INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on January 12, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, NET Treatment Services, 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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705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, the facility failed to provide soap in each bathroom.
The findings include:
An inspection of the facility's physical plant was conducted on January 12, 2012 between approximately 8:30 AM and 9:30 AM. At the time of inspection, the men's client bathroom in the front lobby did not have soap.
An interview with the facility director on January 12, 2012 confirmed the findings.
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Plan of Correction
NET maintenance has corrected the matter of the lack of soap in the men's client bathroom as of January 12, 2012. Soap has been added to the soap dispenser in the men's client bathroom in addition to the presence of hand sanitizer. Maintenance and the NET site clinical supervisor will check daily to ensure the client men's bathroom has soap in the soap dispenser. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on an inspection of the facility's physical plant, the facility failed to have hot water.
The findings include:
An inspection of the facility's physical plant was conducted on January 12, 2012 between approximately 8:30 AM and 9:30 AM. At the time of inspection, the men's and women's client bathrooms in the front lobby did not have hot water. The water temperature did not exceed 50 interview with the facility director on January 12, 2012 confirmed the findings.
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Plan of Correction
NET contacted the owner of the property located at 2701 Broad Street to inform the property owner of the lack of hot water. As a result, on January 14, 2012, building maintenance has conducted an inspection of this problem and corrected the issue of the lack of hot water in the men's and women's client bathrooms in the front lobby area. Building maintenance will continue to check daily, the temperature of the water in the client men's and women's bathroom to ensure that hot water is available. |
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:
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Observations
Based on the review of client records, the facility failed to comply with 4 Pa. Code relating to projects and coordinating bodies: disclosure of client-oriented information.
The findings include:
On January 12, 2012 four client records were reviewed for documentation of informed and voluntary consent, specifically records # 1, 2, 3 and 4. The facility documented the release of client information which exceeded the limitations of 4 Pa. Code in client records # 1, 2, 3 and 4.
Client records # 1, 2, 3 and 4 contained a signed consent to release information form that released the client's "Urinalysis" to the courts.
Client # 1 was admitted on 8/3/11. Client # 1's record contained a signed consent form releasing the client's "Urinalysis" to the courts.
Client # 2 was admitted on 8/17/11. Client # 2's record contained a signed consent form releasing the client's "Urinalysis" to the courts.
Client # 3 was admitted on 9/30/11. Client # 3's record contained a signed consent form releasing the client's "Urinalysis" to the courts.
Client # 4 was admitted on 8/8/11. Client # 4's record contained a signed consent form releasing the client's "Urinalysis" to the courts.
An interview with the facility director on January 12, 2012 confirmed the findings.
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Plan of Correction
By February 13, 2012, NET Facility Director will contact the Director of Philadelphia Treatment Court, to acquire a court order, signed and submitted by a judge of the courts, to order Urinalysis results for each client stipulated to Drug and Alcohol treatment be released to the court. |
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 a psychosocial evaluation that included an accurate composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions, and causes leading to the client's current situation in four out of four records reviewed.
The findings include:
On January 12, 2012, four client records were reviewed for psychosocial evaluations, specifically records # 1, 2, 3 and 4. The facility did not document an accurate psychosocial evaluation that included a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions, and causes leading to the client's current situation in client records # 1, 2, 3 and 4.
In client records 1, 2, 3 and 4, the content of each psychosocial evaluation included various instances of inaccurate, erroneous, and/or contradictory client information. Additionally, the psychosocial evaluations contained frequent pronoun misuse and excessive use of identical standardized language that appeared in all four client records.
Client # 1 was admitted on 8/3/11. The psychosocial evaluation in client # 1's record dated 8/9/11 did not include an accurate composite picture of the individual in relationship to the collected historical information.
Client # 2 was admitted on 8/17/11. The psychosocial evaluation in client # 2's record dated 8/22/11 did not include an accurate composite picture of the individual in relationship to the collected historical information.
Client # 3 was admitted on 9/30/11. The psychosocial evaluation in client # 3's record dated 10/6/11 did not include an accurate composite picture of the individual in relationship to the collected historical information.
Client # 4 was admitted on 8/8/11. The psychosocial evaluation in client # 4's record dated 8/12/11 did not include an accurate composite picture of the individual in relationship to the collected historical information.
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Plan of Correction
As of February 1, 2012, NET clincial supervisor has been reviewing active client records to ensure no erroneous information and that all client evaluations clearly address any and all inconsistencies that may be stated by client throughout the Bio-psychosocial history collection. NET clinical supervisor met with clinical staff on January 26, 2012, instructing the clinical staff to no longer use pronouns within the evaluation to ensure there is no future misuse of pronouns. Lastly, NET clinical supervisor met with the clinical staff on January 26, 2012 and discussed the need to ensure that all contradictory information noted within the BPS history is discussed clearly throughout the Evaluation, and without excessive use of standardized clinical language. To ensure ongoing compliance NET clinical supervisors will review weekly all newly written assessments to eliminate inconsistences, erroneous, or standardized language. |
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.
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Observations
Based on the review of client records, the facility failed to document an individual treatment and rehabilitation plan that included realistic short and long-term goals for treatment as formulated by both the staff and client in four out of four records.
