notes in client records,#1, 2 and 3. Staff interviewed on October 17, 2011 confirmed the findings.
Client #1 was admitted on September 2, 2011. The record contained two individual progress notes dated September 7, 2011 and September 8, 2011. The client's preliminary treatment plan dated September 7, 2011 and comprehensive treatment plan dated October 4, 2011 documented that individual sessions will take place once a week.
Client #2 was admitted on August 15, 2011. In client record #2 the progress notes were not documented.
Client #3 was admitted on July 6, 2011. The record contained one progress note dated July 13, 2011.
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Plan of Correction
The Director of Residential Services met with the entire clinical team on 10/26/11. She reviewed standard 709.53(a)(5)concerning progress notes. She reviewed the proper way to document client progress, how to write a progress note and when progress notes are needed.
SHe will be responsible for insuring compliance through weekly chart reviews. Once hired, the clinical supervisor will be responsible for future complinace in this area. |
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, the facility failed to document case consultation in one of eight client records.
The findings include:
Eight client records were reviewed on October 17, 2011. Case consultations were required in one of the eight client records. The facility policy states case consultations are to be conducted within 90 days of the clients admission date. The facility did not document case consultations in client record # 3. An interview with facility staff on October 17, 2011 confirmed the findings.
Client # 3 was admitted on July 6, 2011 and the case consultation was due by October 6, 2011. A case consultation was not documented in client record #3.
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Plan of Correction
A review of our policy found that it states that each client will have at least one case consult per treatment experience. It does not state that it would be conducted within 90 days of the admission date. This client #3 was admitted on 7/6/11 but was still a client on 10/17/11 and therefor we were not out of compliance.
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