INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 23, 2011 through May 24, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Insights, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill logs were reviewed on May 23, 2011. The facility did not document any alternate exits that were used during fire drills. The rear door was the exit route used during every fire drill for the months June 2010 through May 2011. An interview with the Project Director on May 23, 2011 confirmed these findings.
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Plan of Correction
The Executive Director will provide special instruction prior to conducting the next two fire drills at both sites. This instruction will direct both sites to utilize an alternate exit route, once during the evening and the next month during the day to assure exposure to key staff members during both work shifts. The Executive Director regularly receives a copy of all fire drill logs from both sites which will be the means to monitor this corrective action. These drills will take place during the months of June and July, 2011, at both facilities. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the fire drill log, the facility failed to ensure the fire drills were conducted at different times of the day and on different staffing shifts.
The findings include:
Fire drill logs were reviewed on May 23, 2011. Per regulation, the nonresidential facility shall conduct fire drills on different days of the week, at different times of the day and on different staffing shifts. The facility is open from 9:00 AM to 9:00 PM Monday through Thursday, Friday 9 AM to 5 PM and 9:00 AM to 1:00 PM on Saturday. The facility conducted only one fire drill during the morning shift between June 2010 and May 2011. This was conducted at 11:30 AM on April 19, 2011. An interview with the Project Director on May 23, 2011 confirmed the findings.
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Plan of Correction
The Executive Director will require that all fire drills at both sites will be required to rotate the times of day when they are conducted. These three time frames of morning, afternoon and evening drills will rotate each succeeding month. The Executive Director regularly receives a copy of all fire drill logs from both sites which will be the method to monitor this activity. This new policy will be addended to the manuel and will be in effect as of June, 2011. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to provide a psychosocial evaluation to included a composite picture, client problem/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and the counselor conclusions and or impressions of the client in three of four partial client records.
The findings include:
Twelve client records were reviewed on May 24, 2011. A psychosocial evaluation was required in four of the partial hospitalization records, #9, 10, 11 and 12. An interview with the facility director on May 24, 2011 confirmed the findings.
Client records #9, 11 and 12 lacked an evaluation of the client's composite picture and how they would impact treatment.
Client records #9, 11 and 12 lacked an evaluation of the client's problems/needs and how they would impact treatment.
Client records #9, 11 and 12 lacked an evaluation of the client's assets/strengths and how they would impact treatment.
Client records #9, 11 and 12 lacked an evaluation of the client's support systems and how they would relate to treatment.
Client records #9, 11 and 12 lacked an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
Client records #9, 11 and 12 lacked an evaluation of the client's negative factors and how they would impact treatment.
Client records #9, 11 and 12 lacked an evaluation of the counselor's conclusion and impression of the client.
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Plan of Correction
The Program Supervisor will review with the clinical staff in the staff meeting on 6/22/11, that all psycho-social composite pictures of the client must include the clients problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and the counselor's conclusions and impressions of the client. Examples will be provided. The Program Supervisor will randomly audit charts for compliance by random audits of one clinical chart at each clinical supervision for 6-months. |
709.83(a)(11) LICENSURE Client records
709.83. 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.
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Observations
Based on a review of client records, the facility failed to document follow-up attempts in one of two partial hospitalization discharge records.
The findings include:
Twelve client records were reviewed on May 24, 2011. Four of the twelve client records were partial hospitalization client records and of the four, two were required to have follow-up attempts documented, #9 and 10. Per the facility policy, follow up on clients is to be completed within 30 days of discharge if not being referred. An interview with the Project Director on May 24, 2011 confirmed the findings.
Record # 9 was admitted on July 20, 2010 and discharged on October 11, 2010. The follow up attempt was due on November 11, 2010.
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Plan of Correction
The front office has a "tickler file" with a folder for each of the 12-months of the year. When a clinician discharges a client from treatment, a discharge status form will be placed in the tickler file in the folder for the following month. At the end of each month, the front office staff will send out our standard follow-up letter to all clients in that months folder. This system and prodedure will be explained by the program supervisor to the front office staff at the staff meeting on 6/22/11, and will be initiated on or before 6/29/11. The office manager will monitor the tickler file monthly for compliance. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on the review of administrative documentation and discussion with project director, the facility failed to make available to the public an annual report within six months of the end of the facility's fiscal year June 30, 2010.
The findings include:
The facility presented documentation on May 23, 2011, that the public was notified of the annual report availability. A notice was posted in a local newspaper on February 4, 2011. It was required to have been posted by December 31, 2010. An interview with the project director on May 23, 2011 confirmed the notice was posted late.
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Plan of Correction
The Executive Director and the Chief Financial Council will both monitor the task of making sure the Public Annual Report be available to the public at the time of completing our auditing requirements. This Public Annual report will be available to the public no later than December 31, 2011. The fact that two Administrators are both responsible will provide an effective check and balance. |
715.29(4) LICENSURE Exceptions
A narcotic treatment program is permitted, at the time of application or any time thereafter, to request an exception from a specific regulation.
(4) The narcotic treatment program shall maintain documentation of the Department 's approval of an exception.
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Observations
Based on a review of the policy and procedure manual, administrative documentation and discussion with the project and facility directors, the facility failed to comply with the conditions of an exception granted by the Department.