The findings include:
On January 12, 2012, four client records requiring individual treatment and rehabilitation plans were reviewed for short and long-term goals, specifically records # 1, 2, 3 and 4. The individual treatment and rehabilitation plans in client records # 1, 2, 3 and 4 contained excessive use of identical standardized language including short and long-term goals that were identical in part. Additionally, the excessive number of identified treatment objectives were unrealistic, and many of the treatment objectives were not concrete and would not lead to treatment goal completion.
Client # 1 was admitted on 8/3/11. The individual treatment and rehabilitation plan in client # 1's record dated 8/8/11 did not include realistic short and long-term goals for treatment as formulated by both the staff and client.
Client # 2 was admitted on 8/17/11. The individual treatment and rehabilitation plan in client # 2's record dated 8/22/11 did not include realistic short and long-term goals for treatment as formulated by both the staff and client.
Client # 3 was admitted on 9/30/11. The individual treatment and rehabilitation plan in client # 3's record dated 10/14/11 did not include realistic short and long-term goals for treatment as formulated by both the staff and client.
Client # 4 was admitted on 8/8/11. The individual treatment and rehabilitation plan in client # 4's record dated 8/12/11 did not include realistic short and long-term goals for treatment as formulated by both the staff and client.
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Plan of Correction
NET clinical supervisors met with counseling staff on January 26, 2012, to discuss the need to ensure that a client's treatment plan is reflective of clients noted personal goals as well as realistic short and long term goals to assist client in achieving that goal. Couneling staff will utilize supporting documents such as the Life Domain Assessment Scale, the SNAPs, the URICA, DAST, AUDIT, ZUNG, and Trauma Assessment for Adults, as well as the Recovery Planning worksheet to effectively identify clients noted goals as well as realistic and achievable objectives client can take in order to achieve those goals. Lastly, NET Quality Assurance Team has educated clinical staff on the need to ensure all short and long term objectives are concrete and able to be measured in order to ensure that the client is able to achieve these objectives, and, ultimately, lead to treatment goal completion. NET clinical supervisor will audit all newly written plans to ensure compliance with the above prior to approving, via signature, of all treatment plans. |
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 the review of client records, the facility failed to document treatment plan updates to include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in four out of four records.
The findings include:
On January 12, 2012 four client records requiring treatment plan updates were reviewed, specifically records # 1, 2, 3 and 4. The facility did not document a treatment plan update to include an assessment of the client's progress in client records # 1, 2, 3 and 4.
Client # 1 was admitted on 8/3/11. The treatment plan updates in client # 1's record dated 9/26/11 and 11/14/11 did not include an assessment of progress.
Client # 2 was admitted on 8/17/11. The treatment plan updates in client # 2's record dated 10/17/11 and 11/28/11 did not include an assessment of progress.
Client # 3 was admitted on 9/30/11. The treatment plan update in client # 3's record dated
10/14/11 did not include an assessment of progress.
Client # 4 was admitted on 8/8/11. The treatment plan updates in client # 4's record dated
10/10/11 and 11/30/11 did not include an assessment of progress.
An interview with the facility director on January 12, 2012 confirmed the findings.
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Plan of Correction
NET clinical supervisors met with counseling staff on January 26, 2012 and educated the counseling staff on the need to ensure that all treatment plan updates include a clear assessment of the client's progress since entering treatment. NET clinical supervisors discussed the need for the counseling staff to include a clear prognosis of the client's progress on each update as well as include an overall assessment of the progress noted. Additionally, NET clinical supervisor educated the counseling staff on the need to ensure that each goal is addressed, and, should the client not make progress on any particular goal, an assessment of why a lack of progress will be noted for that goal as well as a modification to therapeutic interventions as a means of further supporting the client in making progress on such goal. To ensure ongoing compliance, NET clinical supervisors will review weekly all newly developed treatment plan updates to ensure the above is completed. The clinical supervisor's signature on the treatment plan update will signify compliance with above. |
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 the review of client records, the facility failed to document a complete record of services provided in four out of four records.
The findings include:
On January 12, 2012 four client records requiring a record services were reviewed, specifically records # 1, 2, 3 and 4. The facility did not document a record services provided to include individual counseling sessions in client records # 1, 2, 3 and 4.
Client # 1 was admitted on 8/3/11. The record of services in client # 1's record documented group counseling sessions only. It did not include individual counseling sessions.
Client # 2 was admitted on 8/17/11. The record of services in client # 2's record documented group counseling sessions only. It did not include individual counseling sessions.
Client # 3 was admitted on 9/30/11. The record of services in client # 3's record documented group counseling sessions only. It did not include individual counseling sessions.
Client # 4 was admitted on 8/8/11. The record of services in client # 4's record documented group counseling sessions only. It did not include individual counseling sessions.
An interview with the facility director on January 12, 2012 confirmed the findings.
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Plan of Correction
As of February 1, 2012, NET Quality Assurance Team has met with the medical records team to discuss the need to ensure the completion and filing of client record of service. This record of service will be a detailed report of all clinical services provided to client since admission, which will include group therapy sessions, psycho-educational group sessions, individual therapy sessions, psychiatric services, etc. These services will include the date of the service provided, the type of service provided, the duration of the service provided, and the name of the individual who provided the service. The quality assurance team will review client records weekly to ensure the completion and filing of the client record of service. |