INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 1, 2010 through November 5, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Parkside Recovery 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 and a plan of correction is due on December 5, 2010.
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Plan of Correction
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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 personnel records, staffing requirements facility summary report and a staff interview, the facility failed to ensure that all staff obtained a minimum of 6 hours of training in HIV/AIDS and a least 4 hours related topics within one year of the date of hire for counselors and counselor assistant and within two years of the date of hire date for all other staff.
The findings include:
Seventeen personnel records were reviewed on November 1, 2010 through November 5, 2010 and the staffing requirements facility summary report was reviewed on November 1, 2010 through November 5, 2010. There was no documentation of HIV/AIDS or TB/STD training in five employee records. Of the five records, four were required to have HIV/AIDS and TB/STD training within the first year of employment and the remaining staff were required to have HIV/AIDS and TB/STD training within the first two years of employment.
Employee #13 was hired April 14, 2009 and was required to have HIV/AIDS & TB/STD training by April 14, 2010. There was no documentation of TB/STD training in the employee's record as of November 5, 2010.
Employee #14 was hired September 24, 2009 and was required to have HIV/AIDS & TB/STD training by September 24, 2010. There was no documentation of TB/STD training in the employee's record as of November 5, 2010.
Employee #15 was hired September 28, 2009 and was required to have HIV/AIDS & TB/STD training by September 28, 2010. There was no documentation of TB/STD training in the employee's record as of November 5, 2010.
Employee #16 was hired March 30, 2009 and was required to have HIV/AIDS & TB/STD training by March 30, 2010. There was no documentation of TB/STD training in the employee's record as of November 5, 2010.
Employee #17 was hired October 9, 2008 and was required to have HIV/AIDS & TB/STD training by October 9, 2010. There was no documentation of HIV/AIDS training in the employee's record as of November 5, 2010.
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Plan of Correction
The training department will conduct mandatory trainings which include HIV/AIDS and TB/STD to insure that all new hires meet the DOH mandatory training requirements.Trainings are scheduled to complete all mandatory trainings for all employees before December 31, 2010 The clinical supervisors will monitor all new counselors trainings to ensure compliance with regulations the to ensure this deficiency does not re-occur
Completion date: December 31, 2010
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to ensure and document that counselors completed at least 25 hours of training for the 2009/2010 training year in one of five personnel records.
The findings include:
Seventeen personnel records were reviewed on November 1, 2010 through November 5, 2010. Five employee records represented the counselors who were required to have obtained 25 hours of training for the 2009/2010 training year based on the hire dates, #8, 9, 10, 11 and 12.
Employee #12 was hired September 28, 1989 and was required to have obtained 25 training hours for the 2009/2010 training year. Employee #12 only had 24 hours of training for training year 2009/2010.
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Plan of Correction
Counselors will be instructed that it is their responsibility to complete 25 hours of training per year. The training department will schedule the trainings and clinical supervisors will monitor all trainings to ensure compliance. The training department along with the clinical supervisors will conduct quarterly reviews to assure compliance with DOH requirements. The clinical supervisors will report to the Program Director the results of the quarterly reviews.
The employee noted has completed her 25 hours.
Completed: Immediately for employee lacking the 25 hours
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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 record, the facility failed to conduct fire drills during the evening hours.
The findings include:
The fire drill record was reviewed on November 1, 2010. The facility did not conduct any fire drills after 3:15 pm for the months of January 2010 through September 2010. The hours of operation are from Monday through Friday 7 am to 7 pm, Saturday 7:30 am to 1:30 pm and Sunday 8 am to 11:30 pm. The hours of operation were confirmed in an interview with the Project Director.
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Plan of Correction
The security supervisor has begun to conduct monthly fire drills which include drills during the evening hours. The Program Director will monitor compliance by reviewing the fire log book monthly with security supervisor.
Completed.
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709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on the review of the facility's annual report for fiscal year July 1, 2009 through June 30, 2010, the facility failed to ensure that the annual report included a financial statement of income and expenses.
The findings include:
An interview was conducted with the Project Director on November 1, 2010. The Project Director confirmed that the financial statement of income and expenses was not documented on the annual report for July 1, 2009 to June 30, 2010.
