INITIAL COMMENTS
|
This report is a result of an on-site licensing inspection conducted on March 6, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Carbon-Monroe-Pike Drug and Alcohol Commission, 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:
|
Plan of Correction
|
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on the review of client records, the facility failed to document a letter of termination for each client who was involuntarily discharged.
The findings included:
An onsite licensure renewal inspection was conducted on March 7, 2012. Nine client records were reviewed. Two of these client records were those of clients who were discharged for non-compliance with facility rules. Two of two applicable client records failed to include documentation of a letter of termination notifying the client of an involuntary discharge.
Client record # 1- The client was admitted on 8/22/11 and discharged on 10/3/11 for not adhering to attendance requirements. No letter of termination was documented in this individual's client record.
Client record # 2- The client was admitted on 6/2/11 and discharged on 7/26/11 for not adhering to attendance requirements. No letter of termination was documented in this individual's client record.
The findings were reviewed with the Facility Director and lead counselor and were not disputed.
|
Plan of Correction
709.33 (a) Notification of Termination;
On April 2, 2012 clinical staff will meet with the Outpatient Supervisor to review this finding. Staff will sign off on attendance and if absent will review individually and then sign off on the date they received the new protocol. The process for sending out letters of termination will be reviewed and documented in the notes of the meeting which will be signed off on by all staff. Templates will be provided to each staff member electronically to utilize for clients who are being terminated. Two templates have been designed for the most common reasons for termination to include; not being seen in thirty days and violation of an attendance contract. Should other reasons arise which do not fit into these templates the clinical staff will be instructed to see the Outpatient Supervisor and draft an appropriate letter together which will include the date of termination, how to reengage in services, and the grievance policy.
See attachment examples below
Date:
Client Name:
Address:
Dear __________,
Our records indicate that you have not been seen in a few weeks. Our policy indicates that in order to remain an active client with our agency you must be seen within thirty days. You have been scheduled for an appointment on _______________. If you do not show for that appointment, you will be terminated from our program on ____________________.
Should you need to access services at a later time you will need to contact our Referral Center at 1-866-824-3578 to reengage in services. If you feel you were unfairly terminated from our program you may file a grievance by calling our Administrative Office at (570) 421-1960 Ext. 3726. You will be asked to leave a message and someone from our administrative team will contact you to discuss your concerns.
Sincerely,
Counselor Name
Counselor Title
Example if attendance contract in place:
Date:
Client Name:
Address:
Dear __________,
Our records indicate that you did not show for your last scheduled appointment. As a result of being on an attendance contract stating you were unable to miss any further appointments, you are being terminated from our program effective ___________________.
Should you need to access services at a later time you will need to contact our Referral Center at 1-866-824-3578 to reengage in services. If you feel you were unfairly terminated from our program you may file a grievance by calling our Administrative Office at (570) 421-1960 Ext. 3726. You will be asked to leave a message and someone from our administrative team will contact you to discuss your concerns.
Sincerely,
Counselor Name
Counselor Title
|
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 the review of client records, the facility failed to document psychosocial evaluations that addressed client needs, support systems, the clients' attitude toward treatment, negative factors and the counselor's clinical impressions in five of eight client records.
The findings included:
An onsite licensing renewal inspection was conducted on 3/7/12 . Nine client records were reviewed. Eight client records were due to include documentation of psychosocial evaluations. Five of eight client records failed to include documentation of psychosocial evaluations that included the client's needs, available support systems, attitude toward treatment, negative factors and the clinical impressions of the clinician.
Client record # 1- This client was admitted on 8/22/11 and discharged on 10/3/11. The psychosocial evaluation failed to include documentation of the client's needs, available support systems, attitude toward treatment and the clinical impressions of the clinician. The content of the psychosocial evaluation tended to document a historical perspective rather than draw clinical impressions from the collected history.
Client record # 3- The client was admitted on 2/9/11 and discharged on 8/1/11. The psychosocial evaluation failed to include documentation of the client's needs, coping mechanisms, negative factors which may impact treatment and the clinical impressions of the counselor. The content of the psychosocial evaluation tended to document a historical perspective rather than draw clinical impressions from the collected history.
Client record #4- The client was admitted on 2/9/11 and discharged on 8/1/11. The psychosocial evaluation failed to document a description of the client's needs, the client's coping mechanisms, negative factors impacting treatment and the clinical impressions of the counselor. The content of the psychosocial evaluation tended to document a historical perspective rather than draw clinical impressions from the collected history.
Client record # 8- The client was admitted on 11/17/11 and was last seen on 2/16/12. The psychosocial evaluation failed to include documentation of support systems available to the client.
Client record # 9 - The client was admitted on 1/12/12 and was last seen on 3/5/12. The psychosocial evaluation failed to include documentation of the client's needs, support systems and coping mechanisms and failed to include the clinical impressions of the counselor. The content of the psychosocial evaluation tended to document a historical perspective rather than draw clinical impressions from the collected history.
The findings were reviewed with the Facility Director and Lead Counselor and were not disputed.
