D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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KIRKBRIDE CENTER
111 NORTH 49 STREET
PHILADELPHIA, PA 19139

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Survey conducted on 02/14/2008

INITIAL COMMENTS
This report is a result of an on-site investigation conducted by staff from the Division of Drug and Alcohol Program Licensure as a follow-up to an unusual incident on January 19, 2008. The on-site inspections were conducted on February 8, 2008 and February 12, 13 and 14, 2008. Based on the findings, the Kirkbride Center 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 and a plan of correction is due on March 14, 2008.	Plan of Correction
704.6(c) LICENSURE Core Curriculum - Supervisor Training 704.6. Qualifications for the position of clinical supervisor. (c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
Observations Based on a review of personnel and training records from February 12 through February 14, 2008, the facility failed to document the completion of the core curriculum training on clinical supervision in two of two records reviewed, # 15 and 16. The facility was found to be in noncompliance for this same issue and same staff during the licensing inspection conducted on December 4 through 7, 2007. The Department approved a plan of correction on January 23, 2008 and the facility expects to be in compliance on February 29, 2008.	Plan of Correction 1. The Project Director will solicit information about the core curriculum from the Pennsylvania Bureau of Drug and Alcohol Programs. 2. The Project Director and the Facility Director will facilitate attendance by the Clinical Supervisor at the core curriculum training. 3. One of the two Clinical Supervisors has left the facility's employment. 4. The Project Director and the Facility Director will contact the Pennsylvania Bureau of Drug and Alcohol Programs for information concerning the next series of trainings in the Philadelphia area. (The facility did learn of such a training in March in Southeastern Pennsylvania; however, the facility was able to meet the deadline.) 5. Following determination of the next scheduled training, the Project Director and the Facility Director will schedule the Clinical Supervisor for the training and notify the Division of Drug and Alcohol Program Licensure. 6. Following completion of the required training, the Project Director will notify the Supervisor of the Division of Drug and Alcohol Program Licensure that the trainings have been completed and copies of certificates will be forwarded. 7. The facility's Human Resources Department will ensure that for future hires/promotions that the core curriculum has been completed within one year of hiring or promotion.
704.11(f)(2) LICENSURE Trng Hours Req-Coun 704.11. Staff development program. (f) Training requirements for counselors. (2) Each counselor shall complete at least 25 clock hours of training annually in areas such as: (i) Client recordkeeping. (ii) Confidentiality. (iii) Pharmacology. (iv) Treatment planning. (v) Counseling techniques. (vi) Drug and alcohol assessment. (vii) Codependency. (viii) Adult Children of Alcoholics (ACOA) issues. (ix) Disease of addiction. (x) Aftercare planning. (xi) Principles of Alcoholics Anonymous and Narcotics Anonymous. (xii) Ethics. (xiii) Substance abuse trends. (xiv) Interaction of addiction and mental illness. (xv) Cultural awareness. (xvi) Sexual harassment. (xvii) Developmental psychology. (xviii) Relapse prevention. (3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
Observations Based on a review of personnel and training records from February 12 through February 14, 2008, the facility failed to document 25 training hours for the July 2006 through June 2007 training year in three of seven records reviewed, #17, 26 and 27. The facility could document 12 hours of training for employee #17 during that time period; 20 hours for employee #26; and 22 hours for employee #27. The facility was found to be in non compliance with this standard, for the same counselors,during the inspection conducted from December 4, to December 7, 2007. The Department approved a plan of correction on January 23, 2008 where the facility plans to be in compliance from January 15, 2008 forward through the upcoming training year.	Plan of Correction 1. The Project Director has develoepd a grid to document attendance by Primary Therapists and Detox Counselors at both internal trainings. 2. The grid will be updated quarterly by the Facility Director and the Clinical Operations Supervisor as well as the Director of Social Services, who will review personnel files of counselors and counselor assistants at the end of each quarter. The Project Director will review the training hours of the Facility Director, the Clinical Operations Supervisor and the Director of Social Services on a quarterly basis. 3. The Project Director, the Facility Director and the Director of Social Services will report their findings to the Executive Committee for oversight and monitoring. 4. Employees who appear to be deficient in training hours will be counseled by the Project Director, the Facility Director, the Director of Social Services and the Clinical Operations Supervisor.
