INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 10, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Addictive Diseases- Main Line Affiliates 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 November 27, 2007.
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Plan of Correction
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711.91(b)(3(ii) LICENSURE D & A History
711.91. 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 a review of client records conducted on October 10, 2007 the facility failed to document lengths and patterns of substance use/abuse related to the client's drug and alcohol history. A review of three of four client records, specifically #1, 3 and 4, revealed that the facility failed to address the client's progression of drug and alcohol use related to lengths and patterns of substance use/abuse in the drug and alcohol history.
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Plan of Correction
The forms where clinicians collect data are satisfactory and have required elements related to the lengths and patterns of substance use/abuse. A clinical chart audit will be completed quarterly by the Clinical Director where a random selection of 2 charts per clinician will be reviewed for completeness and attention to this section. First quarterly audit to be completed by 1/15/08 |
711.91(b)(3)(iii) LICENSURE Personal History
711.91. 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 a review of client records conducted on October 10, 2007 it was determined that the facility failed to consistently document in the personal history details regarding family, legal, employment/vocation, education and recreation in four of four client records, specifically #1, 2, 3 and 4.
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Plan of Correction
Assessment form used by clinicians is sufficent to collect the personal history details of clients. A clinical chart audit will be completed quarterly by the Clinical Director where a random slection of 2 charts per clinician will be reviewed for completeness and attention to personal history detail. First quarterly audit will be completed by 1/15/08. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records on October 10, 2007 it was determined that the facility failed to document a psychosocial evaluation based on the clinician's analysis of the client's history and present circumstances. A review of four of four client records, specifically #1, 2, 3 and 4, revealed that the psychosocial evaluation was a historical summary that failed to include clinical impressions.
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Plan of Correction
A clinical chart audit will be completed quarterly by the Clinical Director to assure clinical impressions are documented within the psychosocial evaluation. First quarterly audit to be completed by 1/15/07.
Additionally, a staff meeting was held on 10/17/07 in which the expectations of what is required in the psychosocial evaluation were presented. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records on October 10, 2007 it was determined that the facility failed to document treatment plan updates. In two of three client records reviewed, specifically #3 and 5, the treatment plan updates failed to include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan. In client record #3 the treatment plan update carried over the gaols stated on the comprehensive treatment plan, but did not include the client's progress. In client record #5 the treatment plan updates dated March 14, 2007 and June 6, 2007 were identical and failed to include client specific progress.
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Plan of Correction
All treatment plan updates are signed by the Clinical Director. The Clinical Director will carefully read all treatment plan reviews prior to signing to assure they are updating the client's specific progress in relation to the stated goals.
Additionally, a staff meeting was held 10/17/07 where the expectations for the treatment plan updates were reviewed. |
711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records conducted on October 10, 2007 it was determined that the facility failed to document goals with time frames in the aftercare plan. The documentation in the aftercare plan failed to include measurable goals with time frames in client record #5, representing one of one records where this documentation was required.
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Plan of Correction
This was found in one record, and was immediately brought to the clinician's attention. Clinician is a new hire to CAD and the correct procedure for completing aftercare documentation was also reviewed. The aftercare plan will be incorporated into the new Clinical chart audit that will occur quarterly performed by the Clinical Director. First sudit to be completed by 1/15/08 |