INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 3, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Brighter Visions Counseling, was found to be not 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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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.
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Observations
Seven client records were reviewed on January 3, 2018, the facility failed obtain a valid consent to release in client record, #4.Client #4 was admitted on 2/22/17 and discharged on 5/18/17. A facsimile transmission to a government agency dated 11/14/17 was found in the client record, however there was no consent to release information to this agency documented at the time of the licensing inspection.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
No information from any client record will be released without signed consent of the client using the consent form approved in the BVC Manual of Policies and Procedures stipulating the exact content of the information to be released. This plan of correction is in place January 8, 2018. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Seven client records were reviewed on January 3, 2018, the facility failed to document a comprehensive drug and alcohol history in client records, #3, 4, & 5. The facility failed to specify the substances most frequently abused, the length and patterns of use, age of first use and date of last use.Client #3 was admitted on 8/22/17 and was an active client at the time of the licensing inspection. The drug and alcohol history was documented in narrative fashion and stated only "admits alcohol dependence " . Client #4 was admitted on 2/22/17 and discharged on 5/18/17. The drug and alcohol history was documented in narrative fashion and stated only " quit drinking around Christmas; denies any drinking problem " .Client #5 was admitted on 10/5/17 and discharged on 12/12/17. The drug and alcohol history was documented in narrative fashion and stated only " heroin addiction; currently taking Suboxone " .This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Drug or alcohol histories shall be documented in the client record in both a grid format providing comprehensive information specifying the substances abused, length and patterns of use, age of first use and date of most recent use. A narrative summary will also provide discussion of progression, and any history of treatment. Currently active charts will be updated to include this detail on the date of the next session with the client, and new charts will automatically include this detail. The plan of correction is in place January 9, 2018. |
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
Seven client records were reviewed on January 3, 2018, the facility failed to update the treatment plan every 60 days in client records, #1, 4, 5 & 6.Client #1 was admitted on 4/10/17 and was an active client at the time of the licensing inspection. The comprehensive treatment plan was documented on 4/10/17; a treatment plan update was due by 6/10/17 but was not documented until 6/15/17.Client #4 was admitted on 2/22/17 and discharged on 5/18/17. The comprehensive treatment plan was documented on 2/22/17; a treatment plan update was due by 4/22/17 but was not documented at the time of the licensing inspection.Client #5 was admitted on 10/5/17 and discharged on 12/12/17. The comprehensive treatment plan was documented on 10/5/17; a treatment plan update was due by 12/5/17 but was not documented at the time of the licensing inspection.Client #6 was admitted on 5/25/17 and discharged on 10/20/17. The comprehensive treatment plan was documented on 5/25/17; a treatment plan update was due by 7/25/17 but was not documented at the time of the licensing inspection.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Treatment plans will be reviewed and updated every 60 days. In the case of a missed appointment, the counselor will update the assessment and plan on the required date and review with the client at the next completed session. This plan of correction begins January 9, 2018 and applies to all active cases. |
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:
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Observations
Seven client records were reviewed on January 3, 2018, the facility failed document a complete client record for records, #4, 5, 6 & 7.Client #4 was admitted on 2/22/17 and discharged on 5/18/17. No follow up information was documented.Client #5 was admitted on 10/5/17 and discharged on 12/12/17. The discharge summary was dated 10/23/17, however there was a progress note, dated 11/22/17, for an individual session and the facility listed the discharge date as 12/12/17.Client #6 was admitted on 5/25/17 and discharged on 10/20/17. No follow up information was documented.Client #7 was admitted on 5/25/17 and discharged on 7/7/17. No follow up information was documented.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The client record will include discharge summary and follow up information. A follow up plan is part of the aftercare plan in successfully closed cases. When a session is cancelled or no-showed a reminder letter will be sent out asking the client to contact the office. In the event that a case is closed without a collaborative aftercare plan, the client will be contacted at 60 days from the final session and this contact will be documented in the client record. The plan of correction is implemented in cases closed on or after January 9, 2018. |