704.11(g)(1) LICENSURE Trng Req-Couns Asst (g) Training requirements for counselor assistants. (1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as: (i) Pharmacology. (ii) Confidentiality. (iii) Client recordkeeping. (iv) Drug and alcohol assessment. (v) Basic counseling. (vi) Treatment planning. (vii) The disease of addiction. (viii) Principles of Alcoholics Anonymous and Narcotics Anonymous. (ix) Ethics. (x) Substance abuse trends. (xi) Interaction of addiction and mental illness. (xii) Cultural awareness. (xiii) Sexual harassment. (xiv) Developmental psychology. (xv) Relapse prevention. (h) Training hours. Training hours are not cumulative from one personnel classification to another.
Observations Based on a review of personnel and training records from February 12 through February 14, 2008, the facility failed to document the minimum of 30 hours of training for the July 2006 through June 2007 training year in one of one record reviewed, #21. The facility was able to document only 24 hours of training for employee #21 over the stated time period. This was found to be an area of non compliance during the licensing inspection conducted from December 4 to December 7, 2007. The Department approved the facility plan of correction on January 18, 2008. The facility submitted a plan that is intended to ensure that from this time forward, the facility will be in compliance.	Plan of Correction 1. The Facility Director and the Clinical Operations Supervisor will review personnel records quarterly to ensure compliance with training requirements for counselors (25 hours) and counselor assistants (30 hours). 2. Results of the quarterly review of personnel records will be reviwed monthly with the Executive Committee for oversight and monitoring. 3. The facility has increased its on-site training initiatives: A. Quarterly, the facility provides for employees the state-required HIV/AIDS training (6 hours) and the TB/STD training (4 hours). B. On April 17, a state-certified trainer will provide a 7-hour training in ethics. C. In March, a state-certified trainer provided a 7-hour training in the Pennsylvania Client Placement Criteria. D. Monthly, the facility sends primary therapists and social workers to the Institute for Cognitive Therapy for a case conceptualization training (1.5 hours) with Aaron T. Beck, MD.
709.123(b)(1)(iii) LICENSURE Support Service 709.123. Treatment and rehabilitation. (b) Treatment and rehabilitation services. (1) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of: (iii) Proposed type of support service.
Observations Based on patient record reviews conducted from February 12 through 14, 2008, the facility failed to document support services on the treatment plans in two of three patient records reviewed, #13 and 14.	Plan of Correction 1. As part of monthly clinical trainings for staff, the Project Director, the Facility Director and the Clinical Operations Supervisor will outline the steps counselors need to take to review support services with their patients and inclusion of goals and objectives on the treatment plan. 2. Monthly chart audits by the Facility Director and the Clinical Operations Supervisor will ensure compliance.
709.123(c)(4) LICENSURE Aftercare Plan 709.123. Treatment and rehabilitation. (c) Client records. 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: (4) Drug and alcohol aftercare plan, if applicable.
Observations Based on a review of patient records from February 12 through 14, 2008, the facility failed to document complete aftercare plans in two of two patient records, #12 and #13. The aftercare plans were missing the criteria for reentry into the facility, including the name and phone number of a contact person should the patient wish to attempt reentry.	Plan of Correction 1. In the fall of 2006, the facility developed a Crisis Plan to be given to all discharging patients at the time of discharge. Among other items,the Crisis Plan includes information on how the patient accesses appropriate emergency services as well as re-entry to the facility. 2. The Clinical Operations Supervisor will review and revise the Continuing Care form to ensure it includes information on the steps discharged patients may take to seek re-entry to the facility.
709.123(c)(5) LICENSURE Follow-up information 709.123. Treatment and rehabilitation. (c) Client records. 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: (5) Follow-up information.
