INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 18-19, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Aldie Counseling 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:
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of the policy and procedure manual and personnel records, the facility failed to document an assessment of staff training needs in five of eleven employee records.
The findings include:
Facility Policy labeled "Staff Development and Training" states "Aldie's Training Needs Assessment form is to be completed by all staff at the end of May of each year to provide feedback on needed and suggested trainings". The facility training year runs July-June.
Eleven personnel records requiring documentation of a training needs assessment were reviewed on December 18, 2012. The facility failed to document the completion of a training needs assessment in five of eleven records, specifically employee records # 2, 3, 10, 11, and 12.
Employee # 2 was hired as the Facility Director on 3/24/10. The facility failed to provide documentation of a training needs assessment according to policy for the July 2012-June 2013 training year.
Employee # 3 was hired as the Clinical Supervisor on 12/13/10. The facility failed to provide documentation of a training needs assessment according to policy for the July 2012-June 2013 training year.
Employee # 5 was hired as the Clinical Director on 8/1/11. The facility failed to provide documentation of the completion of the training needs assessment by the end of May 2012 for the July 2012-June 2013 training year. The training needs assessment in this personnel file was completed on 11/23/11.
Employee # 8 was hired as a counselor on 7/30/07. The facility failed to provide documentation of the completion of the training needs assessment by the end of May 2012 for the July 2012-June 2013 training year. The training needs assessment in this personnel file was completed on 11/28/11.
Employee # 9 was hired as a counselor on 1/4/11. The facility failed to provide documentation of the completion of the training needs assessment by the end of May 2012 for the July 2012-June 2013 training year. The training needs assessment in this personnel file was completed on 1/4/12.
Employee # 10 was hired as a counselor on 3/24/06. The facility failed to provide documentation of a training needs assessment according to policy for the July 2012-June 2013 training year.
Employee # 11 was hired as a counselor on 6/21/11. The facility failed to provide documentation of a training needs assessment according to policy for the July 2012-June 2013 training year.
Employee # 12 was hired as a counselor on 6/4/12. The facility failed to provide documentation of a training needs assessment according to policy for the July 2012-June 2013 training year.
The Operations Director confirmed the findings.
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Plan of Correction
An assessment of staff training needs for the 2013-2014 training year will be accomplished via a staff discussion led by the clinical director that has been scheduled for the May 7, 2013 staff meeting. The narrative summary of this discussion will be used by the clinical director in the development of the overall staff training plan for the 2013-2014 training year. The executive director will monitor compliance via a completed plan being in place by July 1, 2013. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the staffing requirements facility summary report and personnel records, the facility failed to provide documentation of individual training plans in 19 of 25 employee records.
The findings include:
The facility staffing requirements summary report and 25 personnel records requiring documentation of an individual training plan were reviewed on December 18, 2012. The facility failed to document an individual training plan in 19 of 25 records, specifically employee records # 3, 4, 7, 9, 10, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, and 28.
An interview with the Operations Director and Clinical Supervisor on December 18 and 19, 2012 confirmed that the training plans for July 2012-June 2013 training year were not completed for staff.
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Plan of Correction
The listed employee records will each have an individualized training plan completed for the 2012-2013 training year by Feb. 22, 2013.
The executive director will create an electronic spreadsheet that will be readily available to all supervisors and other staff which lists the required trainings and completion dates for all staff members, and will also include a column for completed individual treatment plans. Each supervisor will be responsible for checking this list at least quarterly, and for making sure that their supervisees have completed an individual treatment plan within the applicable timeframe. The executive director will review this list on a quarterly basis to ensure compliance with this requirement. |
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 the Staffing Requirements Facility Summary Report, training records, and personnel records, the facility failed to provide documentation of HIV/AIDS and TB/STD training in three of ten employee records.
The findings include:
The Staffing Requirements Facility Summary Report and ten personnel records requiring documentation of HIV/AIDS and TB/STD training were reviewed on December 18-19, 2012. Per regulation, staff persons shall receive a minimum of four hours of TB/STD training and six hours of HIV/AIDS training. Counselors and counselor assistants shall complete the training within the first year of employment and all other staff shall complete the training within the first two years of employment. The facility failed to provide documentation for the required training in three of ten employee records, specifically employee records # 13, 14, and 15.
