INITIAL COMMENTS
|
This report is a result of an on-site licensing inspection conducted on April 9-10, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, MCP/Caring Together 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
|
704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
|
Observations
Based on a review of the facility's staff development records, the facility failed to document an annual evaluation of the overall training plan.
The findings include:
On April, 10, 2012, the facility's staff development records were reviewed for documentation of an annual evaluation of their overall training plan. The facility did not document an annual evaluation of their 2010-2011 training plan.
An interview with the facility director on April 10, 2012 confirmed the findings.
|
Plan of Correction
PM will review state guidelines regarding review of previous training year and create reminder system for the future. |
711.91(b)(3(ii) LICENSURE D & A History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
|
Observations
Based on the review of client records, the facility failed to document a drug and alcohol history in two out of nine records reviewed and failed to date and sign drug and alcohol histories in four out of nine records reviewed.
The findings include:
On April 10, 2012, nine client records were reviewed for drug and alcohol histories, specifically records # 1, 2, 3, 4, 5, 6, 7, 8 and 9. The facility did not document a drug and alcohol history in client records # 7 & 8 and failed to date and sign the drug and alcohol histories in client records # 1, 5, 6, and 9.
Client # 1 was admitted on 1/27/12. Client # 1's record contained a drug and alcohol history, but the drug and alcohol history was not signed or dated. It was not possible to determine when the drug and alcohol history was completed.
Client # 5 was admitted on 2/20/12. Client # 5's record contained a drug and alcohol history, but the drug and alcohol history was not signed or dated. It was not possible to determine when the drug and alcohol history was completed.
Client # 6 was admitted on 2/9/12. Client # 6's record contained a drug and alcohol history, but the drug and alcohol history was not signed or dated. It was not possible to determine when the drug and alcohol history was completed.
Client # 7 was admitted on 1/17/12. Client # 7's record did not contain a drug and alcohol history.
Client # 8 was admitted on 10/7/11. Client # 8's record did not contain a drug and alcohol history.
Client # 9 was admitted on 7/8/11. Client # 9's record contained a drug and alcohol history, but the drug and alcohol history was not signed or dated. It was not possible to determine when the drug and alcohol history was completed.
An interview with the facility director on April 10, 2012 confirmed the findings.
|
Plan of Correction
The employee associated with these deficiencies is no longer employed with the program. Going forward, PM to increase length of training for new employees and to do full review of all clinical documentation on a weekly basis for first 3 months after hire. |
711.91(b)(3)(iii) LICENSURE Personal History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
Based on the review of client records, the facility failed to document a personal history in two out of nine records reviewed and failed to date and sign personal histories in four out of nine records reviewed.
The findings include:
On April 10, 2012, nine client records were reviewed for personal histories, specifically records # 1, 2, 3, 4, 5, 6, 7, 8 and 9. The facility did not document a personal history in client records # 7 & 8 and failed to date and sign personal histories in client records # 1, 5, 6, and 9.
Client # 1 was admitted on 1/27/12. Client # 1's record contained a personal history, but the personal history was not signed or dated. It was not possible to determine when the personal history was completed.
Client # 5 was admitted on 2/20/12. Client # 5's record contained a personal history, but the personal history was not signed or dated. It was not possible to determine when the personal history was completed.
Client # 6 was admitted on 2/9/12. Client # 6's record contained a personal, but the personal was not signed or dated. It was not possible to determine when the personal history was completed.
Client # 7 was admitted on 1/17/12. Client # 7's record did not contain a personal history.
Client # 8 was admitted on 10/7/11. Client # 8's record did not contain a personal history.
Client # 9 was admitted on 7/8/11. Client # 9's record contained a personal history, but the personal history was not signed or dated. It was not possible to determine when the personal history was completed.
|
Plan of Correction
The employee associated with these deficiencies is no longer employed with the program. Going forward, PM to increase length of training for new employees and to do full review of all clinical documentation on a weekly basis for first 3 months after hire.
|
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation in six out of nine records.
The findings include:
On April 10, 2012, nine client records were reviewed for psychosocial evaluations, specifically records # 1, 2, 3, 4, 5, 6, 7, 8 and 9. The facility did not document a psychosocial evaluation in client records # 1, 5, 6, 7, 8 and 9.
