INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 20, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Holcomb Associates, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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 a review of client records, the facility failed to obtain an informed and voluntary consent form in five of ten client records reviewed.
The findings include:
Ten client records were reviewed on March 20, 2014. All records were reviewed for informed and voluntary consent forms.
Client #2 was admitted on July 8, 2013 and discharged on February 25, 2014. Consent to release form dated July 29, 2013 to the client's parole officer did not document the purpose for the release, what was being release on the consent form and the client signed it July 29, 2013 and staff (witness) signed it July 15, 2013. Additionally, there was a letter dated July 1, 2013 to "Whom It My Concern".
Client #4 was admitted on August 8, 2013 and there was a letter dated 7/25/13 to "Whom It My Concern."
Client #5 was admitted on December 6, 2013 and there was a discussion with the client's parents and a government agency pertaining to the client and the facility failed to have a consent to release for the parents and the government agency.
Client #8 was admitted on October 8, 2013 and discharged on December 30, 2013. The consent to release dated November 5, 2013 to the client's PCP did not document what was being released. Additionally, there was a letter to the client's PCP dated November 5, 2013 with no documentation of what is going to be release on the consent to release form.
Client #10 was admitted on December 6, 2013 and discharged on October 10, 2014 and the consent to release form to the client ' s parole officer dated January 10, 2014 did not document the purpose for the release.
The facility did not dispute the findings
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Plan of Correction
It is the policy of Holcomb Behavioral Health that all Releases of Information are completely and properly filled out, to a specific individual, for a specific purpose.
HBHS will conduct a Documentation training to reinforce these concepts within the next sixty days. it will be taught by, and documented by, the Program Coordinator.
We will also ensure that Client #5 has a current signed release for any and all further conversations that HBHS may have with outside entities.
This training will stress that all ROI must be completely and specifically filled out, addressing only a specific person, and clarifying a specific purpose for the release. As part of this training, we will review exactly what information is allowed to be released under the D&A regulations, also. We will make sure all new hires receive this training, and give it annually to all staff.
The Program Coordinator will be responsible for the above, and it will be completed by 6-25-14. |
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
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and/or counselor conclusions and impressions in nine of ten records reviewed.
The findings include:
Ten client records were reviewed March 20, 2014. A psychosocial evaluation was reviewed in all client records.
The psychosocial evaluations in client records # 1, 2, 3, 4, 5, 7, 8, 9 and 10 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records # 1, 2, 3, 4, 5, 7, 8, 9 and 10 did not include an evaluation of the client's support systems.
The psychosocial evaluations in client records # 1, 2, 3, 4, 5, 7, 8, 9 and 10 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records # 1, 2, 3, 4, 5, 7, 8, 9 and 10 did not include an evaluation of the negative factors of the client.
The psychosocial evaluations in client records # 1, 2, 3, 4, 5, 7, 8, 9 and 10 did not include an evaluation of the counselor conclusions/impressions of the client.
The facility did not dispute the findings
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Plan of Correction
It is Holcomb behavior Health System's policy that all Psychosocial evaluations include the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and/or counselor conclusions and impressions.
HBHS will hold a Staff training within the next sixty days to review this process . This training will focus on:
-Evaluation of the client's assets/strengths, and how they would impact treatment;
-evaluation of the client's support system;
-evaluation of the client's coping mechanisms;
-evaluation of the negative factors of the client;
-evaluation of the counselor conclusions/impressions.
This training will be conducted and documented by the program Coordinator, who will also be responsible for monitoring these issues in an ongoing basis.
This corrective action will be completed by 6-25-14. |
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
Based on a review of client records, the facility failed to document support services in five of ten records reviewed.
The findings include:
Ten client records were reviewed on March 20, 2014. All records were reviewed for a comprehensive treatment plan that is to include support services. Five of the ten failed to show documentation on their comprehensive treatment plan that support services were offered in the following client records, #1, 2, 3, 5 and 10.
The findings were not disputed
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Plan of Correction
Holcomb Behavioral Health System plans to update it's Treatment Plan form to be able clearly document supports in the client's life. The Program Coordinator will hold a training with in the next sixty days to update staff on the proper usage of the form. The Coordinator will also monitor proper usage in the future.
This corrective action will be completed by 6-25-14. |
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
Based on a review of client records, the facility failed to document a treatment plan update every 60 days in three of five client records reviewed.
The findings include:
Ten client records were reviewed on March 20, 2014. Five client records were required to have a treatment plan update. The facility failed to document a treatment plan update in client records #1, 3 and 9.
Client #1 was admitted on October 31, 2013. The comprehensive treatment plan was completed on December 2, 2013. A treatment plan update was due by January 2, 2014. As of the date of the licensing inspection there was no documentation of a treatment plan update.
Client #3 was admitted on August 2, 2013. The comprehensive treatment plan was completed on August 30, 2013. The treatment plan updates were due by October 30, 2013, December 30, 2013 and March 2, 2014. The first treatment plan update was not completed until December 6, 2013 and the next one, which should have been completed by February 6, 2013, was not documented.
Client #9 was admitted on October 18, 2013 and discharged on January 31, 2014. The comprehensive treatment plan was completed on October 18, 2013. A treatment plan update was due by December 18, 2013. As of the date of the licensing inspection there was no documentation of a treatment plan update.
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Plan of Correction
It is the policy of Holcomb Behavioral Health systems that all Treatment Plans are updates every sixty days.
HBHS will hold a Training session within the next thirty days to reinforce this issue with all existing staff, and train all new staff on the issue, as well. The training will be conducted, and documented, by the Program Coordinator, who will be responsible for monitoring the ongoing progress of the training initiative as well.
The Program Coordinator will complete this plan of correction by 5-25-14. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to have a complete record in three of ten records reviewed.
The findings include:
Ten client records were reviewed on March 20, 2014. Nine records required documentation of case consultations and five required documentation of follow-ups.
Client #2 was admitted on July 8, 2013 and discharged on February 25, 2014. The first case consultation should have been completed by October 8, 2013 and it was not documented until November 4, 2013. The discharge summary was to be completed within 7 days of the clients discharge date. Client #2's discharge summary was not documented until March 10, 2014. Additionally, the aftercare plan, dated February 11, 2014, failed to include the goals with time frames and support services for the client.
Client #6 was admitted on April 3, 2013 and discharged on October 7, 2013. The aftercare plan, dated August 7, 2013, failed to include the time frames for the goals documented and support services for the client. Additionally, there was no documentation of a follow-up contact as of the date of the licensing inspection.
Client #7 was admitted on August 11, 2013 and discharged on November 14, 2013. As of the date of the licensing inspection there was not documentation of a follow-up contact for client #7.
The facility did not dispute the findings
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Plan of Correction
It is the policy of Holcomb behavioral Health Systems that all documentation, including discharge plans and aftercare plans (including goals), be completed in a timely fashion. In addition, there must be follow up contact for discharged clients. (HBHS will reach out to client #7, to ascertain insurance status, and if further intervention is desired ).
The Program Coordinator will hold a training for all staff on this issue, and set up internal protocols to insure future compliance. The coordinator will also be responsible for ensuring compliance.
She will monitor charts to ensure that case consultation notes, discharge notes, and aftercare plans are completed on time. Likewise, the coordinator will monitor follow up contact for all discharged clients to assure that it happens, and happens in the established time frame.
The POC will be completed by the program Coordinator bY 5-25-14 |