INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 20, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Rehab Management 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)(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 and the facility's policies and procedures, the facility failed to document a comprehensive treatment plan to include proposed types of supportive services. The findings include:In reference to treatment plans, the project's policy stated: The comprehensive treatment plan shall include, but not be limited to, written documentation of a proposed type of support services. Services may include medical, psychiatric or mental health services, financial, legal, AA, NA, etc.Eight client records were reviewed for a comprehensive treatment plan that included support services on March 20, 2013. Three of eight client records lacked documentation of a treatment plan that included a proposed type of support service, specifically client records # 2, 6 and 7.Client #2 was admitted on December 6, 2012. The comprehensive treatment plan was documented on January 22, 2013; however it did not include a proposed type of support service for client #2. Client #6 was admitted on September 11, 2012 and discharged on December 12, 2012. The comprehensive treatment plan was documented on October 3, 2012; however it did not include a proposed type of support service for client #6. Client #7 was admitted on September 18, 2012 and discharged on February 7, 2013. The comprehensive treatment plan was documented, however the date was illegible and it did not include a proposed type of support service for client #7. The findings were reviewed with the Site Director prior to the exit interview.
|
Plan of Correction
The site director of Lansdale will begin training immediately and it will be ongoing. A staff training will be conducted on 4/12/13 at the Lansdale location for all counselors regarding documentation of the comprehensive treatment plan, most noteably written documentation of a proposed type of support services. Services may include medical, psychiatric or mental health services, financial, legal, AA, NA, etc. All counselors will attend the training. The site director will conduct random, month chart audits to ensure that the standard is met.
|
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.
|
Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a treatment plan update that included the client's progress on goals.The findings include:Seven client records were reviewed for treatment plan updates on March 20, 2013. Four out of seven treatment plan updates lacked documentation of the client's progress on goals, specifically client records #4, 5, 6, and 7. Client #4 was admitted on December 19, 2012. The treatment plan update completed on February 19, 2013 did not include the client's progress on goals. Client #5 was admitted on April 23, 2012 and discharged on August 13, 2012. The treatment plan update completed on October 1, 2012 did not include the client's progress on goals. Client #6 was admitted on September 11, 2012 and discharged on December 12, 2012. The treatment plan update was due by November 11, 2012. As of the date of inspection, there was no treatment plan update for client #6.Client #7 was admitted on September 18, 2012 and discharged on February 7, 2013. The treatment plan update completed on January 24, 2013 did not include the client ' s progress on goals. The findings were confirmed with the Cite Director during the exit interview.
|
Plan of Correction
The site director of Lansdale will begin training immediately and it will be ongoing. On 4/12/13, the Lansdale staff will attend a training on the documentation of progress on the treatment plan update. All staff will be required to attend and this will be conducted by the site director. The site director will conduct monthly, ranndom chart audits to ensure that the standard has been met. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
|
Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document an aftercare plan in accordance with the project's policies and procedures.The findings include:In reference to aftercare plans the project's policy stated: "A Continuing Care Plan is to be completed within one month of the scheduled discharge date....in relation to ongoing individual sessions. To be completed and signed by the counselor and client prior to discharge."Three client records were reviewed for an aftercare plan on March 20, 2013. Two out of three client records lacked documentation of an aftercare plan, specifically client records # 6 and 7.Client #6 was admitted on September 11, 2012 and discharged on December 12, 2012. An aftercare plan was due to be documented by December 12, 2012. As of the date of inspection, there was no aftercare plan documented for client #6. Client #7 was admitted on September 18, 2012 and discharged on February 7, 2013. An aftercare plan was due to be documented by February 7, 2013. As of the date of inspection, there was no aftercare plan documented for client #7. The findings were confirmed by the Site Director during the exit interview.
|
Plan of Correction
The site director of lansdale will begin training immediately and it will be ongoing. On 4/12/13, the Lansdale staff will be required to attend a training on documentation regarding the continued care plans - "A Continuing Care Plan is to be completed within one month of the scheduled discharge date....in relation to ongoing individual sessions. To be completed and signed by the counselor and client prior to discharge." All staff will be required to attend and the site director will perform monthly, random chart audits to ensure that the center is in full compliance.
|
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 client records and the facility's procedures, the facility failed to document a follow-up in accordance with the project's procedures.The findings include:In reference to follow-ups the project states: A follow up is to be documented in 7 days for all clients, regardless of discharge status. Four client records were reviewed for documentation of a follow-up on March 20, 2013. Two out of four client records lacked documentation of a follow-up, specifically client records # 5 and 6. Client #5 was admitted on April 23, 2012 and discharged on August 13, 2012. A follow-up was due to be documented by August 20, 2012, as of the date of the inspection, there was no follow-up documented for client # 5. Client #6 was admitted on September 11, 2012 and discharged on December 12, 2012. A follow-up was due to be documented by December 19, 2012. As of the date of inspection, there was no follow-up documented for client #6. The findings were confirmed with the Cite Director during the exit interview.
|
Plan of Correction
The site director will begin traininig immediatley and it will be ongoing. On 4/12/13, the site director of Lansdale will conduct and in-srevice training on Follow-up documentation, mainly that - A follow up is to be documented in 7 days for all clients, regardless of discharge status. All counselors will be required to attend and the site director will conduct monthly, random chart audits to ensure that the standard has been met.
|