Employee # 13 was hired 7/5/11 as a counselor. This employee was required to obtain four hours of TB/STD and six hours of HIV/AIDS training by 7/5/12. Employee #13 failed to obtain both TB/STD and HIV/AIDS training as of the date of the inspection.
Employee #14 was hired 12/12/11 as a counselor. This employee was required to obtain four hours of TB/STD and six hours of HIV/AIDS training by 12/12/12. Employee #14 failed to obtain six hours of HIV/AIDS training as of the date of the inspection.
Employee #15 was hired 9/29/10 as a support staff member. This employee was required to obtain four hours of TB/STD and six hours of HIV/AIDS training by 9/29/2012. Employee #15 failed to obtain both TB/STD and HIV/AIDS training as of the date of the inspection.
The Operations Director confirmed the findings.
This is a repeat citation. The facility was cited on December 13, 2011 for noncompliance with this standard.
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Plan of Correction
The three listed employees shall provide documentation of having completed the missing trainings within the next three months. The executive director will create an electronic spreadsheet that will be readily available to all supervisors and other staff, which lists the required trainings and completion dates for all staff members. Each supervisor will be responsible for checking this list at least quarterly, and for making sure that their supervisees obtain all the trainings within the applicable timeframes. The executive director will review this list on a quarterly basis to ensure compliance with this requirement. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report form completed by the facility on 12/18/12 and an interview with the Operations Director, the facility failed to ensure that staff caseloads remained at or under 35:1 and comply with the exception for the patient to counselor ratio granted by the Division on October 20, 2009.
The findings include:
The Staffing Requirements Facility Summary Report form completed by the facility was reviewed on 12/18/12. The form listed 11 counselors, three clinical supervisors, a project director and facility director as clinical staff .The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 40 hours per week.
Based on the total number of hours per week that the facility reported the employees devoted to their clients, the total number of hours in the facility's standard work week (40), and the total number of clients assigned to the following employees on 12/18/12 employee # 29 exceeded the allowable maximum 35:1 caseload.
The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients' treatment by the facility's standard workweek.
Employee # 29 was hired as a counselor on 9/27/10. The number of hours per week devoted by employee # 29 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 40 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that employee #29 had 43 active clients with six clients on reduced counseling status which resulted in a caseload of 40:1.
The Operations Director confirmed the findings.
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Plan of Correction
The program coordinators shall review caseload assignment reports on a monthly basis to insure that the 35:1 ratio is not exceeded for each individual counselor, and will make reassignments to other counselor as necessary to maintain compliance. The clinical director shall also review caseload reports on a quarterly basis to also verify ongoing compliance. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on observation by the Licensing Specialists, the facility failed to ensure that there were no portable heaters within the facility.
The findings include:
A portable space heater was discovered inside the cabinet of an office at approximately 12:58 PM on December 19, 2012.
The discovery of the portable space heater in the cabinet of the office was discussed with the Operations Director who confirmed the findings.
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Plan of Correction
All staff were reminded at the Jan. 15, 2013 staff meeting that portable space heaters are not allowed within the facility and that any such heaters are to be either removed from the facility or permanently mounted/installed. Supervisors will monitor compliance via visual inspections of supervisee office areas. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to ensure that each employee received the required training in the use of a fire extinguisher upon employment.
The findings included:
Eight personnel records requiring documentation of fire extinguisher training were reviewed on December 18, 2012. The facility failed to document fire extinguisher training in two of eight personnel records, specifically employee records # 9 and 11.
Employee # 9 was hired on 1/4/11 as a counselor. This employee record contained a certificate for fire extinguisher training but it did not include the date the training was completed. It could not be determined whether or not this employee received the training and/or when that training was completed.
Employee # 11 was hired on 6/21/11 as a counselor. The facility failed to document the completion of fire extinguisher training in this employee record.
The Operations Director confirmed the findings.