The findings include:
An exception for the facility to provide medication assisted treatment (buprenorphine) was granted by the Department on March 9, 2011. In this exception, it was stated that the Department would review the policy and procedures for the activity and the documents reflecting governing body approval during on-site licensure inspections. The policy and procedure manual was reviewed on May 23, 2011. The policy in place for medication control addressed the administration of medication only. It stated the facility does not store, dispense or administer medication onsite. It also stated the client will self-administer onsite, but no medications are onsite.
An interview with the project director was conducted on May 23, 2011 at approximately 10:30 AM. At this time it was revealed by administrative staff that a policy and procedure was not available regarding the provision of buprenorphine. The facility director was included in the discussion and he stated he would have to get the policy from his home and provide it the following day.
On May 24, 2011 at approximately 10:00 AM, the project director provided the facility's written policy and procedure for medication assisted treatment. Information contained in this documentation stated that anyone seeking this service would be referred to the facility director, who is also the medical director for the project, and his "private practice" would provide the medication assisted services. In discussion with the facility project/medical director, it was stated the facility did not want to develop a policy and procedure for this added activity as it would imply the Department could then review the medical records. It was discussed with the project director that any and all records that are developed to document the services provided for all activities licensed by the Department are subject to review however facility staff implied they would not provide client records to the Department for review as they were the private patients of the medical director.
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Plan of Correction
Any client that is admitted to New Insights for drug and alcohol treatment services, whom is currently on Buprenorphine through an outside provider, will be indicated in the clinical chart behind the medical history. A standardized form will be developed by the program director, and the form will include the form of Buprenorhoine the client is taking (Suboxone, Subutex), the dose, and the prescribing physician. This form will be reviewed with the clinical staff at the staff meeting on 6/22/11. In addition the clincician is to encourage the client to sign a relase of information for the prescribing physician for continuity of care, given the client is willing. For a period of 6-months, during clinical supervision, the Clinical Supervisor will randomly review one chart of each clinician, of any client currently on Buprenorphine maintenance therapy to monitor for compliance.
For clients who wish to be put on Buprenorphine maintenance therapy after admission to New Insights, the clinician will aid in the referral process, which may include referring the client to Dr. Christipher Davis' private addiction medicine practice or any other Buprenorphine certified physician. As previously mentioned, it will be indicated in the clinical chart if said client is prescribed Buprenorphine. New Insights does not intend to store or dispense medications to their clients. Clients are responsible for their own self administration of medications of all medications, be it Buprenorphine, psychotropic medications, or non-psychotropic medications. |
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 a review of client records and an interview with the facility director, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment in eight of eight outpatient client records.
The findings include:
Twelve client records were reviewed on May 24, 2011. Eight of the twelve were outpatient client records. A psychosocial evaluation was required in eight of those records, #1, 2, 3, 4, 5, 6, 7 and 8. An interview with the Project Director on May 24, 2011 confirmed the findings.
Client records #1, 2, 3, 4, 5, 6, 7 and 8 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
Client records #1, 2, 3, 4, 5, 6, 7 and 8 did not include an evaluation of the client's support systems and how they would relate to treatment.
Client records #1, 2, 3, 4, 5, 6, 7 and 8 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
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Plan of Correction
The Program Supervisor will review with the clinical staff in the staff meeting on 6/22/11, documentation in the psych-social evaluation to include assets/strengths, support systems, coping mechanisms and negtive factors that may inhibit treatment. Examples will be provided. The program supervisor will randomly audit one chart from each clinician for compliane for 6-months at clinical supervisions. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on the review of client records, the facility failed to document progress notes in accordance with the regulations in five of eight outpatient client records.
The findings include:
Twelve client records were reviewed May 24, 2011. Eight of the Twelve client records were outpatient clients. Eight records were reviewed specifically for client progress notes. There were progress notes documented after individual and group counseling sessions. The data, assessment and plan (DAP) format was utilized.
Client record # 1 contained group notes written in DAP format. The notes did not include the counselor's analysis or conclusions regarding the status. The plan did not reflect actions to be taken by the counselor, action steps or client assignments or tasks. Instead, the date of the next group was the plan.
Client record # 3 contained group notes written in DAP format. The notes did not include the counselor's analysis or conclusions regarding the status. The plan did not reflect actions to be taken by the counselor, action steps or client assignments or tasks. Instead, the date of the next group was the plan.
Client record # 4 contained group notes written in DAP format. The notes did not include the counselor's analysis or conclusions regarding the status. The plan did not reflect actions to be taken by the counselor, action steps or client assignments or tasks. Instead, the date of the next group was the plan.
Client record # 7 contained group notes written in DAP format. The notes did not include the counselor's analysis or conclusions regarding the status. The plan did not reflect actions to be taken by the counselor, action steps or client assignments or tasks. Instead, the date of the next group was the plan
Client record # 8 contained group notes written in DAP format. The notes did not include the counselor's analysis or conclusions regarding the status. The plan did not reflect actions to be taken by the counselor, action steps or client assignments or tasks. Instead, the date of the next group was the plan
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Plan of Correction
The Program Supervisor will review with the clinical staff in the staff meeting on 6/22/11, that all notes for group sessions must be written in DAP format, reflecting the counselor's assessment, analysis or conclusions and any assignments for the following session. The Program Supervisor will monitor for compliance by random audits of one clinical chart at each clinical supervision for 6-months. |