INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 16- 17, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Services of Beaver Valley, Inc 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:
|
Plan of Correction
|
709.92(a) 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:
|
Observations
Based on a review of client records, the facility failed to document that the individual treatment and rehabilitation plan was developed with the client in 4 of 10 client records.
The findings include:
Ten client records were reviewed on October 16-17, 2013. The facility failed to document that the individualized treatment and rehabilitation plans were developed with the client in client records #1, 5, 7 and 9.
Client #1 was admitted on May 30, 2013. The individual treatment and rehabilitation plan was developed on June 28, 2013. The plan was not signed by the client and there was no progress note documented to indicate that the plan was developed with the client.
Client #5 was admitted on April 15, 2013. The individual treatment and rehabilitation plan was developed on May 15, 2013. The plan was not signed by the client and there was no progress note documented to indicate that the plan was developed with the client.
Client #7 was admitted on March 19, 2013. The individual treatment and rehabilitation plan was developed on April 19, 2013. The plan was not signed by the client and there was no progress note documented to indicate that the plan was developed with the client.
Client #9 was admitted on May 13, 2013. The individual treatment and rehabilitation plan was developed on June 14, 2013. The plan was not signed by the client and there was no progress note documented to indicate that the plan was developed with the client.
An interview with the Project / Facility Director and the Clinical Supervisor took place on October 17, 2013, at which time the aforementioned information was confirmed.
|
Plan of Correction
In order to insure documentation reflects that all treatment/rehabilitation plans are developed with the client, Drug and Alcohol Services of Beaver Valley, Inc.(DASBV) has taken the following steps: *A training memo, from the clinical Supervisor, was provided to all counselors to meet the full compliance date of 12/31/2013. *All counselors received training, presented by the clinical supervisor to review this standard to meet the full compliance date of 12/31/2013.
In addition to obtaining the client signature on the plan, the progress notes will also reflect the mutually developed treatment plan. The clinical supervisor will monitor this standard by reviewing all treatment plans prior to obtaining the medical director's review and signature. DASBV will be in full compliance by 12/31/2013 |
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.
|
Observations
Based on a review of client records, the facility failed to document that the individual treatment and rehabilitation plan, including short and long-term treatment goals, was developed with the client, in 4 of 10 client records.
The findings include:
Ten client records were reviewed on October 16-17, 2013. The facility failed to document that the individualized treatment and rehabilitation plan, including short and long-term treatment goals, was developed with the client in client records #1, 5, 7 and 9.
Client #1 was admitted on May 30, 2013. The individual treatment and rehabilitation plan was developed on June 28, 2013. The plan was not signed by the client and there was no progress note documented to indicate that the plan was developed with the client.
Client #5 was admitted on April 15, 2013. The individual treatment and rehabilitation plan was developed on May 15, 2013. The plan was not signed by the client and there was no progress note documented to indicate that the plan was developed with the client.
Client #7 was admitted on March 19, 2013. The individual treatment and rehabilitation plan was developed on April 19, 2013. The plan was not signed by the client and there was no progress note documented to indicate that the plan was developed with the client.
Client #9 was admitted on May 13, 2013. The individual treatment and rehabilitation plan was developed on June 14, 2013. The plan was not signed by the client and there was no progress note documented to indicate that the plan was developed with the client.
An interview with the Project / Facility Director and the Clinical Supervisor took place on October 17, 2013 at which time the aforementioned information was confirmed.
|
Plan of Correction
To insure documentation reflects that all short and long-term goals are formulated by both counselor and client, DASBV has taken the following steps: *A training memo, from the clinical supervisor. was provided to all counselors to meet the full compliance date of 12/31/2013. *All counselors received training from the clinical supervisor, in order to be in full compliance by 12/31/2013
In addition to obtaining the client's signature on the mutually formulated short and long-term goals, the progress notes will reflect the development of the short and long-term goals. The clinical supervisor will monitor this standard by conducting 3 case reviews per counselor each quarter during 2014. DASBV will be in complete compliance with this standard by 12/31/2013 |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of client records, the facility failed to document that the individual treatment and rehabilitation plan, including type and frequency of treatment and rehabilitation services, was developed with the client in 4 of 10 client records. The facility failed to document the frequency of treatment and rehabilitation services in 2 of 10 client records.
The findings include:
Ten client records were reviewed on October 16-17, 2013. The facility failed to document that the individualized treatment and rehabilitation plan, including type and frequency of treatment and rehabilitation services, was developed with the client in client records #1, 5, 7 and 9. The facility failed to document the frequency of treatment and rehabilitation services in client records # 6 and 8.
