INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 29, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Counseling Center of Mercer County 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 August 25, 2008.
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Plan of Correction
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on review of of the fire drill log on July 29, 2008, the facility failed to document monthly unannounced fire drills. The fire drill for June was not documented.
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Plan of Correction
The fire drill for the month of June was erroneously omitted due to the fire inspection conducted that month. All future drills will be conducted monthly and documented by office staff. Compliance will be reviewed by facility director. |
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
Based on review of client records on July 29, 2008, the facility failed to document informed and voluntary consents to release information. Documented in client records #1, 2, 3, and 4, on the information page of the the client records, is a list of assigned employees. The names on the list exceed the staff that is included on the "Staffing Requirements Facility Summary Report" which lists both clinical and support staff . Those staff not listed on the Facility Summary Report cannot have access to the clients or their records.
The facility failed to document the specific information that would be released in client record #2. The language used to describe the information to be released was "intake information" which fails to designate what specific information is to be released. The facility failed; to document the purpose of the release of information in client record #2 as the purpose given was not consistent with the function of the recipient of the information. The purpose was listed as "coordination of treatment" but the agency the information was released to is a third party payer.
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Plan of Correction
By September 30, 2008, a review of the confidentiality laws concerning informed consent and the completion of consent forms will be provided to all staff involved with addicted clients. This review will focus on the proper completion of the consent form and definition of terms.It will be provided by the facility director and the compliance officer.
By November 1, 2008, support staff necessary to process fiscal documentation and provide clerical services will be identified and informed of the training requirements related to their duties in Drug and Alcohol Programing. They will be assigned to the first available required trainings offered.
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709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on review of client records and the orientation packet on July 29, 2008, the facility failed to document client rights. A sign off form was documented in client records #1, 2, 3 and 4, demonstrating that the clients were made aware of their rights. Upon further review, the facility failed to document all the required areas of the client rights policy and procedure in the orientation packet that the client sign off form refers to.
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Plan of Correction
By October 15,2008; a full review of the required rights and the information provided to the clients will be completed and all missing information added to the intake packet.The review and the corrections, if needed, will be conducted by the compliance officer. |
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 a review of client records on July 29, 2008, the facility failed to give a drug and alcohol history that was inclusive of the clients' lengths and patterns of use. In client record #1 , the the drug and alcohol history failed to document if the client had used any other drugs or alcohol, besides the one listed, failed to give a clear description of the client's past use and history. In client record #4, the drug and alcohol history failed to provide clear documentation of the client's past use and current use, what drugs or alcohol the client had used. The drug and alcohol histories were incomplete in 2 out of 3 applicable records, client record # 1 and 4. Client record # 2 was not applicable due to time frames.
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Plan of Correction
Due to the recent addition of our forms to the new computer software, some areas are not as expansive or ,if not applicable, not recorded as covered. Much of the actual paper documentation does not translate into computer format well, and so recomposing forms is one of the current issues being addressed in the software by our IT staff. By October 15, our goal is to have the biopsychosocial re-written in the software, which will allow more thorough reporting. Additionally, we have purchased an instrament(GAIN) which also will assure that all areas are covered adequately.As soon as the Facility Director is trained and able to navigate this software program,
we will also have a training addressing completing the GAIN. More immedeately, a training by the Facility Director will be given on developing a complete history September 4.
QA quarterly audits will review documentation for completeness. |
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 a review of client records on July 29, 2008, the facility failed to document a complete personal history in 3 out of 3 applicable client records, # 1, 3 and 4. Client record #2 was not applicable due to timeframes. In client record #1, family, education and sexual histories were incomplete. In client record #3, family, education, and employment histories were incomplete. In client record #4, family, employment, education, recreational and sexual histories were incomplete.
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Plan of Correction
As indicated in the previous POC, some of these issues are related to software and are currently being addressed by the IT department. Additionally, by September 30, a training will be provided on documentation of the various life domains, as well as the justification for gleaning this information.This training will be provided by the Facility Director. |
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
Based on review of client records on July 29, 2008, the facility failed to document treatment and rehabilitation plans that included short and long term goals that include realistic and measurable criteria. In client record #1, the steps for the goals failed to be measurable. In client record #3 the comprehensive treatment was not documented. Client records #2 and 3 were not applicable to this review due to timeframes.
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Plan of Correction
By September 30, a review of treatment plan writing will be provided to all staff, including the drug and alcohol staff. This review is provided regularly to assure use of measurable goals.
Ongoing review of records for completeness through QA audits will be the responsibility of the Compliance Officer. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the policy manual during the licensing inspection on July 29, 2008, the facility failed to provide a complete follow-up policy. The policy refers to completing follow-up as outlined on the aftercare plan. Aftercare plans are only completed for successful discharges. The policy fails to address follow-up for those clients who do not receive an aftercare plan.
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Plan of Correction
The policy will be re-written to reflect the actual pracise of follow-up letters being sent to all clients by September 30, 2008.With the new software, it is possible to track all discharges and automatically trigger a follow-up letter being sent in 6 months.
All trainigs and changes to policy will be the responsibility of the facility Director. |