INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 4, 2007 through December 7, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kirkbride Center 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 January 4, 2008.
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel and training records, the facility failed to document the completion of the core curriculum in clinical supervision in two of two records reviewed, #3 and 4.
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Plan of Correction
1. The Project Director will solicit information about the core curriculum in clinical supervision from the Pennsylvania Bureau of Drug and Alcohol Programs.
2. The Project Director and the Facility Director will facilitate attendance by the Clinical Supervisors at the core curriculum training.
3. The Project Director and the Facility Director will contact the Pennsylvania Bureau of Drug and Alcohol Programs for information concerning the next series of supervisory trainings in the Philadelphia area.
4. Following determination of the next scheduled training, the Project Director and the Facility Director will scheduled both Clinical Supervisors for the training and notify the Division of Drug and Alcohol Program Licensure.
5. Following completion of the required trainings, the Project Director will notify the Supervisor of the Division of Drug and Alcohol Program Licensure that the trainings have been completed and copies of certificates will be forwarded.
6. Because completion of this Plan of Correction is contingent on the scheduling of the next training in the Philadelphia area, the Project Director could not determine a completion date.
7. The facility's Human Resources Department will ensure that for future hires/promotions to the position of Clinical Supervisor that the core curriculum has been completed or will be completed within one year. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure two employees met the qualifications for the position of counselor, #11 and 16. Both employees have Bachelor ' s degree in a related field, but did not have the required clinical experience for the position of counselor.
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Plan of Correction
1. The Facility Director will initiate direct and close supervision of Employee #11 for a period of six months. The employee will sign a job description for counselor assistant and his job classification will be changed from counselor to counselor assistant. At the conclusion of the six-month period, Employee #11 will be considered for promotion to the position of counselor. The Project Director will consult with the Supervisor of the Division of Drug and Alcohol Program Licensure concerning the possible promotion of the employee.
Documentation will be placed in the employee's personnel file.
2. The Director of Social Services will initiate direct and close supervision of Employee #16 for a period of six months. The employee will sign a job descriptin for counselor assistant, and her job classification will be changed from counselor to counselor assistant. At the conclusion of the six-month period, Employee #16 will be considered for promotion to the position of counselor. The Project director will consult with the Supervisor of the Division of Drug and Alcohol Program Licensure concerning the possibel prmotion of the employee. Documentation will be place in the employee's personnel file.
3. The Project Director will ensure that all future candidates for the position of counselor or counselor assistant will be reviewed by the state. The candidates' resumes, including educational histories and work experiences, will be forwarded to the Division of Drug and Alcohol Program Licensure for review. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of personnel records, the facility failed to document the counselor assistant was working toward counselor status for the 2006 calendar year in one of one record reviewed, #9.
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Plan of Correction
1. Employee #9 has completed the required period of direct and close supervision, which was approved by on-site surveyors December 4 to 7, 2007.
2. As a result, Employee #9 has applied to the Pennsylvania Certification Board to begin the process of applying for the Certified Addiction Counselor designation through that organization.
3. Once Employee #9 has secured his CAC designation, he will be promoted to the position of counselor.
4. The Project Director will ensure that all counselor assistants within the project actively work toward becoming a counselor. Documentation of steps taken by counselor assistants toward promotion of counselor will be maintained in each counselor assistant's personnel file. The Human Resources Department is charged with monitoring compliance and ensuring personnel files are kept up-to-date.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel and training records, the facility failed to document HIV/AIDS training in three of fifteen records reviewed, #6, 17 and 18. Additionally, the facility failed to document TB/STD training in five of fifteen records reviewed, #5, 6, 15, 17 and 18.
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Plan of Correction
1. In the facility's Plan of Correction submitted to the Department of Health, Division of Drug and Alcohol Program Licensure, in May 2007, the Project Director committed the facility to providing both the six-hour HIV/AIDS and the four-hour TB/STD trainings for staff who were deficient in this requirement. The two trainings are offered quarterly, with about 25 employees identified each quarter to attend. The facility has engaged a Pennsylvania Department of Health-certified trainer to provide both trainings on a quarterly basis.
