INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 20-21, 2007 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 April 16, 2007.
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Plan of Correction
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711.91(b)(3)(i) LICENSURE Medical History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Family medical histories were missing or incomplete in 3 of 5 client records that were reviewed [record # 1, 3, 4]. Documentation of symptoms and illnesses, was inconsistently documented, unable to determine if completed in 3 of 5 client records reviewed, records # 2, 3, 4.
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Plan of Correction
Staff will be trained on how to do a family medical history that will capture a more complete medical history and about the importance of the problems, needs and characteristics of a client's family of origin to the etiology and dynamics of addiction and recovery. The importance of inquiring carefully and thoroughly about family medical histories will be stressed so as to identify possibly family patterns which might alert the Kensington Hospital Medical Staff of possible genetic components (as for example in the case of alcoholism, mental illnesses and other diseases occurring more often within the client's family than statistical probability would predict).
Training on the importance of more detailed documentation of family medical histories has already been initiated, and the Director is and will continually carefully review every recent psychosocial history to insure comprehensiveness and completeness in this area, as well as, every new case within 30 days of admission. |
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
Psychosocial evaluations did not address all of the required areas. In 3 of 5 client records reviewed, the psychosocial evaluations did not include clinical assessment of the historical data, #1, 2, 4. The records reviewed did not include a clinical assessment of available or potential support systems for the client, and the client needs, assets/strengths and coping mechanisms were a checklist without any assessment statement by the clinician. The client's attitude towards treatment was either vague or missing altogether. Counselor's impression did not provide a conclusion demonstrating evaluative interpretation in 3 of 5 records, as numbered above.
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Plan of Correction
Staff will receive training on how to do a clinical assessment of the historical data gleaned for the psychosocial history, with special emphasis upon the difference between client "facts" and thoughful interpretation of the psychological meaning of these "facts". The Intake Supervisor and Program Director will be responsible for the compliance of this Plan of Correction. |
711.91(b)(7) LICENSURE Preliminary Treatment Plan
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
All preliminary treatment plans are identical with no individualization demonstrating that it is based on client-specific data.
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Plan of Correction
The preliminary treatment plan will be re-designed adding a section where the interviewing counselor can (and will be requested to) add a brief, initial, individualized clinical assessment of the client's special problems, needs and characteristics. The Program Director will be responsible for the compliance of this Plan of Correction |
711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) 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
The comprehensive treatment plan was not completed as per program policy in 2 of 5 client records reviewed. The treatment plan was completed almost 2 months late for client #3, and was missing for client #5.
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Plan of Correction
The Program Director will train counselors on the best practice strategies for developing a treatment plan within the required time frame with client participation, which may include client review and feeback on a written draft with the opportunity to request changes before signing or when opportunities permit, developing and writing the treatment plan in the client's presence. The Program Director will require all counselors to review at least 1/5 of their client records every work day so as to insure their completeness and accuracy, and to review all changes with the Program Director during weekly supervision. |
711.92(c)(3) LICENSURE Support Service
711.92. Treatment and rehabilitation services.
(c) 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
In 2 of 4 client records reviewed, proposed support services were not appropriate based in the documentation reviewed.
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Plan of Correction
The Program Director will re-train the Counselors to understand the meaning of "Support Services" on the treatment plan to include public case management resources and other community resources which help to meet the client's needs, in addition to family, friends, fellowship meetings, church memberships, etc. which already tend to be indicated adequately. The Program Director will review every Treatment Plan before signing it to ensure sufficient reference to community resources for client needs. |
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
In 1 of 2 client records reviewed for treatment plan updates, the review for client #1 did not discuss the progress of the client in regard to all of the stated goals. There was no discussion of the need to revise or restate the goals, the need to modify the strategies or the status of the stated goal despite clear documentation in other areas of the record indicating the goals and strategies as stated were not effective.
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Plan of Correction
Counselors will be re-trained by the Program Director to fill out the Progress & Comments sections of each previous treatment plan at the time that a new 60 day treatment plan update is written so as to evaluate and document the client's progress in the clinical notes on the old tretment plan before writing the new one. Special emphasis will be placed upon inquiring about the client's own perceptions and judgments of progress (or lack therof), not just the counselor's judgments. The Program Director will review every Treatment Plan to ensure the progress of the patient in regard to all of the stated goals are addressed. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) 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
The consents to disclose information obtained from clients in 5 of 5 records reviewed, [#1, 2, 3, 4, 5,] cannot be considered informed consent since the consent to release information to various entities did not include all the required information prior to the client signing them. The client could not have been informed about the release of information.
