INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 13-14, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Parkside Recovery 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 December 23. 2008.
|
Plan of Correction
|
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a review of the facility ' s fire drill log, the facility failed to document alternate exit routes to be used during fire drills.
Findings:
The facility ' s fire drill log was reviewed on November 13-14, 2008. The facility was required to document alternate exit routes to be used during fire drills. The facility documented the front and rear exits only during all monthly fire drills
|
Plan of Correction
The Program Director will provide oversight with the facility's compliance of regulation 705.28 (d) (5) by working with the designated site Fire Marshall to develop and implement a plan to document the alternate exit routes that will be used during fire drills at 5429 Germantown Ave over the next 12 months by 12/31/08.
The Fire Marshall will close off at least one of the two exits at 5429 Germantown Ave during at least six fire drills over the 12 month period from 1/2009 to 1/2010.
The Program Director will work with representatives of the NHS Program Evaluation Unit on a monthly basis to review the fire log in order to evaluate the programs compliance to regulation 705.28 (d) (7).
The program will be in compliance of regulation 705.28 (d) by 12/31/09
|
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:
|
Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent for the disclosure of client information in seven of seventeen client records.
Findings:
Seventeen client records were reviewed on November 13-14, 2008. Informed and voluntary consent from the client for the disclosure of information was required in seventeen of seventeen client records.
The facility did not document the client ' s right to verbally revoke their voluntary consent for the release of information in client records # 1, 2, 3, 4, 7, 8 and 9. The facility documented the client must revoke in writing voluntary consent for the disclosure of information.
The facility did not document whether a copy of the release was offered to the client in client records # 4, 7 and 8.
|
Plan of Correction
The Program Director will provide oversight with the facility's compliance of regulation 709.28(c) by working with the Clinical Supervisor and The NHS Program Evaluation unit to document an informed and voluntary consent for the disclosure of client information by including a written statement on the consent form acknowledging the client's right to verbally revoke their voluntary consent for the release of information. by 12/30/08.
Program Director will work with the NHS Training Coordinator to conduct a clinical documentation training by 2/9/09 to educate the clinical staff on the process for documenting and completing the essential elements on treatment plans, psychosocial evaluations, and client consent forms.
The Program Director will work with the NHS Program Evaluation Unit thereafter on a monthly basis to conduct audits of client records in order to evaluate the programs compliance to regulation 709.28(c)
The program will be in compliance of regulation 709.28(c) by 2/9/09.
|
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
|
Observations
Based on a review of client records, the facility failed to document drug and alcohol histories in four of nine client records.
Findings:
Seventeen client records were reviewed on November 13-14, 2008. Drug and alcohol histories were required in nine client records. The facility did not document drug and alcohol histories in client records # 1, 3, 13 and 14.
|
Plan of Correction
The Program Director will provide oversight with the f facility's compliance of regulation 709.91(b)(3)(ii) by working with the NHS Training Coordinator and the Clinical Supervisor to provide clinical staff with a clinical documentation training by 2/9/09 that will educate them on the essential elements needed to document and complete the clients Drug and alcohol history .
The Clinical Supervisor will then utilize the weekly counselor supervision session to review, identify mistakes and document the completion of the essential elements of clients drug and alcohol history over the next 12 months. The document will be signed by the Clinical Supervisor, noted on the supervisors TPU tool and forwarded to the medical records department to be filed in the client's record.
The Program Director will work with the NHS Program Evaluation Unit on a monthly basis to conduct audits of client records in order to evaluate the programs compliance to regulation 709.91(b)(3)(ii)
The program will be in full compliance of regulation 709.91(b)(3)(ii) by 2/9/09
|
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
Based on a review of client records, the facility failed to document personal histories in four of nine client records.
Findings:
Seventeen client records were reviewed on November 13-14, 2008. Personal histories were required in nine client records. The facility did not document drug and alcohol histories in client records # 1, 3, 13 and 14.
|
Plan of Correction
The Program Director will provide oversight with the facility's compliance of regulation 709.91(b)(3)(iii) by working with the NHS Training Coordinator and the Clinical Supervisor to provide clinical staff with a clinical documentation training by 2/9/08 that will educate them on the essential elements needed to document and complete the clients Personal History.
The Clinical Supervisor will then utilize the weekly counselor supervision session to review, identify mistakes and document the completion of the essential elements of clients Personal History over the next 12 months. The document will be signed by the Clinical Supervisor, noted on the supervisors TPU sheet and forwarded to the medical
records department to be filed in the client's record.
