INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on August 16 and 17, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Naaman Center Elizabethtown 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.
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Plan of Correction
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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 treatment plan updates as per agency policy in one of ten client records.
The findings include:
Ten complete outpatient client records were reviewed on August 17, 2012. Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days. Treatment and rehabilitation plans were not updated at least every 60 days in client record # 7.
Client #7 was admitted to the outpatient program on 2-24-2012. The preliminary treatment plan was completed on 2-24-2012. The comprehensive treatment plan was completed on 3-7-2012. This treatment and rehabilitation plan was due to be reviewed and updated by 5-7-2012 . The update was completed on 6-25-2012.
This was confirmed by the Clinical Supervisor on August 17, 2012 at 3:30 P.M.
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Plan of Correction
Clinical Supervisor will be responsible to insure all counselors are completing the Treatment Plan Updates in compliance with agency and state licensing documentation requirements. All-staff clinical meeting/training, facilitated by the Clinical Supervisor, to be held September 12, 2012 to review clinical procedures, including the time frame to complete Treatment Plan Updates, as well as the process of documenting Treatment Plan Updates, to include the progress of the stated goals in all client records. Clinical Supervisor will perform periodic and random chart reviews of each counselor following that training to insure compliance in this area. Random chart reviews will also be part of individual weekly/bi-weekly supervision of counselors. Facility to be in compliance by October 31, 2012. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records the facility failed to document a case consultation every ninety days in three of ten client records.
Findings:
Ten client records were reviewed on August 17, 2012. Case consultations were required to be completed in all ten client records. Case consultations were not documented every ninety days in client records #'s 3 and 8. Client # 6 had only one documented signature on the case consultation form.
Client #3 was admitted 12-16, 2011. The preliminary treatment plan was completed on 12- 16-2011. The comprehensive treatment plan was completed on 1-24-2012. The update was completed on 3-9-2012. A case consultation was due to be completed by 3- 16-2012. A case consultation was completed on 5-27-2012.
Client # 8 was admitted on 1-27-2012. The preliminary treatment plan was completed on 1-27-2012. The comprehensive treatment plan was completed on 2-9-2012. The update was completed on 4-9-2012. A case consultation was due to be completed 4-27-2012. A case consultation was completed on 8-09-2012. .
Client #6 was admitted on 5-15-2012. A case consultation was completed on 5-15-2012 and 7-30- 2012. The case consultations were completed in a timely manner by the counselor, however the case consult lacked additional reviewing member to comprise the consulation.
The findings were confirmed by the Clinical Supervisor on August 17, 2012 at 3:30 P.M.
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Plan of Correction
Executive director will designate the Clinical supervisor to insure case consultation notes are completed at least quarterly on clients in treatment to comply with required documentation regulations. The Clinical Supervisor will meet with all clinical staff on September 12, 2012 to train and correct this issue. Clinical Supervisor will also randomly review charts on a weekly basis to insure compliance on this issue. Executive Director will also perform random audits of charts for compliance. Facility to be in compliance by 10/31-2012. |