INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 24, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on September 21, 2006.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Feedback forms were not completed on training attended in two of four records reviewed, #1 and 3.
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Plan of Correction
Feedback forms will be used for all trainings. The facility director will monitor compliance. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Individual training plans were not completed in two of four records reviewed, # 1 and 3.
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Plan of Correction
Annual training plans will be completed for all staff, and include D&A training requirements.
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
The client to counselor ratio was 40 to 1.
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Plan of Correction
Additional clinical hours will be added to the project, in order to maintain at least the minimum staff to client ratio. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Blank consent to release forms were signed in three of five records reviewed, #1, 2 and 4.
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Plan of Correction
Additional training will be provided for all relevant clinical and administrative staff to ensure full completion of all consent for release of information forms. The Clinical Supervisor will monitor compliance with this issue. |
709.28(c)(2) 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. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The information to be released to governmental agencies exceeded that allowable by 4 Pa. Code 255.5 in four of five records reviewed, #1, 3, 4 and 5.
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Plan of Correction
Additional training will be provided for all relevant clinical and administrative staff to ensure that all consent for release of information forms and agency response are in compliance with 4 Pa. Code 255.5. The Clinical Supervisor will monitor compliance with this issue. |
709.28(c)(3) 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. The consent shall be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Consent to release information forms were missing the purpose of the consent in four of five records reviewed, #1, 3, 4 and 5.
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Plan of Correction
Additional training will be provided for all relevant clinical and administrative staff to ensure full completion of all consent for release of information forms. The Clinical Supervisor will monitor compliance with this issue. |
709.28(c)(6) 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. The consent shall be in writing and include, but not be limited to:
(6) Expiration date of the consent.
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Observations
Consent to release information forms were missing an expiration date in three of five record reviewed, # 3, 4 and 5.
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Plan of Correction
Additional training will be provided for all relevant clinical and administrative staff to ensure full completion of all consent for release of information forms, including expiration dates. The Clinical Supervisor will monitor compliance with this issue. |
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
The lengths and patterns of use and the client's perception were missing in two of five records reviewed, #4 and 5.
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Plan of Correction
Additional training will be provided for all relevant clinical staff to ensure these issues are addressed with the client and properly documented. The Clinical Supervisor will monitor compliance with this issue. |
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
Psychosocial evaluations did not address assets/strengths, coping/defense mechanisms and support systems in five of five records reviewed, # 1, 2, 3, 4 and 5. Evaluations were historical rather than the counselor's assessment of the provided information in five of five records reviewed.
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Plan of Correction
Additional training will be provided for all relevant clinical staff to ensure a comprehensive assessment summary, ensuring these components are fully addressed and properly documented on the agency-required forms. The Clinical Supervisor will monitor compliance with this issue. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Preliminary treatment plans were missing in five of five records reviewed, #1, 2, 3, 4 and 5.
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Plan of Correction
Additional training will be provided for clinical staff to ensure that treatment plans are completed on the first visit. The Clinical Supervisor will monitor compliance
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709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Treatment plan goals did not contain measurable action steps in five of five records reviewed, #1, 2 ,3, 4 and 5.
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Plan of Correction
Additional training will be provided for all clinical staff to ensure that Treatment Goals are broken down into measurable steps (i.e., treatment objectives). The Clinical Supervisor will monitor compliance.
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709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Support services were missing in five of five records reviewed, # 1, 2, 3, 4 and 5.
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Plan of Correction
Additional training will be provided for clinical staff to ensure that Support Services are listed in the client record. The Clinical Supervisor will monitor compliance with this issue |
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
Treatment plan updates were missing in five of five records reviewed, # 1, 2, 3, 4 and 5.
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Plan of Correction
Additional training will be provided for all relevant clinical staff to ensure that treatment Plan updates are completed in a timely fashion. The Clinical Supervisor will monitor compliance. |
709.93(a)(2) 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:
(2) Medication records.
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Observations
The medication question was not answered in five of five records reviewed, #1, 2, 3, 4 and 5.
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Plan of Correction
Additional training will be provided for the clinical staff to ensure that medication information is properly documented. The Clinical Supervisor will monitor compliance with this issue. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
The plan portion of the individual notes did not include the plan or direction of treatment in five of five records reviewed, #1, 2, 3, 4 and 5.
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Plan of Correction
Additional training will be provided for the clinical staff to ensure that progress notes include the direction or plan of treatment. The Clinical Supervisor will monitor compliance with this issue. |
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
Case consultations were missing four of five records reviewed, # 1, 3, 4 and 5.
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Plan of Correction
Additional training will be provided for all relevant clinical staff to ensure that Case Consultation is performed and documented, in compliance with agency policy and BDAP regulations. The facility director will monitor compliance of the Clinical Supervisor.
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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
Aftercare plans were missing in five of five records reviewed, # 6, 7, 8, 9 and 10.
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Plan of Correction
Additional training will be provided for all relevant clinical staff to ensure the timely completion of Aftercare Plans. The Clinical Supervisor will monitor compliance with this issue. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Discharge summaries did not address the client's response to treatment plan goals in two of six records reviewed, # 6 and 8. The prognosis or client status was missing in six of six records reviewed, #6, 7, 8, 9, 10 and 11.
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Plan of Correction
Additional training will be provided for all relevant clinical staff to ensure that Discharge Plans include the client's response to Treatment. The Clinical Supervisor will monitor compliance with this issue. |