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Plan of Correction
"The Project Director will introduce the standard to the NHS Parkside Board of Directors and ask them to acknowledge that from this time forward the Department of Treasury Internal Revenue Service Form 990 will be available to the public as a financial statement of income and expenses. This Form 990 will be made available to the public upon request in the same manner as the annual report. The Project Director will ensure all components of the standard are fulfilled."
This is effective as of December 14, 2010.
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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
Based on the review of client record, the facility failed to document drug & alcohol histories in ten of forty records reviewed.
The findings include:
Forty client records were reviewed on November 3, 2010 through November 5, 2010. Documentation of drug & alcohol histories were required for review in thirty records, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30. Per the facility's policy and procedure manual, drug and alcohol histories and evaluations are to be completed within 30 days of admission.
Client #9 was admitted on 6/4/10 and, as November 3, 2010, there was no documentation of client's drug and alcohol history in record reviewed.
Client # 12 was admitted on 8/6/10; the drug and alcohol history and was not completed until 9/15/10.
Client # 18 was admitted on 8/20/10; the drug and alcohol history was not completed until 10/27/10.
Client #19 was admitted on 7/28/10 and, as November 4, 2010, the client's drug and alcohol history was not documented in the record.
Client #20 was admitted on 8/16/10 and, as November 4, 2010, the client's drug and alcohol history was not documented in the record.
Client #22 was admitted on 6/17/10 and, as November 4, 2010, the client's drug and alcohol history was not documented in the record.
Client #23 was admitted on 6/4/10 and, as November 4, 2010, the client's drug and alcohol history was not documented in the record.
Client #24 was admitted on 8/17/10 and, as November 4, 2010, the client's drug and alcohol history was not documented in the record.
Client #25 was admitted on 3/24/10 and, as November 4, 2010, the client's drug and alcohol history was not documented in the record.
Client #27 was admitted on 7/9/10 and, as November 4, 2010, the client's drug and alcohol history was not documented in the record.
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Plan of Correction
A directive has be given and a follow up training will be held which directs that all counselors will submit a biopsychosocial with completed drug and alcohol history to their supervisor for review within 15 business days of the clients admission. The clinical supervisors will be responsible for monitoring this process during weekly supervision with the counselors to ensure this deficiency does not re-occur.
Completion date: Directive immediately. Training by December 20th.
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of client record, the facility failed to document personal histories in ten of forty records reviewed.
The findings include:
Forty client records were reviewed on November 3, 2010 through November 5, 2010. Documentation of personal histories were required for review in thirty records, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30. Per the facility's policy and procedure manual histories and evaluations are to be completed within 30 days of admission.
Client #9 was admitted on 6/4/10 and, as November 3, 2010, documentation of the client's personal history was not documented in the client record.
Client # 12 was admitted on 8/6/10; the personal history was not documented in the patient record until 9/15/10.
Client # 18 was admitted on 8/20/10; the personal history was not completed until 10/27/10.
Client #19 was admitted on 7/28/10 and, as November 4, 2010, documentation of clients history was not documented in the client record.
Client #20 was admitted on 8/16/2010 and, as November 4, 2010, documentation of clients history was not documented in the client record.
Client #22 was admitted on 6/17/10 and, as November 4, 2010, documentation of clients history was not documented in the client record.
Client #23 was admitted on 6/4/10 and, as November 4, 2010, documentation of clients history was not documented in the client record.
Client #24 was admitted on 8/17/10 and, as November 4, 2010, documentation of clients history was not documented in the client record.
Client #25 was admitted on 3/24/10 and, as November 4, 2010, documentation of clients history was not documented in the client record.
Client #27 was admitted on 7/9/10 and, as November 4, 2010, documentation of clients history was not documented in the client record.
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Plan of Correction
A directive will be given with a follow up training that all counselors will submit a Biopsychosocial with a completed client's personal history to their supervisor for review within 15 business days of the clients admission. The clinical supervisors will be responsible for monitoring this process through weekly supervision with counselors to ensure that this deficiency does not re-occur.
Completion date: Directive immediately. Training by December 20th
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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 record, the facility failed to document psychosocial evaluations in nineteen of forty records reviewed.
The findings include:
Forty client records were reviewed on November 3, 2010 through November 5, 2010. Documentation of psychosocial evaluations were required for review in thirty records, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30. Per the facility's policy and procedure manual, histories and evaluations are to be completed within 30 days.
