INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 21 -23, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Open Door 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 and a plan of correction is due on May 19, 2008.
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Plan of Correction
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of administrative material during the licensing inspection of April 21 -23, 2008, the facility failed to maintain individual client to counselor caseloads at 35:1 or less. Two caseloads exceeded the 35 : 1 client to counselor ratio. Employee # 5 had a caseload of 40 : 1 and employee # 7 had a caseload of 36 : 1.
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Plan of Correction
The Administrative Officer will monitor the client/counselor ratios on a weekly basis to ensure compliance with regulations. The census report will be utilized as the monitoring tool. |
709.28(c) 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:
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Observations
Based on review of client records on April 21 -22, 2008, the facility failed to obtain a Qualified Service Organization Agreement (QSOA) for a collaborative effort between themselves and a mental health facility while co - facilitating groups. This was documented in group notes in client records. The group notes were recorded on March 27, 2008 and March 6, 2008. The drug and alcohol treatment facility allowed a mental health counselor from an independent mental health treatment agency to co facilitate group treatment sessions at the drug and alcohol treatment facility. The drug and alcohol treatment facility did not obtain consents to release information from the group participants, nor was a QSOA enacted with the mental health facility and the mental health counselor to ensure the maintenance of client confidentiality.
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Plan of Correction
Execute a QSOA immediately between The Open Door and the Community Guidance Center outlining the partnership of this collaborative effort. Obtain consents to release information to the Community Guidance Center from all clients participating in the group as to ensure the maintenance of client confidentiality. |
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.
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Observations
Based on review of client records during the licensing inspection on April 21- 23, 2008, the facility failed to document the specific information that would be disclosed on the consent to release information forms. Consent to release information forms identifying the Single County Authority (SCA) as the recipient of the information failed to document the specific information that would be disclosed on the release form in client records #1, 2, 3, 4 and 5. Consent to release information forms identifying insurance companies as the recipient of the information failed to document the specific information that would be disclosed on the release forms in client records #1, 2, 3, 4 and 5. The consent to release information forms identifying family members as the recipient of the information failed to document the specific information that would be disclosed on the release forms in client records # 1,2, 3, 4 and 5. The information that was listed in that section was not specific and/or was not consistent with the purpose listed for the release.
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Plan of Correction
Staff training and individual supervision will be provided to all staff members completing consents to release information. Emphasis of training and supervision will be the documenting of the exact, specific information to be released to the various sources, such as Single County Authority, insurance companies and family members. Random, monthly chart audits by the Clinical Director and Executive Director will ensure compliance |
709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
Based on review of client records during the licensing inspection on April 21 -23, 2008 the facility failed to document the purpose of the disclosure on consent to release information forms in client records #1, 2, 3, 4 and 5. The purpose listed for the release of information to family members was "ER". The abbreviation is cryptic and does not provide for an informed consent.
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Plan of Correction
Staff training and individual suprvision will be provided to all staff members completing consents to release information. Emphasis of training and supervision will be the documenting of the exact purpose of the disclosure. The exact purpose is to be clearly spelled out not using abbreviations, jargon or slang so that the disclosure is indeed informed consent. Random, monthly chart audits by the Clinical Director and Executive Director will ensure compliance. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on review of client records during the licensing inspection of April 21 -23, 2008, the facility failed to document complete psychosocial evaluations in client records # 1, 2, 3, 4 and 5. Client problem and needs were not documented in client records # 1, 2, 3, 4, and 5. Support systems were not assessed in client records # 1, 3, and 5. Coping mechanisms were not assessed in client record #5. The counselor's conclusions were not evaluative in client records #1, 3, 4 and 5.
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Plan of Correction
Staff supervision, staff clinical team meetings, staff trainings both internal and external as well as articles will be provided to staff on an ongoing basis to address these areas of concern. The emphasis will be on the completion of psycho-social evaluations, identification of client problems and needs. The assessing of and documenting of support systems as well as coping mechanisms. The counselor's conclusions need to be more evaluative in nature with regard to client's overall needs and support. Random, monthly chart audits by the Clinical Director and Executive Director will ensure compliance. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on review of client records during the licensing inspection on April 21 -23, 2008, the facility failed to insure that discharge summaries were documented in a timely fashion. Discharge summaries were not documented until more than seven days from the discharge date in client records # 3, 6 and 7, three of eight client records reviewed.
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Plan of Correction
Discharge summaries will be completed within the timeframe of seven days. The results of the inspection will be reviewed with staff as well as the licensure expectations with regard to this finding. Random chart review will ensure compliance. |
709.94(d) LICENSURE Project management services
709.94. Project management services.
(d) The project shall develop a written client aftercare policy.
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Observations
Based on review of the policy manual on April 21, 2008, the facility failed to ensure that the current facility practice regarding the application of aftercare activities was consistent with the facility's policy and procedure on aftercare.
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Plan of Correction
The policy manual will be changed to state that Aftercare Plans will be in all client files that have successfully completed treatment. The words successful discharge will be added to the policy manual. |