Observations Based on a review of patient records from February 12 through February 14, 2008, the facility failed to document follow up information in two of two patient records reviewed, #12 and #13.	Plan of Correction 1. The Facility Director and the Clinical Operations supervisor have with the Primary Therapists, who are responsible for completing the seven-day follow-ups, to review the state standards governing seven-day follow-ups. 2. Weekly, the Facility Director and the Clinical Operations Supervisor will conduct an audit of 10 percent of closed records for that week for a one-month period to determine the level of compliance with the standards. 3. Remediation will be provided to those Primary Therapists failing to comply with the state standard. 4. Should results fall below 100 percent, the Project Director, the Facility Director and the Clinical Operations Supervisor will initiate a performance improvement plan to address the seven-day follow-ups.
709.23(b)(1) LICENSURE Project Director 709.23. Project director. (b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually: (1) Project goals and objectives which include time frames and available resources.
Observations Based on a review of administrative documents on February 12 through February 14, 2008, the project director failed to include available resources as part of the project goals and objectives for July 1, 2007 through June 30, 2008, the fiscal year. The facility was found to be out of compliance with this regulation during the licensing inspection conducted on December 4 through December 7, 2007. The Department of Health approved a plan of correction on January 18, 2008. The expected date of compliance was February 15, 2008. The facility was not in compliance as of February 14, 2008.	Plan of Correction 1.The 2007-2008 project goals and objectives have been revised to include available resources. 2. The goals and objectives for 2007-2008 will be resubmitted to the board for approval of the amended version. 3. The Project Director will create a template for the annual development of the goals and objectives for the 2008-2009 fiscal year, which are due no later than June 30, 2008. The template will include the requirement that resources be identified.
709.25(a) LICENSURE Fiscal Management 709.25. Fiscal management. (a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
Observations Based on a review of administrative materials and documents, the facility failed to complete an independent annual audit for the fiscal year.	Plan of Correction 1. The audit for the fiscal year ending June 30, 2007, has not been completed and, as a result, the 10K has not been filed with the Securities and Exchange Commission. 2. The audit for the fiscal year ending June 30, 2007, will be completed by April 30, 2009. The corporation president is responsible to ensure completion of the 2006-2007 independent audit.
709.28 (c)(1) 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 shall include, but not be limited to: (1) Name of the person, agency or organization to whom disclosure is made.
Observations Based on a review of patient records, the facility failed to clearly and consistently identify to whom disclosures were made. Based on a review of 17 patient records from February 12 to February 14, 2008, consent to release information forms found in client records # 13, 14, 15, 16 and 17 failed to identify the name of the person, agency or organization that would receive the information.	Plan of Correction 1. The Director of Admissions, the Facility Director, the Clinical Operations Supervisor and the Director of Social Services will conduct trainings in the basics of completing consent to release information forms, with special emphasis on the inclusion of the identity of sources to whom information is being disclosed.
709.28(c)(2) 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: (2) Specific information disclosed.
Observations Based on a review of patient records from February 12 to February 14, 2008, the facility failed to comply with 4 Pa. Code Subsection 255.5(b) in 17 of 17 patient records reviewed. Some of the consent to release information forms found in all 17 patient records reviewed, #1 through #17, allowed for the release of client identifying information to third party payers that was in excess of the limitations imposed at 4 Pa. Code Subsection 255.5(b). Mental health consent to release information forms were combined with drug and alcohol treatment consent to release information forms. The form, when completed, was contradictory regarding the specific information that would be released in patient records #1 through #17. The first section pertained to mental health records and the second section to drug and alcohol treatment records, both of which listed sections of the record that would be released, but neither limiting the release to the specific sections. The result would be a release of information in excess of the limitations imposed at 4 Pa. Code Subsection 255.5(b).	Plan of Correction 1. The Director of Admissions has revised the Release of Information form to request patient permission to provide information to their Managed-Care Organization. The consent form includes only those five areas that are permitted for release to Managed-Care Organizations: Presence in treatment; patient prognosis; program description; patient's progress; and whether the patient has relapsed. 2. The Director of Social Servcies and Utilization Management will meet with Utilization Management Coordinators to review state limitations on teh release of information to Managed-Care Organizations. This will occur by April 15, 2008.