Client #9 was admitted on 6/4/10 and, as November 3, 2010, documentation of the client's psychosocial evaluation was not documented in record reviewed.
Client # 12 was admitted on 8/6/10; the client's psychosocial evaluation was not completed until 9/20/10.
Client # 18 was admitted on 8/20/10; the client's psychosocial evaluation was not completed until 10/27/10.
Client #19 was admitted on 7/28/10 and, as November 4, 2010, the client's psychosocial evaluation was not documented in the client record.
Client #20 was admitted on 8/16/10 and, as November 4, 2010, the client's psychosocial evaluation was not documented in the client record. and as November 4, 2010
Client #22 was admitted on 6/17/10 and, as November 4, 2010, the client's psychosocial evaluation was not documented in the client record.
Client #23 was admitted on 6/4/10 and, as November 4, 2010, the client's psychosocial evaluation was not documented in the client record.
Client #24 was admitted on 8/17/10 and, as November 4, 2010, the client's psychosocial evaluation was not documented in the client record.
Client #25 was admitted on 3/24/10 and, as November 4, 2010, the client's psychosocial evaluation was not documented in the client record.
Client #26 was admitted on 7/14/10 and, as November 4, 2010, the client's psychosocial evaluation was not documented in the client record.
Client #27 was admitted on 7/9/10 and, as November 4, 2010, the client's psychosocial evaluation was not documented in the client record.
Client's #5, 11 psychosocial evaluations were illegible during the review of the records and the licensing specialists were unable to review the documentation.
Client's #12, 13, 15, 16, 17, 18 and 29 failed to document the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions/impressions.
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Plan of Correction
A directive will be given with a follow up training that all counselors will submit the completed biopsychosocial to their supervisor for review within 15 business days of the clients admission. The clinical supervisors will be responsible for monitoring this process. This will be done in weekly supervision with the counselor and supervisor to ensure this deficiency does not re occur.
Completion date: Directive immediately. Training by December 20.
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709.92(a) 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:
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Observations
Based on the review of client record, the facility failed to document comprehensive treatments plans after the completion of the client's histories and evaluations in twenty of forty records reviewed.
The findings include:
Forty client records were reviewed on November 3, 2010 through November 5, 2010. Documentation of comprehensive treatment plans were required for review in thirty records, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30. Per the facility's policy and procedure manual histories and evaluations are to be completed within 30 days to be able formulate the client's comprehensive treatment plan.
Client #5 was admitted on 8/10/10 and psychosocial evaluation was completed on 8/30/10 and comprehensive treatment plan was completed on 8/27/10.
Client #6 was admitted on 9/7/10 and psychosocial evaluation was completed on 10/18/10 and comprehensive treatment plan was completed on 9/22/10.
Client #7 was admitted on 7/13/10; their psychosocial evaluation was completed on 9/3/10 and the comprehensive treatment plan was completed on 8/20/10.
Client #8 was admitted on 7/16/10; their psychosocial evaluation was completed on 9/10/10 and the comprehensive treatment plan was completed on 8/11/10.
Client #9 was admitted on 6/4/10 and, as November 5, 2010, there was no documentation of the client's comprehensive treatment plan in record.
Client #10 was admitted on 8/12/10 and, as November 4, 2010, the client's psychosocial evaluation was not documented in the client record.
Client # 12 was admitted on 8/6/10 and, as November 4, 2010, the client's psychosocial evaluation was not documented in the client record.
Client #15 was admitted on 6/3/10; their psychosocial evaluation was completed on 6/30/10 and the comprehensive treatment plan was completed on 6/16/10.
Client #17 was admitted on 7/12/10; their psychosocial evaluation was completed on 8/5/10 and the comprehensive treatment plan was completed on 7/30/10.
Client #18 was admitted on 8/20/10; their psychosocial evaluation was completed on 10/27/10 and the comprehensive treatment plan was completed on 9/9/10.
Client #19 was admitted on 7/28/10 and, as November 4, 2010, the client's psychosocial evaluation was not documented in the client record.
Client #20 was admitted on 8/16/10 and, as November 4, 2010, the client's psychosocial evaluation was not documented in the client record. Their comprehensive treatment plan was documented on 8/20/10.
Client #22 was admitted on 6/17/10 and, as November 4, 2010, the client's psychosocial evaluation was not documented in the client record.