2. Employees #5, 6, 15, 17, 18 will be required to participate in the trainings scheduled for March 2008.
3. The Nurse Educator and the Director of Human Resources will monitor to ensure compliance.
4. The facility will continue to offer the two state-required trainings on a quarterly basis throughout 2008 and the Human Resources Department will continue to identify those employees who must attend. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel and training records, the facility failed to document 25 hours of training for the July 2006 to June 2007 training year in three of seven records reviewed, #5 who earned 12 hours, #14 who earned 20 hours and #15 who earned 22 hours.
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Plan of Correction
1. The Project Director has developed a grid to document attendance by Primary Therapists and Detox Counselors at both internal and external trainings.
2. The grid will be updated quarterly by the Facility Director and the two Clinical Supervisors as well as the Director of Social Services, who will review personnel files of counselors and counselor assistants at the end of each quarter. The Project Director will review the training hours of the Facility Director, the Director of Social Services and the two Clinical Supervisors on a quarterly basis.
3. The Project Director, the Facility Director and the Director of Social Services will report their findings on a quarterly basis to the Executive Committee for oversight and monitoring.
4. Employees who appear to be deficient in training hours will be counseled by the Project Director, the Facility Director, the Director of Social Services and the two Clinical Supervisors to ensure compliance. |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of personnel and training records, the facility failed to document the minimum number of 30 hours of training for the July 2006 to June 2007 training year for one of one record reviewed, #9. Only 24 hours were obtained.
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Plan of Correction
1. The Clinical Supervisor of Employee #9 has counseled him to ensure compliance with the 30 hours of annual trainings required by the Pennsylvania Department of Health.
2. The personnel file of Employee #9 will be reviewed by his Clinical Supervisor on a quarterly basis to determine his status in meeting the 30 hours of training required annually of counselor assistants.
2. Results of the quarterly audit of training hours by the Clinical Supervisor will be reported quarterly to the Executive Committee for oversight and monitoring. |
709.123(b)(2) LICENSURE Tx Plan Update
709.123. Treatment and rehabilitation.
(b) Treatment and rehabilitation services.
(2) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regimen 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 a review of client records, the facility failed to document an assessment of the client's progress in relationship to the stated goals of the treatment plan in one of two client records reviewed, #4.
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Plan of Correction
1. As part of their monthly clinical trainings for staff, the two Clinical Supervisors will review with staff the documentation of patient progress or lack of progress on specific treatment plan goals.
2. Routine chart audits by the Facility Director and the two Clinical Supervisors will ensure compliance. |
709.123(c)(5) LICENSURE Follow-up information
709.123. Treatment and rehabilitation.
(c) Client records. 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) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in four of four client records reviewed, #4, 5, 6 and 7.
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Plan of Correction
1. The Facility Director and the Clinical Supervisors have met with the Primary Therapists, who are responsible for completing the seven-day follow-ups, to review the state standard governing seven-day follow-ups.
2. Weekly, the Facility Director and the Clinical Supervisors will conduct a audit to ensure completion of the follow-up.
3. The bulk of the Follow-up form will be completed at the time the Primary Therapist completes the Discharge Summary, with the phone call to the aftercare agency occurring with seven days of actual discharge.
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on the physical plant inspection on 12/5/07, the facility failed to store all trash, garbage and rubbish in covered containers in the kitchen area.
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Plan of Correction
1. The Assistant Food Services Manager and the consulting registered dietician have notified staff that all trash cans -- including those for garbage -- must be secured with their lids at all times.
2. The Assistant Food Services Manager and the consulting registered dietifician will monitor compliance on a weekly basis for four weeks and report their findings to the Executive Committee for oversight and monitoring.
3. Lids on trash cans have become a focus of the JCAHO prep team, which has been performing mock tracers throughout the facility in anticipation of the facility's two triennial surveys in 2008.
4. The consulting registered dietician and the the Assistant Food Services Manager will continue to monitor trash can lids monthly for an indefinite period of time following the first four weeks of reviews. |
705.10 (b) (2) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(2) On floors with resident bedrooms, maintain a smoke detector which shall be located within 15 feet of each bedroom door. On floors with no resident bedrooms, the smoke detection device shall be located in a common area or hallway. All detection devices shall be interconnected.
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Observations
Based on the physical plant inspection on 12/5/07, the facility failed to maintain interconnected smoke detectors within 15 feet of bedrooms #354 and #355. The remaining bedrooms on L3 did not have interconnected smoke detectors.