709.32(c)(1) LICENSURE Medication Control 709.32. Medication control. (c) The project shall have a written policy regarding all medications used by clients which shall include, but not be limited to: (1) Administration of medication.
Observations Based on a review of 11 patient records and interviews with medical and administrative staff, the facility failed to ensure that nursing staff who administered the methadone followed the physician's order and facility policy and procedures. Specifically, nurse #1 administered a second dose of 50 mgs. to patient # 9 within 2 1/2 hours of the administration of the first 50 mgs. dose of methadone without obtaining a physician's order or contacting the in-house physician. Written facility procedure requires physician approval prior to the administration of a second dose. Patient #9 reported to nursing that she had vomited just after ingesting her daily 50 mg dose of methadone. There was no verification that this had occurred.	Plan of Correction 1. The employment of Nurse #1 was terminated and the incident was reported to the Pennsylvania Board of Nursing, which has confirmed acceptance of the notification. 2. The Director of Nursing and the Assistant Director of Nursing have re-iterated the following: A. Patient reports of expelling medications due to vomit require that staff observe the remains, before considering readministration of any medication, including Methadone. B. No medications, including Methadone, may be administered a second time in the same day without a physician's order.
709.32(c)(2) LICENSURE Medication Control 709.32. Medication control. (c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to: (2) Drug storage areas.
Observations Based on a review of facility policy and procedure, the facility failed to provide for supervised access to the methadone storage area for cleaning crews. The policy stated that only the consulting pharmacist can access the main drug storage area. The area houses two safes that have been approved by the Drug Enforcement Administration. The safes secure methadone, a controlled Schedule II drug. The drug storage area was unsanitary and unsafe at the time of the inspection as evidenced by the presence of soiled rags stuffed into the heater and air conditioning vents. The walls were dirty and dusty and the floor was dirty with visible dust balls.	Plan of Correction 1. The Housekeeping Department has obtained a key to the outer office of the Methadone Storage Area. 2. The outer office was cleaned thoroughly by the Housekeeping Department on February 15, 2008, and photos of the clean-up were forwarded to the Division of Drug and Alcohol Program Licensure. 3. The Housekeeping Department will clean the outer office at least monthly.
709.62(c)(vi) LICENSURE Psychosocial Eval 709.62. Intake and admission. (c) Intake procedures shall include documentation of the following: (6) Psychosocial evaluation.
Observations Based on a review of patient records conducted from February 12 through February 14, 2008, the facility failed to document a complete psychosocial evaluation in three of three patient records reviewed, #15, 16 and 17. Psychosocial evaluations did not include a clinical assessment of the patients' assets and strengths, support systems and coping mechanisms.	Plan of Correction 1. The facility has been particiapte with the Institute for Cognitive Therapy in Bala Cynwyd in case conference demonstrations by Aaron T. Beck, MD, since April 2006. Additional case conference demonstrations are scheduled for May and June. A contingent of Primary Therapists and Managers have been participating in the case conference demonstrations, conducted live by Dr. Beck. Participation has been deseigned to help improve the quality of psychosocial assessments. 2. The Clinical Operations Supervisor and the Director of Social Services by March 21 will revise the current biopsychosocial document to require additional assessments of the following areas for each patient: A. Spirituality B. Leisure Activities C. Relapse History. 4. The Director of Nursing and the Assistant Director of Nursing will revise the Nursing Assessment by March 21 to require additional evaluation in pain management. 5. The Project Director will create three sample biopsychosocial narratives by March 21. The samples will be the basis of a training for all Primary Therapists and Detox Counselors provided by the Project Director on March 24.The training will include the assessment of patient assets and strengths, support systems and coping mechanisms. 6. The Director of Social Services will utilize the samples to provide a training for all social workers on the pscyhiatric units on March 24. The training is designed to help clinicians avoid a recap of demographic information in the biopsychosocial assessment, but rather to provide an assessment of the patient's assets and strengths, support systems and coping mechanisms. 6. The Facility Director, the Director of Social Services and the Clinical Operations Supervisor have been providing monthly trainings to Primary Therapists and Social Workers on improvements in the assessments.