Client #23 was admitted on 6/4/10 and, as November 4, 2010, the client's psychosocial evaluation was not documented in the client record.
Client #24 was admitted on 8/17/10 and, as November 4, 2010, the client's psychosocial evaluation was not documented in the client record. Their comprehensive treatment plan was documented on 9/3/10.
Client #25 was admitted on 3/24/10 and, as November 4, 2010, the client's psychosocial evaluation was not documented in the client record.
Client #26 was admitted on 7/14/10 and, as November 4, 2010, the client's psychosocial evaluation was not documented in the client record. Their comprehensive treatment plan was documented on 8/3/10.
Client #27 was admitted on 7/9/10 and, as November 4, 2010, the client's psychosocial evaluation was not documented in the client record. Their comprehensive treatment plan was documented on 8/6/10.
Client #29 was admitted on 7/12/10; their psychosocial evaluation was completed on 7/12/10 and the comprehensive treatment plan completed on 8/17/10, five days after the stipulated 30 days.
Client #30 was admitted on 6/21/10; their psychosocial evaluation was completed on 7/16/10 and the comprehensive treatment plan completed on 7/2/10.
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Plan of Correction
Through directive and training, each counselor will submit completed Biopsychosocial to their immediate supervisor for review within 15 business days of client's admission. The comprehensive treatment plan will be due to the supervisor within 5 days after the completion of the Biopsychosocial. The clinical supervisors will be responsible for monitoring this process during weekly supervision sessions. The clinical supervisors will use the newly developed documentation tracker to ensure future compliance with DOH requirements to insure this deficiency does not re-occur
Directive immediately; Training by December 20th.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to document counseling services provided according to the individual treatment plan in thirteen of thirty client records.
The findings include:
Forty client records were reviewed on November 3, 2010 through November 4, 2010. Thirty records required documentation of counseling services provided according to the treatment plan. The facility did not document counseling services according to the treatment plan in client records #3, 4, 5, 10, 11, 12, 13, 16, 17, 18, 20, 29 and 30.
In client record #3 the treatment plan, dated 7/9/10, stated that the individual counseling sessions would occur 2 times a month and group sessions 3 times a week, but at the time of review, individual counseling sessions were only documented on 8/17/10, 9/13/10, 9/27/10 and 10/4 and group sessions were documented 9/3/10 and 9/7/10.
In client record #4 the treatment plan, dated 8/5/10, stated individual counseling sessions would be biweekly and group sessions 3 time a week, but at the time of review, individual counseling sessions were only documented on 8/5/10, 9/17/10, 10/1/10 and 10/12/10.
In client record #5 the treatment plan, dated 8/27/10, stated individual counseling sessions would occur biweekly and group sessions 3 times a week, but at the time of review, individual counseling sessions were only documented on 8/27/10, 8/30/10 and 10/12/10.
In client record #10, the treatment plan, dated 9/2/10, stated individual counseling sessions would occur 2 times a month and group sessions 3 times a month. The treatment plan update, dated 10/14/10, stated individual counseling sessions would occur 4 times a month and group sessions 4 times a week, but at the time of review, individual sessions were only documented 9/2/10, 9/20/10 and 10/4/10.
In client record #11, the treatment plan, dated 7/6/10, and the treatment plan updates dated 8/17/10, 9/23/10 and 10/25/10 stated individual counseling sessions would occur 2 times a month and group sessions 3 times a week, but at the time of review, group counseling sessions were only documented on 7/6/10, 7/2/10, 7/26/10, 8/2, 8/9/10, 8/16/10, 8/30/10, 9/13/10, 9/27/10, 10/4/10, 10/7/10, 10/18/10 and 10/25/10.
In client record #12, the treatment plan, dated 8/25/10, stated individual counseling sessions would occur 2 times per week and group counseling sessions 3 times per week and the treatment plan update, dated 10/25/10, stated individual counseling sessions 1 times a month and group sessions would occur 4 times a week, but at the time of review, group counseling sessions were only documented on 10/11/10 and individual counseling sessions were only documented on 8/25/10, 8/16/10, 9/15/10 and 10/15/10.
In client record #13, the treatment plan, dated 8/27/10, and the treatment plan update, dated 10/6/10, stated that individual counseling sessions would occur 1 times a week and group sessions 2 times a month, but at the time of review, group counseling sessions were only documented on 8/27/10, 9/10/10 and 10/22/10.