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Plan of Correction
Documentation of the date employee #9 completed fire extinguisher training has been entered in the person's personnel file. Documentation of employee #11 completion of fire extinguisher training has been entered in the person's personnel file.
Each new employee's supervisor is responsible for insuring that the employee completes the fire extinguisher training within the first week of employment. The executive director will create an electronic spreadsheet that will be readily available to all supervisors and other staff, which lists the required trainings and completion dates for all staff members. Each supervisor will be responsible for checking this list at least quarterly, and for making sure that their supervisees obtain all the trainings within the applicable timeframes. The executive director will review this list on a quarterly basis to ensure compliance with this requirement. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
The findings include:
Eight personnel records requiring documentation of training of assigned tasks during emergencies were reviewed on December 19, 2012. The facility failed to provide documentation of the completion of the required training in two of eight records, specifically records # 9 and 11.
Employee # 9 was hired on 1/4/11 as a counselor. The facility failed to document the completion of emergency training in this employee record.
Employee # 11 was hired on 6/21/11 as a counselor. The facility failed to document the completion of emergency training in this employee record.
The Operations Director confirmed the findings.
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Plan of Correction
Documentation of these two employees both having completed emergency training has been entered in their personnel files.
Each new employee's supervisor is responsible for insuring that the employee completes the emergency response training. The executive director will create an electronic spreadsheet that will be readily available to all supervisors and other staff, which lists the required trainings and completion dates for all staff members. Each supervisor will be responsible for checking this list at least quarterly, and for making sure that their supervisees obtain all the trainings within the applicable timeframes. The executive director will review this list on a quarterly basis to ensure compliance with this requirement. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs, the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
The findings include:
Fire drill logs were reviewed on December 18, 2012 for the time period of January - November 2012. The documentation on the fire drill logs did not include the exit route used, the number of persons in the facility at the time of the file, and whether the fire alarm or smoke detector were operative.
The Operations Director confirmed the findings.
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Plan of Correction
The fire drill log form has been changed to include the items required by this standard. The office manager will document these items upon the completion of each fire drill. The facility director will monitor compliance via an initial review of the log after the next drill, and then bi-annually. |
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.
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Observations
Based on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill logs were reviewed on December 18, 2012 for the time period of January - November 2012. The facility fire drill logs included documentation of appropriate evacuation routes used by staff and clients, however, the logs did not specify which exits were used. It could not be determined if alternate exits were used during the drills.
The Operations Director confirmed the findings.
This is a repeat citation. The facility was cited on December 13, 2011 for noncompliance with this standard.
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Plan of Correction
The fire drill log form has been changed to include this item. The office manager will document the alternate used when completing the form. The facility director will monitor compliance via an initial review of the log after the next drill, and then bi-annually. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the fire drill logs, the facility failed to ensure that fire drills were conducted during different times of the day.
The findings include:
Fire drill logs were reviewed on December 18, 2012 for the time period of January - November 2012. The facility's hours of operation are Monday-Thursday from 6:00 AM until 9:00 PM, Friday 6:00 AM until 4:00 PM, and Saturday 8:00 AM until 12:00 PM. The facility is open on Sunday's for dispensing only. The hours are 8:00 AM until 10:00 AM The facility failed to document fire drills between the hours of 6:00 AM until 9:15 AM and 2:30 PM until 9:00 PM All of the fire drills documented were between the hours of 9:15 AM and 2:30 PM.
The Operations Director confirmed the findings.
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Plan of Correction
The office manager will conduct each fire drill at different times than the previous two drills, ensuring the times are representative of the facility's range of office hours, and will document those times when completing the fire drill log form. The facility director will monitor compliance via an initial review of the log after the next drill, and then bi-annually. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill logs, the facility failed to document whether the fire alarm/smoke detector system was operational.
The findings include:
Fire drill logs were reviewed on December 18, 2012 for the time period of January - November 2012. The facility fire drill logs did not contain documentation on whether the fire alarm/smoke detector was operational at the time of the fire drill.
The Operations Director confirmed the findings.