The Program Director will also work with NHS Program Evaluation Unit on a monthly basis to conduct audits of client records in order to evaluate the programs compliance to regulation 709.91(b)(3)(iii).
The program will be in compliance of regulation 709.91(b)(3)(iii) by 2/9/09
|
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to document psychosocial evaluations in four of nine client records.
Findings:
Seventeen client records were reviewed on November 13-14, 2008. Psychosocial evaluations were required in nine client records. The facility did not document psychosocial evaluations in client records # 1, 3, 13 and 14.
|
Plan of Correction
The Program Director will provide oversight with the facility's compliance of regulation 709.91(b)(6) by working with the NHS Training Coordinator and the Clinical Supervisor to provide clinical staff with a clinical documentation training by 2/9/08 that will explain how to document and complete the eight essential elements of the psychosocial evaluation.
The Clinical Supervisor will then utilize the weekly counselor supervision session to review, identify mistakes and document the completion of the eight essential elements of the psychosocial evaluation over the next 12 months. The document will be signed by the Clinical Supervisor, noted on the supervisors TPU sheet and forwarded to the medical records department to be filed in the client's record.
The Program Director will also work with the NHS Program Evaluation Unit on a monthly basis to conduct audits of client records in order to evaluate the programs compliance to regulation 709.91(b)(6).
The program will be in full compliance of regulation 709.91(b)(6) by 2/9/09.
|
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
|
Observations
Based on a review of client records, the facility failed to document treatment and rehabilitation plans in three of nine client records.
Findings:
Seventeen client records were reviewed on November 13-14, 2008. Treatment and rehabilitation plans were required in nine client records. The facility did not document treatment and rehabilitation plans in client records # 1, 3, and 14.
Additionally, the facility failed to document a treatment plan within thirty days of admission as stated in their policy and procedures manual.
Client record # 2 admitted 07/09/08, Treatment plan completed 10/08/08
Client record # 13 admitted 08/07/08, Treatment plan completed 09/10/08
|
Plan of Correction
The Program Director will provide oversight with the facility's compliance of regulation 709.92(a)(1) by working with the NHS Training Coordinator and the Clinical Supervisor to provide staff with a clinical documentation training by 2/9/09 that will educate them on the essential timelines, elements and concepts involved in developing, documenting and completing an effective treatment and rehabilitation plan.
The Clinical Supervisor will then utilize the weekly counselor supervision session to review, correct, and document the completion of the treatment and rehabilitation plan in the clinical record over the next 12 months. The document will be signed by the client, counselor and Clinical Supervisor noted on the supervisors TPU sheet and forwarded to the medical records department to be filed in the client's record.
The Program Director will work the NHS Program Evaluation Unit on a monthly basis to conduct audits of the client records in order to evaluate the programs compliance to regulation 709.92(a)(1).
The program will be in compliance of regulation 709.92(a)(1) by 2/9/09
|
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.
|
Observations
Based on a review of client records, the facility failed to document treatment and rehabilitation updates at least every sixty days in five of nine client records.
Findings:
Seventeen client records were reviewed on November 13-14, 2008. Treatment and rehabilitation updates were required in nine client records. The facility did not document treatment and rehabilitation updates at least every sixty days in client records # 4, 5, 8 10 and 15.
Client record # 4 contained an update completed on 07/11/2008 the next update was not completed until 10/01/08.
Client record # 5 contained and initial treatment plan completed 07/31/2008 and the update was not completed until 10/09/2008.
Client record # 8 contained an update completed on 09/11/2007 with no additional updates documented beyond that date.
Client record # 10 contained an update completed on 07/18/2008 with no additional updates documented beyond that date.
Client record # 15 contained an update completed on 05/16/2008 with no additional updates documented beyond that date.
|
Plan of Correction
The Program Director will provide oversight with the facility's compliance of regulation 709.92(b) by working with the NHS Training Coordinator and the Clinical Supervisor to provide staff with a clinical documentation training by 2/9/09 that will educate them on the essential timelines, elements and concepts involved in developing, documenting, completing and submitting an effective treatment and rehabilitation plan within the required time frame.
The Clinical Supervisor will then utilize the weekly counselor supervision session to review, correct, and document the completion of the treatment and rehabilitation plan in the clinical record over the next 12 months. The document will be signed by the client, counselor and clinical supervisor, noted on the supervisors TPU sheet and forwarded to the medical records department to be filed in the client's record.