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Plan of Correction
1. The facility will engage the services of a contractor to install interconnected smoke detectors on the L-3 unit.
2. The interconnected smoke detectors will be installed on the unit within three months from today.
3. The Director of Property Services will monitor to ensure compliance with state standards. |
705.10 (b) (6) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(6) Maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
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Observations
Based on the physical plant inspection on 12/5/07 and 12/6/07, the facility failed to maintain smoke detectors and fire alarms in resident bedrooms so that each person with a hearing impairment will be alerted in the event of a fire for the psychiatric hospital program on N2 and N3 floors.
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Plan of Correction
1. A strobe-lighted fire alarm, for hearing-impaired chemical dependency patients admitted to the acute psychiatric unit, will be installed in one bedroom on either N-2 or N-3.
2. The installation will occur in either room 205 or room 305 within three months.
3. The installation will be completed by the Kirkbride Engineering Department.
4. The Director of Property Services will monitor for compliance. |
705.10 (c) (1) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating, which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, the residential facility shall maintain an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on the physical plant inspection on 12/5/07, the facility failed to maintain two portable fire extinguishers with a minimum of an ABC rating on N2 which is 2800 square feet of floor space. One of the fire extinguishers had an A rating only.
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Plan of Correction
1. The facility will purchase an ABC-rated portable fire extinguisher for the N-2 psychiatric unit within three months.
2. The fire extinguisher to be purchased, with an A-B-C rating, will replace one of the two fire extinguishers on the unit at the time of the on-site inspection that is rated only A.
3. The Director of Property Services and the purchasing agent will monitor for compliance. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of administrative documents on 12/4/07, the project director failed to include available resources for the 2007/2008 project goals and objectives.
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Plan of Correction
1. The 2007/2008 project goals and objectives will be revised by the Project Director to include available resources.
2. The goals and objectives for 2007/20087 will be resubmitted to the board for approval of the amended version.
3. The Project Director will create a template for the annual development of the goals and objectives for the next fiscal year. The template will include the requirement that resources be identified. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records on 12/6/07 and 12/7/07, the facility failed to obtain an informed and voluntary consent in two of seven client records reviewed for the psychiatric units, #4 and 6. The specific information to be released to Community Behavioral Health (CBH) exceeded that allowed by 4 Pa. Code 255.5.
The facility failed to obtain an informed and voluntary consent in five of eleven client records reviewed for the inpatient non-hospital rehabilitation units, #2, 4, 8, 9 and 10. The specific information to be released to BHSI and other funding sources exceeded that allowed by 4 Pa. Code 255.5.
The facility failed to obtain an informed and voluntary consent in four of seven client records reviewed for the detoxification unit, #1, 2, 3 and 7. The specific information to be released to Magellan and other funding sources exceeded that allowed by 4 Pa. Code 255.5.
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Plan of Correction
1. The Director of Admissions has revised the Release of Information form used to request patient permission to provide information to their Managed-Care Organization. The consent form includes only those five areas that are permitted for release to Managed-Care Organizations: Presence in treatment; patient prognosis; program description; patient's progress; and whether the patient has relapsed.
2. The Director of Admissions will meet with Admissions Coordinators on January 16, 2008, to review revisions to the consent forms.
3. The Director of Social Services and Utilization Management will meet with Utilization Management Coordinators to review state limitations on the release of information to Managed-Care Organizations. This will occur by February 15, 2008.
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709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
Based on the review of administrative documents on 12/6/07 and 12/7/07, the facility failed to develop a data collection and record-keeping system that allows for efficient retrieval of data for the closed psychiatric client records.
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Plan of Correction
1. The facility's consulting computer programmer has written a program to easily access a listing of patients with co-occurring disorders who have been discharged from the acute psychiatric program.
2. The program calls for a listing of all patients within specified time periods with a primary diagnosis of a mental health disorder and a secondary diagnosis of a substance abuse disorder. For instance, the program can produce a listing of all patients discharged from the acute psychiatric units within a certain time period. The listing would include only those patients with a primary diagnosis of a psychiatric disorder and a secondary diagnosis of a chemical dependency disorder.
3. The newly written program will facilitate the selection of medical records for review during on-site inspections. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of the client records, the facility failed to document a complete psychosocial evaluation in three of seven client records reviewed, #1, 2 and 4. The psychosocial evaluations were a repeat of the client history and included direct client statements as opposed to a clinical assessment of the client by the counselor.