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Plan of Correction
The fire drill log form has been changed to include this item. The office manager will document whether or not the fire alarm/smoke detector system was operational when completing the form. The facility director will monitor compliance via an initial review of the log after the next drill, and then bi-annually. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of letters of agreement, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24-hour emergency medical coverage.
The findings include:
The letters of agreement were reviewed on December 19, 2012. There was a letter of agreement with a local hospital, however, it failed to indicate that they provided 24- hour emergency medical coverage The agreement was signed on July 13, 2012. There was no other documentation of a 24- hour emergency medical coverage agreement.
The Operations Director confirmed the findings.
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Plan of Correction
A revised referral agreement will be re-submitted to the local general hospital for approval and signature, which will specify that the hospital's emergency department does indeed provide 24-hour medical coverage to persons needing such service. The office manager responsible for maintaining the referral agreements will ensure that written agreement is returned by the hospital to the facility and is placed in the facility's agreement binder. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on observation during the physical plant inspection, the facility failed to secure client records within locked storage containers.
The findings include:
While walking through the hallway where the counselor and administrative offices are located on December 18, 2012 at approximately 2:00 PM, again at 3:30 PM during the physical plant inspection, and lastly on December 19, 2012 at 12:05 PM before the exit interview began, it was discovered that the top portion of the filing cabinet was unlocked. This cabinet contained client records.
The Operations Director confirmed the findings.
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Plan of Correction
The client records stored in the one non-locking file cabinet drawer were removed and placed in another locked storage container. The remainders of the filing cabinet's drawers are securely locked; therefore, no records will be stored in the unsecured drawer until it is fixed.
The facility director has placed a sign on the one cabinet drawer with the faulty locking mechanism stating that this drawer is not to be used for storing client records or other client identifying information until the drawer's locking apparatus is fixed. The facility director checked all the other drawers and they all are properly locked. The office manager was instructed to inform the facility director if any filing cabinet drawers fail to lock properly, and to immediately remove any client identifying information from such drawers until it is fixed.
All staff who handle client records are responsible on a daily basis for maintaining client records in locked storage containers, and are instructed to inform the office manager whenever they access a record storage container that they are not able to re-lock; including any portion of the container such as a file cabinet drawer. |
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 ensure that an informed and voluntary consent to release information was obtained in two of twelve client records. In addition, the facility also exceeded the limitations imposed at 4 Pa. Code, Subsection 255.5(b) in one of twelve client records..
The findings include:
Twelve client records requiring documentation of a consent to release information were reviewed on December 18-19, 2012. Two out of twelve client records failed to include a consent to release information prior to the release of information, specifically clients # 2 and 4. One out of twelve client records had a consent to release of information that exceeded the limits of 4 PA Code 255.5, specifically client #9
Client record #2 contained a Pennsylvania Client Placement Criteria (PCPC) summary which included the disclosure of drugs of choice and current medications. 4 PA Code 255.5 (b) limits the amount of information that can be released to insurance companies, managed care plans and other third party payers to:
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or
alcohol abuse and the frequency of such relapse.
Client record # 4 contained a PCPC summary which included the disclosure of drugs of choice and current medications. 4 PA Code 255.5 (b) limits the amount of information that can be released to insurance companies, managed care plans and other third party payers to:
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client ' s progress.
(5) A short statement as to whether the client has relapsed into drug or
alcohol abuse and the frequency of such relapse.
Client record #9 contained 2 consent to release information forms for a release of client identifying information to a government agency. The first was dated 9/13/12 and allowed for the release of assessment results (treatment recommendations). The second was dated 9/17/12 and allowed for the release of the client's social summary, termination summary, medication information, psychiatric report, and "other": any and all information pertaining to the welfare of children. 4 PA Code 255.5(b) limits the amount of information that can be released to a government agency:
(1) Whether the client is or is not in treatment.
(2) Client ' s prognosis.
(3) The nature of the project.
(4) A brief description of the client ' s progress.
(5) A short statement as to whether the client has relapsed into drug or
alcohol abuse and the frequency of such relapse.
The Operations Director confirmed the findings.