In client record #16, the treatment plan, dated 7/13/10, and the treatment plan updates, dated 9/7/10 and 10/26/10, stated individual counseling sessions would occur 2 times a month and group sessions 3 times a week, but at the time of review, individual counseling sessions were only documented on 6/23/10, 7/13/10, 8/11/10 (no show), 9/24/10 (no show) and 9/7/10.
In client record #17, the treatment plan dated 7/30/10, stated individual counseling sessions would occur 2 times week/month and group counseling sessions 3 times week/month and treatment plan update, dated 9/10/10, state individual counseling sessions would occur 2 times a month and group counseling sessions 3 times a week. The treatment plan update, dated 10/27/10, stated individual counseling sessions would occur 1 time a week and group counseling sessions 4 times a week, but at the time of review, individual counseling sessions were only documented on 7/12/10, 7/30/10, 8/3/10, 8/5/10, 9/10/10 and 10/8/10.
In client record #18, the treatment plan, dated 9/9/10, and the treatment plan update, dated 10/27/10, stated individual counseling sessions would occur 2 times a month and group sessions 3 times a week, but at the time of review, individual counseling sessions were only documented on 8/20/10, 9/8/10 and 10/13/10.
In client record #20 the treatment plan, dated 8/23/10, and the treatment plan update, dated 10/8/10, stated individual counseling sessions would occur 2 times a month and group sessions 3 times a week, but at the time of review, individual counseling sessions were only documented on 8/23/10, 9/17/10 and 10/8/10.
In client record #29 the treatment plan, dated 8/17/10, stated individual counseling sessions would occur 2 times a week/month and group sessions 2 times a week/month, but at the time of review, individual counseling sessions were only documented on 7/20/10 and 8/3/10. Client was discharged on 9/20/10.
In client record #30 the treatment plan, dated 7/2/10, state individual counseling sessions would occur 2 times a month and group sessions 3 times a week, but at the time of review, individual counseling sessions were only documented on 7/2/10 and 7/16/10. The client was discharged on 8/18/10.
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Plan of Correction
The Clinical Supervisors w/Program Director will conduct a training with regards to engaging clients to ensure compliance with the requirements of the modality of treatment noted on the treatment plan. The training will center on insuring that the type and frequency IOP and OP services are in alignment with actual practice. Counselors will also be trained in the appropriate documentation requirements for when a client does not attend his/her recommended treatment services.
The clinical supervisors will monitor documentation of counseling services during weekly supervision to ensure this deficiency does not re-occur.
Training: December 27th
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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 the review of client records, the facility failed to document case consultations within the ninety day time frame in nine of forty client records reviewed.
The findings include:
Forty client records were reviewed on November 3, 2010 through November 5, 2010. Per agency policy, case consultations shall be completed every ninety days. Case consultations were required in twelve client records, specifically client records #1, 2, 4, 7, 8, 9, 11, 14, 15, 16,17, 19. The facility did not document a case consultation within the ninety day time frame in client records # 2, 7, 8, 9, 11, 15, 16, 17 and 19.
Client #2 was admitted on July 22, 2010. The case consultation was due by October 22, 2010. As of the date of inspection, there had not been a case consultation completed for client #2.
Client # 7 was admitted on July 13, 2010. The case consultation was due by October 13, 2010. As of the date of inspection, there had not been a case consultation completed for client #7.
Client #8 was admitted on July 16, 2010. The case consultation was due by October 16, 2010. Client #8's case consultation was done on October 22, 2010.
Client #9 was admitted on June 4, 2010. The case consultation was due by September 4, 2010. As of the date of inspection, there had not been a case consultation completed for client #9.
Client #11 was admitted on June 22, 2010. The case consultation was due by September 22, 2010. Client #11's case consultation was done on October 4, 2010. Also, case consultation was illegible.
Client #15 was admitted on June 3, 2010. The case consultation was due by September 3, 2010. Client #15's case consultation was done on September 30, 2010.
Client #16 was admitted on June 23, 2010. The case consultation was due by September 23, 2010. Client #16's case consultation was done on September 24, 2010.
Client #17 was admitted on July 7, 2010. The case consultation was due by October 7, 2010. Client #17's case consultation was done on October 15, 2010.