The Program Director will work with the NHS Program Evaluation Unit on a monthly basis to conduct audits of the client records in order to evaluate the programs compliance to regulation
709.92(b) The program will be in compliance of regulation 709.92(b) by 2/9/09.
|
709.93(a) 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:
|
Observations
Based on a review of client records, the facility failed to document a complete record on every client.
Findings:
Seventeen client records were reviewed on November 13-14, 2008.
Drug and alcohol histories were not documented in client records # 1, 3, 13 and 14
Personal histories were not documented in client records # 1, 3, 13 and 14
Treatment plans were not documented in client records #1, 3 and 14.
Case consultations were not documented in client records # 1, 2, 3, 10, 11, 12, 13, 14 and 15
Follow up information was missing in client records # 16 and 17
|
Plan of Correction
The Program Director will provide oversight with the facility's compliance of regulation 709.93(a) by working with the NHS Training Coordinator and the Clinical Supervisor to provide staff with a clinical documentation training by 2/9/09 that will educate them on the importance of documenting a complete record. The training will cover in detail the 11 essential domains of the client record.
The Clinical Supervisor will then utilize the weekly counselor supervision session to review selected client records with the counselor to check for deficiencies within the 11 domains offer appropriate recommendations for corrections if need.
The Program Director will work with the NHS Program Evaluation Unit on a monthly basis to conduct audits of the client records in order to evaluate the programs compliance to regulation
709.93(a)
The program will be in compliance of regulation 709.93(a) by 2/9/09.
|
709.93(a)(8) 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:
(8) Case consultation notes.
|
Observations
Based on a review of client records, the facility failed to document case consultation notes at least quarterly in nine of fourteen client records.
Findings:
Seventeen client records were reviewed on November 13-14, 2008. Case consultation notes were required in nine client records. The facility did not document case consultation notes in client records 1, 2, 3, 10, 11, 12, 13, 14 and 15.
|
Plan of Correction
The Program Director will provide oversight with the facility's compliance of regulation 709.93(a) by working with the NHS Training Coordinator and the Clinical Supervisor to provide staff with a clinical documentation training by 2/9/09 that will educate them on the importance of documenting quarterly case consultation notes in the client records.
The Clinical Supervisor will then utilize the weekly counselor supervision session to review, correct, and document the completion of the quarterly case consultation in the client record over the next 12 months. The document will be signed by the counselor of record, staff members in attendance and clinical supervisor, noted on the supervisors TPU tool and forwarded to the medical records department to be filed in the client's record.
The Program Director will work with the NHS Program Evaluation Unit on a monthly basis to conduct audits of the client records in order to evaluate the programs compliance to regulation
709.93(a)(8).
The program will be in compliance of regulation 709.93(a)(8) by 2/9/08
|
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.
|
Observations
Based on a review of client records, the facility failed to document an aftercare plan in one of one client records.
Findings:
Seventeen client records were reviewed on November 13-14, 2008. An aftercare plan was required in one client record. The facility did not document a complete aftercare plan in client record # 17.
Client record #17 was documented as a successful discharge on 08/10/2008, but the clients last date of counseling was 04/22/2008. Additionally, the aftercare plan was completed without the client ' s participation.
|
Plan of Correction
The Program Director will provide oversight with the facility's compliance of regulation 709.93(a)(9) by working with the NHS Training Coordinator and the Clinical Supervisor to provide staff with a clinical documentation training by 2/9/09 that will demonstrate the aftercare planning process and educate them on the importance of documenting and maintaining the aftercare plan in the client records.
The Counselor will be responsible for informing the client about all policies and procedures in regards to after care planning and jointly developing the aftercare plan with the client prior to discharge. The after care plan will given to the client a minimum of seven days before the discharge. Both the client and counselor will sign the aftercare plan. The original will go in the client record and a copy will be given to the client at discharge.
The Clinical Supervisor will be responsible for following up on all transfer clients within 7 day of the transfer.
The Clinical Supervisor will then utilize the weekly counselor supervision session to review, correct, and document the completion of all aftercare plans for discharged clients in the client record over the next 12 months. All discharges will be signed by the Clinical Supervisor and forwarded to the medical records department to be filed in the client's record.
The Program Director will work with the NHS Program Evaluation Unit on a monthly basis to conduct audits of the client records in order to evaluate the programs compliance to regulation
709.93(a)(9).
The program will be in compliance of regulation 709.93(a)(9) by 2/9/09
|