INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 6, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Open Door 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
|
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
|
Observations
Based on a review of client records, the facility failed to provide individual counseling at least twice weekly, in three of the three client records.
The findings include:
Eight client records were reviewed on March 6, 2014. Three of the eight client records were partial hospitalization clients. Three client records were required to include documentation of individual counseling at least twice weekly. The facility failed to document individual counseling at least twice weekly in client records # 1, 2 and 3.
Client # 1 was admitted on February 17, 2014 and was still an active client on March 6, 2014. The facility failed to provide individual counseling at least twice weekly. The record included documentation of one individual counseling session for the week of February 24, 2014, dated February 26, 2014.
Client # 2 was admitted on January 22, 2014 and was still an active client on March 6, 2014. The facility failed to provide individual counseling at least twice weekly. The record did not include documentation of any individual counseling sessions for the week of January 27, 2014. The record included documentation of the following counseling sessions: one individual counseling session for the week of February 3, 2014, dated February 3, 2014; one individual counseling session for the week of February 17, 2014, dated February 17, 2014 and one individual counseling session for the week of February 24, 2014, dated February 25, 2014.
Client # 3 was admitted on November 19, 2013 and discharged on January 13, 2014. The facility failed to provide individual counseling at least twice weekly. The record did not include documentation of any individual counseling sessions for the weeks of November 25, 2013 and December 9, 16 and 23, 2013. The record included documentation of the following counseling sessions: one individual counseling session for the week of December 2, 2013, dated December 7, 2013 and one individual counseling session for the week of January 6, 2014, dated January 7, 2014.
The Project/Facility Director and the Clinical Supervisor were interviewed on March 6, 2014 and did not dispute the findings.
|
Plan of Correction
Regarding the deficiency noted in provision of Partial Hospitalization Program services relating to 709.82 (d) (1), specifically that individual counseling was not provided at least twice weekly to clients enrolled in this service. The Clinical Supervisor re-educated clinical staff on minimum requirements of service provision for clients in a Partial Hospitalization Program level of care, specifically the importance of frequent, i.e., twice weekly hour-long individual sessions and the need to reschedule clients within the week when a client cancels or no-shows a session. Additionally, the importance of addressing attendance with clients and making appropriate referrals should attendance of individual sessions not improve was included in this discussion. Re-education occurred on March 10th, 2014, and was followed up by the Clinical Supervisor with further written information and instruction on March 20th, 2014. Ongoing monitoring to ensure that clients are receiving individual services at an appropriate frequency will occur through internal clinical and fiscal audits conducted by the Utilization Review/Auditor and the Clinical Supervisor. The Executive Director is responsible for ensuring the corrective action plan is implemented.
Completion Date: 3/20/2014
|
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 in three of four client records.
The findings included:
Eight client records were reviewed on March 6, 2014. Five client records were reviewed as outpatient client records. Four client records were reviewed for a psychosocial evaluation. The facility failed to document a psychosocial evaluation in client records # 5, 6 and 7.
Client # 5 was admitted on July 25, 2013. The record included documentation identified as a psychosocial evaluation that was dated July 25, 2013. The facility failed to document a psychosocial evaluation as the documentation included in the record was only a summary of historical information, not an evaluation of the historical information.
Client # 6 was admitted on September 20, 2013. The record included documentation identified as a psychosocial evaluation that was dated September 20, 2013. The facility failed to document a psychosocial evaluation as the documentation included in the record was only a summary of historical information, not an evaluation of the historical information.
Client # 7 was admitted on July 24, 2013. The record included documentation identified as a psychosocial evaluation that was dated July 24, 2013. The facility failed to document a psychosocial evaluation as the documentation included in the record was only a summary of historical information, not an evaluation of the historical information.
The Project/Facility Director and the Clinical Supervisor were interviewed on March 6, 2014 and did not dispute the findings.
|
Plan of Correction
Regarding the deficiency noted in lack of evaluation of historical information in the Psychosocial Assessment rather than documentation limited to a summary of the historical information relating to 709.91 Intake and admission. (b) Intake procedures shall include documentation of: (6) Psychosocial evaluation. The Executive Director and Clinical Supervisor will provide a training on evaluation of historical information as gleaned during the intake and how to document conclusions drawn throughout the Intake process on March 27th, 2014. Clinical staff will be provided with additional resources at this time by the Executive Director and Clinical Supervisor to support them in their efforts to improve the quality of Psychosocial Assessments. Ongoing monitoring to identify maintenance of improvement in evaluation of clients and identification of continued need for improvement will occur through internal clinical audits conducted by the Utilization Review/Auditor and the Clinical Supervisor. Clinicians requiring continued support in this area will be coached in this area during individual supervision with the Clinical Supervisor. The Executive Director is responsible for ensuring the corrective action plan is implemented.
Completion Date: 3/27/2014 |
709.93(a) 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:
|
Observations
Based on the review of client records, the facility failed to document a complete client record that included case consultation notes and/or client follow-up information in two of five client records.
The findings include:
Eight client records were reviewed on March 6, 2014. Five client records were reviewed as outpatient client records. Five client records were reviewed for documentation of case consultation notes and/or follow up information. The facility failed to include documentation of case consultation notes and/or follow up information in client records # 6 and 7.
Client # 6 was admitted on September 20, 2013 and discharged on January 31, 2014. A case consultation note was due to be completed by December 31, 2013 and follow-up information was due to be completed by February 28, 2014. The facility failed to document a case consultation note or follow-up information as of March 6, 2014.
Client # 7 was admitted on July 24, 2013 and discharged on December 20, 2013. Follow-up information was due to be completed by January 20, 2014. The facility failed to document follow-up information as of March 6, 2014.
The Project/Facility Director was interviewed on March 6, 2014 and confirmed the findings.
|
Plan of Correction
Regarding the deficiency noted relating to 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:, specifically, that follow-up information regarding clients after discharge was not completed. The charts found to be missing follow-up information were due to human error in flagging discharged charts for follow-up contacts. The Executive Director will review the process for identification of clients in need of follow-up contacts with the Chief Compliance Officer to identify and problem-solve areas of weakness in this process. Additionally, review of follow-up contacts has been added to the internal clinical auditing tool effective immediately and will be monitored through internal clinical audits conducted by the Utilization Review/Auditor and the Clinical Supervisor. The Executive Director is responsible for ensuring the corrective action plan is implemented.
Completion Date: 6/30/2014 |