Client #1 was admitted on May 30, 2013. The individual treatment and rehabilitation plan was developed on June 28, 2013. The facility failed to document that the individual treatment plan was developed with the client. The treatment plan was neither signed by the client nor was there a progress note in the record to indicate that the treatment plan was developed with the client.
Client #5 was admitted on April 15, 2013. The individual treatment and rehabilitation plan was developed on May 15, 2013. The facility failed to document that the individual treatment plan was developed with the client. The treatment plan was neither signed by the client nor was there a progress note in the record to indicate that the treatment plan was developed with the client.
Client #6 was admitted on March 4, 2013. The individual treatment and rehabilitation plan was developed with the client on April 4, 2013. The facility failed to document the frequency of treatment and rehabilitation services on the treatment plan as the treatment plan included a range of 1-4 individual sessions per month.
Client #7 was admitted on March 19, 2013. The individual treatment and rehabilitation plan was developed on April 19, 2013. The facility failed to document that the individual treatment plan was developed with the client. The treatment plan was neither signed by the client nor was there a progress note in the record to indicate that the treatment plan was developed with the client.
Client #8 was admitted on March 26, 2013. The individual treatment and rehabilitation plan was developed with the client on April 11, 2013. The facility failed to document the frequency of treatment and rehabilitation services on the treatment plan as the treatment plan included a range of 1-4 individual sessions per month.
Client #9 was admitted on May 13, 2013. The individual treatment and rehabilitation plan was developed on June 14, 2013. The facility failed to document that the individual treatment plan was developed with the client. The treatment plan was neither signed by the client nor was there a progress note in the record to indicate that the treatment plan was developed with the client.
An interview with the Project / Facility Director and the Clinical Supervisor took place on October 17, 2013 at which the the aforementioned information was confirmed.
|
Plan of Correction
To insure documentation reflects that all treatment/rehabilitation plans are developed with the client and includes the type and frequency of treatment, DASBV has taken the following steps: *A training memo, from the clinical supervisor, was provided to all counselors in order to be in full compliance by 12/31/2013. *All counselors received training, presented by the clinical supervisor, to review this standard and be in full compliance by 12/31/2013. In addition to obtaining the client's signature on the Treatment Plan, the progress notes will reflect the mutual development of the type and frequency of treatment. The clinical supervisor will monitor this standard by conducting 3 case reviews per counselor each quarter during 2014. DASBV will be in complete compliance with this standard by 12/31/2013. |
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.
|
Observations
Based on a review of client records, the facility failed to document that the individual treatment and rehabilitation plan, including proposed type of support services, was developed with the client in 4 of 10 client records.
The findings include:
Ten client records were reviewed on October 16-17, 2013. The individualized treatment and rehabilitation plans in all ten client records, to include proposed type of support services, were required to be developed with the client. The individualized treatment and rehabilitation plans, including proposed type of support services, were not developed with the client in client records #1, 5, 7 and 9.
Client #1 was admitted on May 30, 2013. The individual treatment and rehabilitation plan was developed on June 28, 2013. The plan was not signed by the client and there was no progress note documented to indicate the plan was developed with the client.
Client #5 was admitted on April 15, 2013. The individual treatment and rehabilitation plan was developed on May 15, 2013. The plan was not signed by the client and there was no progress note documented to indicate the plan was developed with the client.
Client #7 was admitted on March 19, 2013. The individual treatment and rehabilitation plan was developed on April 19, 2013. The plan was not signed by the client and there was no progress note documented to indicate the plan was developed with the client.
Client #9 was admitted on May 13, 2013. The individual treatment and rehabilitation plan was developed on June 14, 2013. The plan was not signed by the client and there was no progress note documented to indicate the plan was developed with the client.
An interview with the Project / Facility Director and the Clinical Supervisor took place on October 17, 2013 at which time the aforementioned information was confirmed.
|
Plan of Correction
To insure documentation reflects that all treatment/rehabilitation plans are developed with the client and includes the proposed types of support services, DASBV has taken the following steps: *A training memo, from the clinical supervisor, was provided to all counselors in order to be in full compliance by 12/31/2013. *All counselors received training, presented by the clinical supervisor, to review this standard and be in full compliance by 12/31/2013. In addition to obtaining the client's signature on the plan of service, the progress notes will reflect the mutual development of the proposed types of support services needed by the client. The Clinical supervisor will monitor this standard by conducting 3 case reviews per counselor each quarter during 2014. DASBV will be in complete compliance with this standard by 12/31/13. |