INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 6, 7 and 9, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, JF Kennedy Community MH/MR 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 February 13, 2009..
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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 the review of client records, the facility failed to document complete psychosocial evaluations in five of five client records
Findings:
Nine client records were reviewed on January 9, 2009. Psychosocial evaluations were required in six client records. The facility did not document a clinical assessment of assets/strengths, support systems and negative factors in client records #1, 2, 3, 4, 5 and 6.
The facility did not document a psychosocial evaluation completed within the timeframe of four weeks as stipulated in facility policy in client records # 2, 3 and 4.
Client record #2 documents an admission date of 9/30/08. The psychosocial evaluation was completed on 12/11/08.
Client record #3 documents an admission date of 9/5/08. The psychosocial evaluation was completed on 10/15/08.
Client record #4 documents an admission date of 9/18/08. The psychosocial evaluation was completed on 11/19/08.
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Plan of Correction
The Division Director will provide three staff training sessions by 3/16/09 to improve staff skills at completing psychosocial evaluations. We have recently revised our psychosocial evaluation to facilitate this process. The Unit Director will be responsible for reviewing evaluations on a weekly bassis to ensure compliance.
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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 an individual treatment and rehabilitation plan which had been developed with each client in two of six client records. The facility failed to document the completion of the individual treatment plan within the 30 day timeframe in accordance with facility policy in two of six client records.
Findings:
Nine client records were reviewed on January 9,2009. An individual treatment and rehabilitation plan was required in six client records. The facility failed to document that the individual treatment and rehabilitation plan was developed with each client in client records #1 and 2. The treatment plan in these client records was not signed by the client and progress notes did not document a discussion of the treatment plan.
The facility failed to document the completion of the treatment plan within 30 days as per facility policy in client records #3 and 4.
Client record #3 documents an admission date of 9/5/08. The treatment plan was completed on 10/15/08.
Client record #4 documents an admission date of 9/18/08. The treatment plan was completed on 11/19/08.
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Plan of Correction
The Unit Director will conduct a staff training by 3/16/09 to ensure that all clients sign their treatment upon completion with their counselor or the counselor reference to a review of the treatment plan with the client at the next session followint the completion of the plan. The Unit Director will monitor this procedure on a weekly basis to ensure compliance.
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709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services in the individual treatment and rehabilitation plan in three of five client records.
Findings:
Nine client records were reviewed on January 9, 2009. Individual treatment and rehabilitation plans with proposed type of support service were required in six client records. The facility failed to document the proposed type of support service in client records #3, 4 and 5.
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Plan of Correction
By 3/16/09, The Unit Director will conduct a training session for all counselors to stress the importance of consistently documenting support services for our clients on their treatment plans. The Unit Director will also monitor the support service component of treatment plans weekly to ensure compliance. |
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 in two of three client records.
Findings:
Nine client records were reviewed on January 9, 2009. Treatment and rehabilitation plan updates were required in three client records. The facility failed to document a review of progress on goals stated in the prior treatment plan in two of three client records, #1 and 3.
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Plan of Correction
By 3/16/09, the Division Director will conduct two traning sessions for staff to improve their skills at documenting a review of client progress on goals stated in the prior treatment plan. The Unit Director will monitor treatment plans on a weekly basis to ensure compliance. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a record of services provided which included who provided the services in six of six client records
Findings:
Nine client records were reviewed on January 9, 2009, Six client records were reviewed for the record of services provided. The facility failed to document a record of services provided which included who provided the services in client records #1, 2, 3, 4, 5 and 6.
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Plan of Correction
The Unit Director will instruct staff to apply the initials (rather than a check mark) on the record of services provided to clearly indicate who provided the service. The Unit Director will monitor record of service forms at least monthly to ensure compliance. |