INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 7 through 8, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Path Incorporated was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of clinical documentation, the facility failed to document a psychosocial evaluation of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation in four of seven records reviewed.The findings include:Seven client records were reviewed for documentation of an evaluative psychosocial assessment on May 8, 2013. The facility failed to document an evaluative psychosocial assessment in four of seven records reviewed, specifically client records # 1, 2, 5, and 7.Client # 1 was admitted to the program on 12/6/12. The facility documented a psychosocial evaluation on 1/17/13; however the psychosocial assessment failed to evaluate the individuals assets/strengths, support systems, and coping mechanisms in relationship to their collected historical information in order to identify possible relations, conditions and causes leading to their current situation.Client # 2 was admitted to the program on 2/6/13. The facility documented a psychosocial evaluation on 3/13/13; however the psychosocial assessment failed to evaluate the individuals assets/strengths, support systems, and coping mechanisms in relationship to their collected historical information in order to identify possible relations, conditions and causes leading to their current situation.Client # 5 was admitted to the program on 1/23/13. The facility documented a psychosocial evaluation on 2/26/13; however the psychosocial evaluation was not legible.Client # 7 was admitted to the program on 8/23/12. The facility documented a psychosocial evaluation on 9/27/13; however the psychosocial assessment failed to evaluate the individuals assets/strengths, and coping mechanisms in relationship to their collected historical information in order to identify possible relations, conditions and causes leading to their current situation. In addition, the counselor did not document conclusions or an impression of the client.The Adult Treatment Director did not dispute the findings.This is a repeat citation. The facility was previously cited for non-compliance on 5/22/12.
|
Plan of Correction
Although there was a comprehensive biopsychosocial evaluation(CBE) and a counselor assessment in each record, the reviewer noted that these assessments did not document a psychosocial evaluation of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the individual's current situation.
All staff will recieve comprhensive training regarding the development of psychosocial evaluations that meet the above described requirements on 6/17/2013. Taining will be provided by the outpatient program director.
The outpatient program director will review all completed counselor assessments(psychosocial evaluations) to ensure that the assessments meet the requirements described above. |
709.93(a)(11) 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:
(11) Follow-up information.
|
Observations
Based on a review of clinical documentation and a review of the facility's policy and procedure manual, the facility failed to document a complete client record which included follow-up information in one of two records reviewed. The findings include:The facility's policy states: a letter will be sent within 60 days for an unsuccessful discharge.Two client records requiring documentation of follow-up information were reviewed on May 8, 2013. The facility failed to document follow-up information in one of two records reviewed; specifically client record # 7.Client # 7 was admitted to the program on 8/23/12 and unsuccessfully discharged on 1/29/13. The facility was required to document a complete client record which included follow-up information within 60 days or by 3/29/13. The facility failed to document follow-up information as of 5/8/13.The Adult Treatment Director confirmed the findings.This is a repeat citation. The facility was previously cited for non-compliance on 5/22/12.
|
Plan of Correction
The outpatient program director will review all discharges and ensure that follow-up occurs within the time frames specified in PATH's policy and procedure manual, which includes a follow-up letter being sent to individuals within 60 days if s/he leaves treatment prior to successful completion of treatment goals.
A follow-up letter has been sent to client#7 and this is documented. |