Client #19 was admitted on July 28, 2010. The case consultation was due by October 28, 2010. Client #19's case consultation was done on November 4, 2010.
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Plan of Correction
All counselors are responsible for ensuring that patient records include a Case conference which is to be completed every ninety days during the first year of treatment, and annually thereafter.
The clinical supervisors will provide training on time frames regarding case consultations. The training will also include the development of a case conference structure in which all participants sign required documentation immediately. The clinical supervisors will also use the documentation report to monitor the due dates of all case conferences.
Clinical supervisors will monitor the documentation and timeliness of case conferences and in weekly supervisor to ensure this deficiency does not re-occur.
Training: December 20th
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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.
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Observations
Based on the review of client records, the facility failed to document aftercare plans in six of twenty discharge rehabilitation client records.
The findings include:
Forty client records were reviewed November 3, 2010 through November 4, 2010. Aftercare plans were required in seven rehabilitation discharge records, #29, 31, 32, 33, 34, 39 and 40. Per the facility's policy and procedure manual aftercare plans will be developed jointly with the counselor and client prior to the client's discharge.
Client record #29 was discharged on 9/20/10 and, as of the date of review, an aftercare plan was not documented.
Client record #31 was discharged on 7/30/10 and, as of the date of review, an aftercare plan was not documented.
Client record #32 was discharged on 6/22/10 and, as of the date of review, an aftercare plan was not documented.
Client record #34 was discharged on 4/22/10 and, as of the date of review, an aftercare plan was not documented.
Client record #39 was discharged on 4/14/10 and, as of the date of review, an aftercare plan was not documented.
Client record #40 was discharged on 6/16/10 and, as of the date of review, an aftercare plan was not documented.
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Plan of Correction
Clinical Supervisors w/Program Director will give a training regarding the completion of an aftercare plan for every client who completes treatment either successfully or is planning on leaving AMA.
Clinical supervisors will be responsible to monitor all upcoming discharges to ensure the discharge aftercare plan has been completed before the client leaves treatment. The monitoring will occur during supervision to insure the deficiency does not re-occur.
Training: December 27th
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document follow-up information in eleven of twenty discharge records reviewed.
The findings include:
Forty client records were reviewed on November 3, 2010 through November 4, 2010. Of the forty records reviewed, twenty required documentation of follow-up information. The facility did not document follow-up information within 30 days from the date of discharge, as per facility policy, in client records, #21, 23, 25, 27, 28, 29, 32, 35, 36, 37 and 40.
Client #21 was admitted to the program 7/29/10 and discharged on 9/9/10, but the follow-up was not documented at the time of review on 11/4/10.
Client #23 was admitted to the program 6/4/10 and discharged on 7/14/10, but follow-up was not documented at the time of review on 11/4/10.
Client #25 was admitted to the program 3/24/10 and discharged on 5/12/10, but follow-up was not documented at the time of review on 11/4/10.
Client #27 was admitted to the program 7/9/10 and discharged on 8/23/10, but follow-up was not documented at the time of review on 11/4/10.
Client #28 was admitted to the program 5/20/10 and discharged on 7/14/10, but follow-up was not documented at the time of review on 11/4/10.
Client #29 was admitted to the program 7/12/10 and discharged on 9/20/10, but follow-up was not documented at the time of review on 11/4/10.
Client #32 was admitted to the program 7/6/06 and discharged on 6/22/10, but follow-up was documented the same time of discharge 6/22/10.
Client #34 was admitted to the program 4/20/09 and discharged on 4/22/10, but follow-up was not documented at the time of review on 11/4/10.
Client #35 was admitted to the program 1/12/10 and discharged on 9/14/10, but follow-up was not documented at the time of review on 11/4/10.
Client #37 was admitted to the program 7/2/10 and discharged on 8/25/10, but follow-up was documented prior to the clients discharge date 8/24/10.
Client #40 was admitted to the program 9/17/02 and discharged on 6/16/10, but follow-up was not documented at the time of review on 11/4/10.
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Plan of Correction
The clinical supervisors will be responsible for ensuring that follow up surveys are sent to clients within the required time frame. All supervisors will log into their supervisory notes the date the survey was sent. The program director will review the supervision notes with each clinical supervisor during group supervision to insure the deficiency does not re-occur.
Completion Date: Immediately
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