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Plan of Correction
The Addictions Intake & Outpatient Methadone staff will be trained on the proper completion of consent forms, with special emphasis upon the need to always include indication of proper limitations on the disclosure of information in client records as defined and described by Federal & State Confidentiality laws. New forms will be developed which explicitly indicate these limitations, in writing, in sufficient detail to prevent any confusion or impoper omission. The Program Director and the Assessment Intake Staff Supervisor will discuss and review these changes together to insure consistency and compliance with all laws, regardless of who does the actual intake interview. The Assessment Intake Unit Supervisor and Methadone Program Director will be responsible for the compliance of this Plan of Correction. |
711.93(c)(2)(i) LICENSURE Name of person/agency/organization
711.93. Client records.
(c) Confidentiality.
(2) 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:
(i) The name of the person, agency or organization to whom disclosure is made.
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Observations
The name of the person, agency or organization was missing on most of the consents to release in 5 of 5 client records reviewed.
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Plan of Correction
Special emphasis will be placed upon the absolute legal necessity of always indicating the name of the person and agency to whom information is to be disclosed when Additions Intake and Methadone staff receive training on the proper way to complete a consent form. Furthermore, as indicated above, new forms will be developed which explicitly indicate these limitations, in writing, in sufficient detail to prevent an confusion or improper omission. The Assessment Intake Unit Supervisor and Methadone Program Director will be responsible for the compliance of this Plan of Correction. All existing consent forms will be reviewed immediately to ensure that there are no illegal consent forms in any client record. |
711.93(c)(2)(ii) LICENSURE Specific Info. Disclosed
711.93. Client records.
(c) Confidentiality.
(2) 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:
(ii) The specific information disclosed.
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Observations
Specific information to be released was missing in 5 of 5 client records reviewed, #1, 2, 3, 4 and 5.
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Plan of Correction
As indicated in the Plan of Correction for Observation #1001, special emphasis will be placed upon the absolute legal necessity of always indicating the name of the person and agency to whom information is to be disclosed when Addictions Intake and Methadone staff are trained on the proper way to complete a consent form. Furthermore, as indicated above, new forms will be developed which explicitly indicate these limitations, in writing, in sufficient detail to prevent any confusion or improper omission. The Assessment Intake Unit Supervisor and Methadone Program Director will be responsible for the compliance of this Plan of Correction. |
711.93(c)(2)(iii) LICENSURE Purpose of Disclosure
711.93. Client records.
(c) Confidentiality.
(2) 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:
(iii) The purpose of disclosure.
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Observations
The purpose of the consent to release information was not consistently documented in 5 of 5 client records reviewed, #1, 2, 3, 4, and 5.
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Plan of Correction
Special emphasis will be placed upon the absolute legal necessity of always indicating the name of the person and agency to whom information is to be disclosed when the Addictions Intake and Methadone staff are trained on the proper way to complete a consent form. Furthermore,new forms will be developed which explicitly indicate these limitations, in writing, in sufficient detail to prevent any confusion or improper omission. The Assessment Intake Unit Supervisor and the Methadone Program Director will be responsible for the compliance of this Plan of Correction. |
711.93(c)(3) LICENSURE Copy-Client Consent
711.93. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Documentation that the client had been offered a copy of the consent was not consistently completed in 5 of 5 client records reviewed, #1, 2, 3, 4 and 5.
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Plan of Correction
Special emphasis will be placed upon the absolute legal necessity of always indicating the name of the person and agency to whom information is to be disclosed when the Addictions Intake and Methadone staff are trained on the proper way to complete a consent form. Furthermore, new forms will be developed which explicitly indicate these limitations, in writing, in sufficient detail to prevent any confusion or improper omission. Documentation will indicate in the appropriate box whether or not the client has accepted the offerred consent prior to signing at the bottom of the form. The charts of all new clients will be audited to ensure that this omission does not re-occur. In addition, as old charts are audited, the Program Director will review these forms to ensure any deficiencies have been corrected.
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