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Plan of Correction
1. The facility has been participating with the Institute for Cognitive Therapy in case conference demonstrations for some time. A contingent of supervisors and primary therapists has been participating in the case conferences conducted live by Aaron T. Beck, MD. Because openings in the case conferences are somewhat limited, the facility has been sending Kirkbride representatives as space permits. Participation has been designed to help improve the quality of psychosocial assessments.
2. The Clinical Supervisors of the Chemical Dependency Programs have begun providing monthly trainings to Primary Therapists in a move to improve the quality of psychosocial narratives and to help ensure that the narratives are not simply a recap of demographic information already documented in the biopsychosocial.
3. The Director of Social Services has begun providing monthly trainings to improve the quality of psychosocial narratives and to help ensure that the narratives are not simply a recap of demographic information already documented in the biopsychosocial.
4. Quarterly for a 12-month period, the Facility Director and the Director of Social Services will report on improvements in the clinical assessments to the Executive Committee for oversight and monitoring. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. 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 document complete psychosocial evaluations in seven of eleven client records reviewed, #1, 3, 4, 5, 6, 8 and 11. The psychosocial evaluations did not provide an evaluation the client's assets/strengths in #1, 3, 5, 6, 7 and 11; client's support systems in #1, 3, 5, 6, 7, 8 and 11; client's coping mechanisms in #1, 3, 4, 5, 6, 7, 8 and 11; and the client's attitude towards and ability to participate in treatment in #1, 3, 4, 6 and 8.
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Plan of Correction
1. The Clinical Supervisors in the Chemical Dependency Programs have been providing trainings on a monthly basis for Primary Therapists on a variety of topics. Included in the overall training plan for 2008 are case conceptualizations and improvements to the psychosocial narratives. The trainings will include sample narratives that include an evaluation of the patient's assets/strengths, the patient's support systems, the patient's coping mechanisms and the patient's attitude toward and ability to participate in treatment.
2. Similar trainings are conducted monthly by the Director of Social Services for the social workers who work on the Acute Psychiatric Units.
3. Quarterly for a 12-month period, the Facility Director and the Director of Social Services will report on improvements to the psychosocial assessments to the Executive Committee for oversight and monitoring. |
709.52(a)(1) LICENSURE Short/Long term TX Goals
709.52. 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.
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Observations
Based on a review of the client records, the facility failed to document treatment plan goals with measurable criteria in seven of eleven client records reviewed, #2, 3, 4, 5, 8, 9 and 10.
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Plan of Correction
1. The Management Team will develop a new audit tool that will assess treatment plan goals and objectives to determine whether goals are measurable and time-framed. Currently, audits of treatment plans have been objective in nature, that is, whether the treatment plans are completed within the specified time frames. The audit tool to be designed will be evaluative in nature.
2. The Clinical Supervisors in the Chemical Dependency Program on a monthly basis provide training to Primary Therapists on treatment planning. The requirement that measurable criteria be a cornerstone of treatment plans will be included in that training. The Project Director also will provide training in various psychometric measures for possible inclusion in the treatment plans as measurable data. The measures include those that evaluate levels of depression, anxiety, psychosis and mania.
3. The Director of Social Services on a monthly basis provides training on treatment plans. The requirement that measurable criteria be included in all plans is a cornerstone of the ongoing trainings. The training also will provide an overview of the use of psychometric measures in treatment planning and treatment plan-writing.
4. Once the treatment plan audit tool has been created, it will be applied to a sampling of 10 percent of open charts. Results will be supplied quarterly for a 12-month period to the Executive Committee for oversight and monitoring. |
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 a review of the client records, the facility failed to document an assessment of the client's progress in relationship to the stated goals of the treatment plan in nine of eleven client records reviewed, #1, 2, 3, 4, 5, 6, 7, 8 and 9.
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Plan of Correction
1. The Clinical Supervisors of the Chemical Dependency Program will provide the Primary Therapists with monthly training in treatment plans and treatment planning to ensure that an evaluation of previous goals and objectives are contained in each successive updated treatment plan. The review of goals and objectives will include whether the goals and objectives were met or whether the goal with new objectives need to be written in updated treatment plans.
2. The Clinical Supervisors will evaluate 10 percent of open records monthly for a period of four months to determine compliance with the requirement governing updated treatment plans.
3. The Clinical Supervisors will report their findings monthly for four months to the Executive Committee for oversight and monitoring. |