715.9(a)(3) LICENSURE Intake (a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall: (3) Obtain a drug use history and current drug use status of the individual.
Observations Based on a review of patient records, the facility failed to document a complete drug and alcohol history in seven of seven records reviewed, # 1, 2, 3, 4, 5, 6, and 7. The facility failed to document current use for patient # 7.	Plan of Correction 1. 1. The Project Director on March 24, 2008, provided a training for the Facility Director, the Clinical Supervisor and all Primary Therapists and Detox Counselors on proper assessment of chemically dependent patients across several dimensions, including an adequate drug and alcohol history that includes current use. Through Socratic questioning, the trainer attempted to draw a link between what actually occurs in clinical practice and how the same information is documented. 2. Monthly for four months, the Project Director and the Clinical Supervisor will audit 10 percent of open Medical Records to ensure that drug and alcohol histories are completed. Deficiencies discovered during the audits will be sent back to the assigned Primary Therapist for completion. Results of the audits will be reported monthly for four months to the Executive Committee for oversight and monitoring.
715.11 LICENSURE Confidentiality of patient records A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and � 709.28 (relating to confidentiality).
Observations Based on a review of patient records, the facility failed to clearly and consistently identify to whom disclosures were made. Based on a review of 17 patient records from February 12 to February 14, 2008, consent to release information forms found in client records # 13, 14, 15, 16 and 17 failed to identify the name of the person, agency or organization that would receive the information. Based on a review of patient records from February 12 to February 14, 2008, the facility failed to comply with 4 Pa. Code Subsection 255.5(b) in 17 of 17 patient records reviewed. Some of the consent to release information forms found in all 17 patient records reviewed, #1 through #17, allowed for the release of client identifying information to third party payers that was in excess of the limitations imposed at 4 Pa. Code Subsection 255.5(b). Mental health consent to release information forms were combined with drug and alcohol treatment consent to release information forms. The form, when completed, was contradictory regarding the specific information that would be released in patient records #1 through #17. The first section pertained to mental health records and the second section to drug and alcohol treatment records, both of which listed sections of the record that would be released, but neither limiting the release to the specific sections. The result would be a release of information in excess of the limitations imposed at 4 Pa. Code Subsection 255.5(b).	Plan of Correction 1. The Director of Admissions has revised the Release of Information form to request patient permission to provide information to their Managed-Care Organization. The consent form includes only those five areas that are permitted for release to Managed-Care Organizations: Presence in treatment; patient prognosis; program description; patient's progress; and whether the patient has relapsed. 2. The Director of Social Servcies and Utilization Management will meet with Utilization Management Coordinators to review state limitations on teh release of information to Managed-Care Organizations. This will occur by April 15, 2008. 2. The Facility Director, the Director of Social Services and the Admissions Director will provide a training for all Primary Therapists and Social Workers to ensure that the source of release of information is contained on all consent forms.
715.17(c)(1)(i-vi)) LICENSURE Medication control (c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum: (1) Administration of medication. (i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician. (ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients. (iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area. (iv) There shall be only one patient permitted at a dispensing station at any given time. (v) Each patient shall be observed when ingesting the agent. (vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
Observations Based on a review of 11 patient records and interviews with medical and administrative staff, the facility failed to ensure that nursing staff who administered the methadone followed the physician's order and facility policy and procedures. Specifically, nurse #1 administered a second dose of 50 mgs. to patient # 9 within 2 1/2 hours of the administration of the first 50 mgs. dose of methadone without obtaining a physician's order or contacting the in-house physician. Written facility procedure requires physician approval prior to the administration of a second dose. Patient #9 reported to nursing that she had vomited just after ingesting her daily 50 mg dose of methadone. There was no verification that this had occurred.	Plan of Correction 1. The employment of Nurse #1 was terminated and the incident was reported to the Pennsylvania Board of Nursing, which has confirmed acceptance of the notification. 2. The Director of Nursing and the Assistant Director of Nursing have re-iterated the following: A. Patient reports of expelling medications due to vomit require that staff observe the remains, before considering readministration of any medication, including Methadone. B. No medications, including Methadone, may be administered a second time in the same day without a physician's order. 3. The Institute for Safe Medication Practices has been retained to provide a clinical review of the facility's medication delivery and administration systems. The review, which will include a pharmacist and master's-level nurse, will be conducted April 3, 2008.