This is a repeat citation.
|
Plan of Correction
709.91 (b)(6) Intake and Admission: On April 2, 2012 the clinical staff will meet with the Outpatient Supervisor to review this finding and provide additional training. All staff will sign off on attendance of this training, and anyone not in attendance will be provided the information individually by the Outpatient Supervisor and then sign off on the attendance with date provided. Examples will be provided to all clinical staff utilizing files which document all required clinical perspectives. In addition the prompts will be reviewed that are given in the psychosocial summary with examples for each prompt. Clinical staff will use an example history to construct a subjective evaluation and read to the group for suggestions. All staff will sign off that they have attended this training. Any psychosocial done on April 3, 2012 and forward will be reviewed in a random sampling by the Outpatient Supervisor at a minimum of one per each clinician weekly. If any component is missing the Outpatient Supervisor will provide notes on what needs to be fixed and give the counselor a week to make corrections before it is to be turned in directly to the Outpatient Supervisor. If issues persist individual supervision will be provided by the Outpatient Supervisor. |
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 the review of client records, the facility failed to document aftercare plans which included timeframes for the stated goals in two of two client records.
The findings included:
Nine client records were reviewed during the onsite licensure renewal inspection conducted on 3/7/12. Two of these were discharged clients where documentation of an aftercare plan was required. Two of two client records failed to include documentation of aftercare plans which included goals with timeframes.
Client record # 3 - This client was admitted on 2/9/11 and discharged on 8/1/11. The aftercare plan failed to include documentation of timeframes on the stated goals.
Client record # 5- This client was admitted on 5/19/10 and discharged on 12/13/11. The aftercare plan failed to include documentation of timeframes on the stated goals.
The findings were reviewed with the Facility Director and the lead counselor and were not disputed.
|
Plan of Correction
709.93 (a)(9) Client Records: Aftercare Plan
On April 2, 2012 the clinical staff will attend a training to review this finding. All staff will sign documenting attendance of this training. The Outpatient Supervisor will discuss need for timeframes, as well as clear, concrete goals. Examples will be provided and suggestions given on how to improve the plans using existing client aftercare plans. The following elements discussed:
1. Need to make sure the plan is reviewed by the counselor and not just completed by the client as indicated by distinction in the writing on the plan. A comment should be added by the counselor on each plan
2. Goals on the aftercare plan should be clear, concrete and include definite time frames
When reviewing a case at discharge the Outpatient Supervisor will review the aftercare plan to assure goals are measurable and include time frames. If it is discovered that this is not occurring the Outpatient Supervisor will schedule individual supervision with the counselor to address this issue
|
709.93(a)(10) 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:
(10) Discharge summary.
|
Observations
Based on the review of client records, the facility failed to document discharge summaries which included the reason for treatment and the services offered to the client while in treatment in three of four client records.
The findings included:
Nine client records were reviewed during the licensure renewal inspection conducted on 3/7/12. Four of these records were required to include documentation of discharge summaries. Three of four discharge summaries were incomplete and did not include documentation of the reasons for treatment and the services provided to the client while in treatment.
Client record # 1 - This client was admitted on 8/22/11 and discharged on 10/3/11. The discharge summary did not include documentation of the reason for treatment.
Client record # 2- The client was admitted on 6/2/11 and discharged on 7/26/11. The discharge summary did include documentation of the services offered to the client while in treatment.
Record # 5- This client was admitted on 5/19/10 and discharged on 12/13/11. The discharge summary did include documentation of the services offered to the client while in treatment.
The findings were reviewed with the Facility Director and the Lead Counselor and were not disputed.
|
Plan of Correction
709.93 (a)(10) Client Records: Discharge Summary
On April 2, 2012 the clinical staff with attend training with the Outpatient Supervisor to review this finding. The staff will sign off that they have attended this training . If a staff member is unable to attend they will meet individually with the Outpatient Supervisor and then note date on the sign in sheet of the training. The Outpatient Supervisor will provided examples of both reasons for treatment and services offered and how to include these in the discharge summary. An example will be provided to staff and they will practice including these elements in the discharge summary. These examples will be retained with the notes of the training.
When reviewing each discharged chart the Outpatient Supervisor will review the discharge summary and prior to signing off on it will return any discharge summary not containing the necessary elements of services offered and/or reason for treatment. The clinician will have one week to make corrections and directly return to the Outpatient Supervisor. If issues persist the Outpatient Supervisor will schedule individual supervision to discuss these issues.
|
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
|
Observations
Based on a review of the policy and procedure manual, the facility failed to provide documentation of a policy on follow up procedures for clients referred to other facilities.
The findings included:
The policy and procedure manual was reviewed during the licensure renewal inspection conducted on 3/7/12. There was no documentation of a policy which addressed follow up procedures for client referrals made to outside agencies.
An interview with the Facility Director confirmed that there was no policy provision to address the issue of the required seven day follow up for referrals out of the facility.
|
Plan of Correction
Carbon Monroe Pike Drug and Alcohol Commission, Inc
POLICY: 7 Day Follow Up on Referrals
PROCEDURE: Based on licensing standard 709.94 (e) the Commission will implement a policy on 7 day follow up of all referrals. No referrals will be made to outside agencies without first signing the appropriate releases of information. Any referral made outside of the agency will be documented in the progress notes if it was made during and Outpatient Session. If the referral was made outside of a session the case management notes will be utilized to document the referral. When the referral is made the counselor will count seven days and put a prompt to contact the referral agency in their Outlook Calendar. If the counselor is out of the office they will call the next business day and explain this in the case management note. These times will be put in during the 9am to 10am calendar slot. The counselor will contact the referral agency and document on a case management note disposition of the referral.
During the weekly treatment meeting the Outpatient Supervisor will discuss with clinical staff if any referrals were made during the week and disposition of any follow up calls, as a way to remind staff of this task and any problems that may be arising in making referrals.
Once approved this policy will be reviewed with staff, put on the agenda for approval at the next board meeting on April 24, 2012, and placed in the policy and procedure book.
|