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Plan of Correction
The clinical director and operations director/compliance officer have scheduled a staff training on Feb. 19, 2013 regarding confidentiality that will include specifics about the proper use and completion of consent forms, and what information may or may not be release to various entities according to Chapter 255.5. Program coordinators shall monitor staff compliance with the proper use and completion of consent forms via their quarterly review of client records, and will address any non-compliance via supervision sessions. |
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, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information which included the specific information to be disclosed in two of eleven client records.
The findings include:
Eleven client records requiring documentation of an informed and voluntary consent were reviewed on December 18-19, 2012. The facility failed to include the specific information to be disclosed in two of eleven records, specifically records # 1 and 4.
Client record # 1 contained a consent to release information to a government agency which was signed 2/2/12. The consent did not include specific information to be disclosed.
Client record # 4 contained a consent to release information to a medical clinic which was signed on 7/10/12. The consent did not include specific information to be disclosed.
The Operations Director confirmed the findings.
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Plan of Correction
The clinical director and operations director/compliance officer have scheduled a staff training on Feb. 19, 2013 regarding confidentiality that will include specifics about the proper use and completion of consent forms, and what information may or may not be release to various entities according to Chapter 255.5. Program coordinators shall monitor staff compliance with the proper use and completion of consent forms via their quarterly review of client records, and will address any non-compliance via supervision sessions. |
709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information which included the purpose of the disclosure in three of eleven client records.
The findings include:
Eleven client records requiring documentation of an informed and voluntary consent were reviewed on December 18-19, 2012. The facility failed to include the purpose of the disclosure on the informed and voluntary consent in three of eleven records, specifically client records # 1, 2 and 4.
Client record # 1 contained a consent to release information to a government agency which was signed 2/2/12. The consent did not include the purpose of the disclosure.
Client record # 2 contained a consent to release information to a physician which was signed on 8/8/12. The consent did not include the purpose of the disclosure.
Client record # 4 contained a consent to release information to a medical clinic which was signed on 7/10/12. The consent did not include the purpose of the disclosure.
The Operations Director confirmed the findings.
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Plan of Correction
The clinical director and operations director/compliance officer have scheduled a staff training on Feb. 19, 2013 regarding confidentiality that will include specifics about the proper use and completion of consent forms, and what information may or may not be release to various entities according to Chapter 255.5. Program coordinators shall monitor staff compliance with the proper use and completion of consent forms via their quarterly review of client records, and will address any non-compliance via supervision sessions. |
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 the review of patient records, the facility failed to document support services on the clients' treatment plan in nine of ten client records.
The findings include:
Ten client records requiring documentation of proposed support services on the treatment and rehabilitation plan were reviewed on December 18-19, 2012. The facility failed to document support services on the clients' treatment plan in nine of ten records, specifically client records # 1, 3, 4, 6, 7, 8, 9, 11, and 12.
Client # 1 was admitted into treatment on 12/30/11 and was discharged on 6/19/12. The facility failed to document support services on the treatment plan.
Client # 3 was admitted into treatment on 1/13/12 and was discharged on 7/17/12. The facility failed to document support services on the treatment plan.
Client # 4 was admitted into treatment on 3/6/12 and was still an active client at the time of the inspection. The facility failed to document support services on the treatment plan.
Client # 6 was admitted into treatment on 12/8/11 and was still an active client at the time of the inspection. The facility failed to document support services on the treatment plan.
Client # 7 was admitted into treatment on 8/21/12 and was still an active client at the time of the inspection. The facility failed to document support services on the treatment plan.
Client # 8 was admitted into treatment on 7/21/11 and was still an active client at the time of the inspection. The facility failed to document support services on the treatment plan.
Client # 9 was admitted into treatment on 9/18/12 and was still an active client at the time of the inspection. The facility failed to document support services on the treatment plan.
Client # 11 was admitted into treatment on 6/8/12 and was still an active client at the time of the inspection. The facility failed to document support services on the treatment plan.
Client # 12 was admitted into treatment on 12/29/11 and was still an active client at the time of the inspection. The facility failed to document support services on the treatment plan.
The Operations Director confirmed the findings.