715.17(c)(2) LICENSURE Medication control (c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum: (2) Drug storage areas. A narcotic treatment program shall develop and implement written policies and procedures regarding storage of medications and access to the medication storage area. Agents shall be stored in a locked safe that has been approved by the DEA under 21 CFR 1301.72 and 1301.74 (relating to physical security controls; and other security controls).
Observations Based on a review of facility policy and procedure, the facility failed to provide for supervised access to the methadone storage area for cleaning crews. The policy stated that only the consulting pharmacist can access the main drug storage area. The area houses two safes that have been approved by the Drug Enforcement Administration. The safes secure methadone, a controlled Schedule II drug. The drug storage area was unsanitary and unsafe at the time of the inspection as evidenced by the presence of soiled rags stuffed into the heater and air conditioning vents. The walls were dirty and dusty and the floor was dirty with visible dust balls.	Plan of Correction 1. The Housekeeping Department has obtained access to a key to the outer office of the Methadone Storage Area. 2. The outer office was cleaned thoroughly by the Housekeeping Department on February 15, 2008, and photos of the clean-up were forwarded to the Division of Drug and Alcohol Program Licensure. 3. The Housekeeping Department will clean the outer office at least monthly -- or more regularly as requested by the consulting pharmacist.
715.23(b)(3) LICENSURE Patient records (b) Each patient file shall include the following information: (3) A complete medical history
Observations A review of eleven randomly selected patient records demonstrated that the facility failed to develop a complete medical history for each patient. The medical history needs to include the patient's personal medical history, the family medical history and a review of the patient's symptoms and illnesses. The facility consistently failed to complete a personal and family medical history on patients # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11.	Plan of Correction 1. The Director of Nursing and the Assistant Director of Nursing will revise the existing Nursing Assessment, which is completed for all patients upon admission. 2. The revisions will include a review of the patient's personal medical history and family history. 3. Following completion of the revisions, nurses will be trained in its use.
715.23(b)(15) LICENSURE Patient records (b) Each patient file shall include the following information: (15) Psychosocial evaluations of the patient.
Observations Based on a review of patient records on February 12 through 14, 2008, the facility failed to ensure that the psychosocial evaluation contained a clinical analysis of the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, patient's attitude toward treatment and overall impressions. A review of seven of eight patient records, specifically #1, 3, 4, 5, 6, 7, and 8, indicated that the psychosocial evaluation failed to document the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, patient's attitude toward treatment and overall impressions based on the clinician's analysis of the collected historical information.	Plan of Correction 1. The facility has been particiapte with the Institute for Cognitive Therapy in Bala Cynwyd in case conference demonstrations by Aaron T. Beck, MD, since April 2006. Additional case conference demonstrations are scheduled for May and June. A contingent of Primary Therapists and Managers have been participating in the case conference demonstrations, conducted live by Dr. Beck. Participation has been deseigned to help improve the quality of psychosocial assessments. 2. The Clinical Operations Supervisor and the Director of Social Services by March 21 will revise the current biopsychosocial document to require additional assessments of the following areas for each patient: A. Spirituality B. Leisure Activities C. Relapse History. 4. The Director of Nursing and the Assistant Director of Nursing will revise the Nursing Assessment by March 21 to require additional evaluation in pain management. 5. The Project Director will create three sample biopsychosocial narratives by March 21. The samples will be the basis of a training for all Primary Therapists and Detox Counselors provided by the Project Director on March 24.The training will include the assessment of patient assets and strengths, support systems and coping mechanisms. 6. The Director of Social Services will utilize the samples to provide a training for all social workers on the pscyhiatric units on March 24. The training is designed to help clinicians avoid a recap of demographic information in the biopsychosocial assessment, but rather to provide an assessment of the patient's assets and strengths, support systems and coping mechanisms. 6. The Facility Director, the Director of Social Services and the Clinical Operations Supervisor have been providing monthly trainings to Primary Therapists and Social Workers on improvements in the assessments.
