INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 7, 2007 and November 8, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kensington Hospital Outpatient treatment Program 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 7, 2007.
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Plan of Correction
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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 twelve client records on November, 8, 2007 it was determined that the psychosocial evaluations were not evaluative and failed to include an evaluation of the historical information in order to establish an individualized treatment plan in each of the 12 client records reviewed.
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Plan of Correction
O97: The Clinical Supervisor of the facility (Kensington Hospital Outpatient Treatment Services Methadone Maintenance Program) will, henceforth, ensure that the psychosocial evaluation contains an assessment of the historical data obtained in patient records. This will be done through clinical supervision 2-4 times a month (or as often as necessary) and training on the best professional practice for completion of a psychosocial history, including careful review of all historical data in the client's chart ? information obtained through previous treatment (previous psychosocial histories, treatment plans, case consults, group and individual progress notes, etc).The Clinical Supervisor provided a special training on the proper, professional completion of a psychosocial history on 11/21/07, and will provide follow-up trainings as needed until all psychosocial histories are truly excellent in the quantity, accuracy and quality of their data.
Every 2-4 weeks when the counselors meet with the Clinical Supervisor, and at least three client charts will be reviewed in depth and detail at that time. In addition, the Clinical Supervisor has begun using, and will continue to use, a tracking form to review every chart of every counselor every month so as to identify deficiencies in documentation of services provided, and to develop a plan of correction to eliminate these deficiencies. This corrective action has already begun, and will continue until there are no more deficiencies.
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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
The hospital failed to review treatment and rehabilitation plans every 60 days. Findings: A review of eight active client records on November 8, 2007 revealed that the hospital failed to complete a treatment plan update every 60 days in three of the eight client records reviewed, specifically client records #1, 2 and 3.
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Plan of Correction
0969 : The Clinical Supervisor of the facility (Kensington Hospital Outpatient Treatment Services Methadone Maintenance Program) will, henceforth, ensure that the psychosocial evaluation contains an assessment of the historical data obtained in patient records. This will be done through clinical supervision 2-4 times a month (or as often as necessary) and training on the best professional practice for completion of history a psychosocial, including careful review of all historical data in the client's chart ? information obtained through previous treatment (previous psychosocial histories, treatment plans, case consults, group and individual progress notes, etc).The Clinical Supervisor provided a special training on the proper, professional completion of a psychosocial history on 11/21/07, and will provide follow-up trainings as needed until all psychosocial histories are truly excellent in the quantity, accuracy and quality of their data. Training was also provided at this time, and will be followed up in the manner described below, on the importance of doing all treatment plans and updates within the required time frame (60 days), and in a manner which builds directly upon the information provided in the psychosocial history and subsequent progress notes.
Every 2-4 weeks when the counselors meet with the Clinical Supervisor, and at least three client charts will be reviewed in depth and detail at that time. In addition, the Clinical Supervisor has begun using, and will continue to use, a tracking form to review every chart of every counselor every month so as to identify deficiencies in documentation of services provided, and to develop a plan of correction to eliminate these deficiencies. This corrective action has already begun, and will continue until there are no more deficiencies.
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711.93(a)(7) LICENSURE Follow-up Information
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:
(7) Follow-up information.
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Observations
The hospital failed to document attempts to follow up on discharged clients. Findings: Five of five client records where the client had been discharged were reviewed on November 8, 2007 revealing that the facility failed to include documentation of client follow-up attempts.
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Plan of Correction
0989: Every 2-4 weeks when the counselors meet with the Clinical Supervisor, and at least three client charts will be reviewed in depth and detail at that time. In addition, the Clinical Supervisor has begun using, and will continue to use, a tracking form to review every chart of every counselor every month so as to identify deficiencies in documentation of services provided, and to develop a plan of correction to eliminate these deficiencies. This corrective action has already begun, and will continue until there are no more deficiencies. These chart reviews will include reviews of closed cases to ensure that follow-up information is included in the record for all discharged clients. |