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Plan of Correction
The treatment plan section of the facility's electronic health record program will be revised to include documentation of proposed support services. Program coordinators shall monitor staff compliance with the proper completion of treatment plans via their quarterly review of client records, and will address any non-compliance via supervision sessions. |
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 policy and procedures and client records, the facility failed to document treatment plan updates every 60 days, as per facility policy, in four of six client records.
The findings include:
Six client records requiring documentation of treatment plan updates were reviewed on December 18-19, 2012. Per facility policy, treatment plan updates will be completed every 60 days. The facility failed to document treatment plan updates within the required timeframes in four of six client records, specifically client records # 6, 8, 11, and 12.
Client # 6 was admitted into treatment on 12/8/11 and was still an active client at the time of the inspection. The comprehensive treatment plan was completed on 12/27/11. The client record contained documentation of treatment plan updates for February 2012, April 2012, June 2012, and August 2012. There was no documentation of a treatment plan update for October 2012 at the time of the inspection. Additionally, all of the treatment plan updates for this client were missing documentation of the client's progress on treatment goals.
Client # 8 was admitted into treatment on 7/21/11 and was still an active client at the time of the inspection. The comprehensive treatment plan was completed on 1/3/12. The client record contained documentation of treatment plan updates for March 2012, May 2012, and July 2012. There was no documentation of a treatment plan update for September and November 2012 at the time of the inspection.
Client # 11 was admitted into treatment on 6/8/12 and was still an active client at the time of the inspection. The comprehensive treatment plan was completed on 7/19/12. The client record contained documentation of a treatment plan update for 11/5/12. There was no documentation of a treatment plan update for September 2012 at the time of the inspection.
Client # 12 was admitted into treatment on 12/29/11 and was still an active client at the time of the inspection. The comprehensive treatment plan was completed on 1/5/12. The client record contained documentation of treatment plan updates for March 2012, May 2012, July 2012, and October 2012. A treatment plan update would have been due in September 2012, however it was not completed until 10/24/12.
The Operations Director confirmed the findings.
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Plan of Correction
The program coordinators shall develop spreadsheets for tracking when treatment plan updates are due for each individual client and when they have been completed by the assigned primary counselor. Coordinators will address timeframe compliance via regular supervisory sessions with program counselors. The clinical director will monitor compliance via quarterly reviews of the coordinators' spreadsheets. |
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.
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Observations
Based on a review of client records, the facility failed to document case consultation notes every 90 days in five of nine client records.
The findings include:
Nine client records requiring documentation of case consultation notes were reviewed on December 18-19, 2012. The facility failed to provide documentation of case consultation notes in five of nine client records, specifically client records # 1, 2, 3, 7, and 8. Additionally, the facility failed to document case consultation notes every 90 days, according to facility policy, in one client record specifically record # 12.
Client #1 was admitted into treatment on 12/30/11 and was discharged on 6/19/12. This client record was missing documenting of case consultation notes.
Client # 2 was admitted into treatment on 8/10/12 and was discharged on 11/7/12. This client record was missing documentation of case consultation notes.
Client # 3 was admitted into treatment on 1/13/12 and was discharged on 7/17/12. This client record was missing documentation case consultation notes.
Client # 7 was admitted into treatment on 8/21/12 and was still an active client at the time of the inspection. This client record was missing documenting of case consultation notes.
Client # 8 was admitted into treatment on 7/21/11 and was still an active client at the time of the inspection. This client record was missing documenting of case consultation notes.
Client # 12 was admitted into treatment on 12/29/11 and was still an active client at the time of the inspection. Case consultation notes are to be completed 90 days from the intake and every 90 days thereafter. The first documenting of case consultation notes for this record occurred on 11/1/12.
The Operations Director confirmed the findings.
This is a repeat citation. The facility was cited on January 11, 2011 and December 13, 2011 for noncompliance with this standard.
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Plan of Correction
The program coordinators shall develop spreadsheets for tracking when case consultations are due for each individual client and when they have been completed by the assigned primary counselor. Coordinators will address timeframe compliance via regular supervisory sessions with program counselors. The clinical director will monitor compliance via quarterly reviews of the coordinators' spreadsheets. |