709.51(b)(3)(i) LICENSURE Medical histories 709.51. Intake and admission. (b) Intake procedures shall include documentation of: (3) Histories, which include the following: (i) Medical history.
Observations Based on a review of patient records from February 12 through February 14, 2008, the facility failed to document a complete medical history in two of three patient records reviewed, #15 and 16. Medical histories were missing a family medical history.	Plan of Correction 1. The Director of Nursing and the Assistant Director of Nursing will revise the existing Nursing Assessment, which is completed for all patients upon admission. 2. The revisions will include a review of the patient's personal medical history and family history. 3. Following completion of the revisions, nurses will be trained in its use.
709.51(b)(3)(iii) LICENSURE Personal History 709.51. Intake and admission. (b) Intake procedures shall include documentation of: (3) Histories, which include the following: (iii) Personal history.
Observations Based on a review of patient records from February 12 through February 14, 2008, the facility failed to document a complete personal history in three of three patient records reviewed, #15, 16 and 17. Educational and recreational histories were incomplete failing to address the impact of substance use/abuse.	Plan of Correction 1. The Project Director provided a training in the personal history and related assessments on March 24, 2008. The training focused on key areas of the personal history including, but not limited to educational and recreational histories. The Facility Director, the Clinical Supervisor and all Primary Therapists attended the training. 2. The Clinical Supervisor and the Director of Social Services have revised the biopsychosocial docoment, where each patient's history is collected, to provide additional prompt questions and the requirement of assessment of how education and recreational histories have impacted the individual's substance use and how the same may pose obstacles for recovery. 3. The completeness of the educational and recreational histories will be evaluated monthly for four months by the Facility Director and the Clinical Supervisor. Monthly for four months, the two will evaluate the personal histories in 10 percent of charts. Results will be reported monthly to the Executive Committee for oversight and monitoring.
709.51(b)(6) LICENSURE Psychosocial evaluation 709.51. Intake and admission. (b) Intake procedures shall include documentation of: (6) Psychosocial evaluation.
Observations Based on a review of patient records conducted from February 12 through February 14, 2008, the facility failed to document a complete psychosocial evaluation in ten of eleven patient records reviewed, # 1, 3, 4, 5, 6, 7, 8, 15, 16 and 17. Psychosocial evaluations did not include a clinical assessment of the patient's assets and strengths, support systems and coping mechanisms. Negative factors, the patients' attitude toward treatment and the counselor's overall impressions were also missing from patient records # 1, 3, 4, 5, 6, 7, and 8.	Plan of Correction 1. The facility has been participating with the Institute for Cognitive Therapy in Bala Cynwyd in case conference demonstrations by Aaron T. Beck, MD, since April 2006. Additional case conference demonstrations are scheduled for May and June. A contingent of Primary Therapists and Managers have been participating in the case conference demonstrations, conducted live by Dr. Beck. Participation has been deseigned to help improve the quality of psychosocial assessments. 2. The Clinical Operations Supervisor and the Director of Social Services by March 21 will revise the current biopsychosocial document to require additional assessments of the following areas for each patient: A. Spirituality B. Leisure Activities C. Relapse History. 4. The Director of Nursing and the Assistant Director of Nursing will revise the Nursing Assessment by March 21 to require additional evaluation in pain management. 5. The Project Director will create three sample biopsychosocial narratives by March 21. The samples will be the basis of a training for all Primary Therapists and Detox Counselors provided by the Project Director on March 24.The training will include the assessment of patient assets and strengths, support systems and coping mechanisms. 6. The Director of Social Services will utilize the samples to provide a training for all social workers on the pscyhiatric units on March 24. The training is designed to help clinicians avoid a recap of demographic information in the biopsychosocial assessment, but rather to provide an assessment of the patient's assets and strengths, support systems and coping mechanisms. 6. The Facility Director, the Director of Social Services and the Clinical Operations Supervisor have been providing monthly trainings to Primary Therapists and Social Workers on improvements in the assessments.