Client # 1 was admitted on 1/27/12. Client # 1's record did not contain a psychosocial evaluation.
Client # 5 was admitted on 2/20/12. Client # 5's record did not contain a psychosocial evaluation.
Client # 6 was admitted on 2/9/12. Client # 6's record did not contain a psychosocial evaluation.
Client # 7 was admitted on 1/17/12. Client # 7's record did not contain a psychosocial evaluation.
Client # 8 was admitted on 10/7/11. Client # 8's record did not contain a psychosocial evaluation.
Client # 9 was admitted on 7/8/11. Client # 9's record did not contain a psychosocial evaluation.
An interview with the facility director on April 10, 2012 confirmed the findings.
|
Plan of Correction
The employee associated with these deficiencies is no longer employed with the program. Going forward, PM to increase length of training for new employees and to do full review of all clinical documentation on a weekly basis for first 3 months after hire.
|
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:
|
Observations
Based on the review of client records, the facility failed to document an individual treatment and rehabilitation plan in six out of nine records.
The findings include:
On April 10, 2012, nine client records requiring treatment and rehabilitation plans were reviewed, specifically records # 1, 2, 3, 4, 5, 6, 7, 8 and 9. The facility did not document an individual treatment and rehabilitation plan based on the information collected from the client history in records # 1, 5, 6, 7, 8 and 9.
Client # 1 was admitted on 1/27/12. The treatment and rehabilitation plan in client # 1's record was dated 2/27/12. The client history in this record was not signed or dated, so it was not possible to determine if the treatment and rehabilitation plan was based on the information collected in the client history.
Client # 5 was admitted on 2/20/12. Client # 5's record did not contain a treatment and rehabilitation plan at the time of review.
Client # 6 was admitted on 2/9/12. Client # 6's record did not contain a treatment and rehabilitation plan at the time of review.
Client # 7 was admitted on 1/17/12. The treatment and rehabilitation plan in client # 7's record was dated 1/17/12. The treatment and rehabilitation plan was not based on the client's history because the record did not contain a client history at the time of review.
Client # 8 was admitted on 10/7/11. The treatment and rehabilitation plan in client # 8's record was dated 11/15/11. The treatment and rehabilitation plan was not based on the client's history because the record did not contain a client history at the time of review.
Client # 9 was admitted on 7/8/11. The treatment and rehabilitation plan in client # 9's record was dated 8/8/11. The client history in this record was not signed or dated, so it was not possible to determine if the treatment and rehabilitation plan was based on the information collected in the client history.
An interview with the facility director on April 10, 2012 confirmed the findings.
|
Plan of Correction
The employee associated with these deficiencies is no longer employed with the program. Going forward, PM to increase length of training for new employees and to do full review of all clinical documentation on a weekly basis for first 3 months after hire.
|
711.93(a)(2) LICENSURE Record of Services Provided
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes all information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(2) Record of services provided.
|
Observations
Based on the review of client records, the facility failed to document a record of services provided in ten out of ten records.
The findings include:
On April 10, 2012, ten client records requiring a record services were reviewed, specifically records # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10. The facility did not document a record of services to include a chronological listing of the various specific services provided in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
Client # 1 was admitted on 1/27/12. Client # 1's record did not include a record of services provided.
Client # 2 was admitted on 1/25/12. Client # 2's record did not include a record of services provided.
Client # 3 was admitted on 11/15/11. Client # 3's record did not include a record of services provided.
Client # 4 was admitted on 9/2/11. Client # 4's record did not include a record of services provided.
Client # 5 was admitted on 2/20/12. Client # 5's record did not include a record of services provided.
Client # 6 was admitted on 2/9/12. Client # 6's record did not include a record of services provided.
Client # 7 was admitted on 1/17/12. Client # 7's record did not include a record of services provided.
Client # 8 was admitted on 10/7/11. Client # 8's record did not include a record of services provided.
Client # 9 was admitted on 7/8/11. Client # 9's record did not include a record of services provided.
Client # 10 was admitted on 3/5/12. Client # 10's record did not include a record of services provided.
An interview with the facility director on April 10, 2012 confirmed the findings.
|
Plan of Correction
Program had changed the format of its record of service between last inspection and this one. Was informed by inspector that the new format did not meet guidelines for record of service. PM has resumed previous record of service format as of the date of the inspection. |