INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 25 and 26, 2014, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, Harbor Counseling 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:
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Plan of Correction
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709.81(b)(3)(i) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of client records, the facility failed to document medical, drug and alcohol and personal history in one of one record.
The findings included:
Ten client records were reviewed during the on-site inspection. One of the client records was for the partial hospitalization activity, # 1.
Client # 1 was readmitted to the facility on November 18, 2013. The medical, drug and alcohol, and personal history were not updated to include the time period from the previous admission, May 13, 2013, to November 18, 2013. Additionally, the clinical evaluation was not documented for this treatment event.
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Plan of Correction
Program Director will conduct a staff in-service/in-house training on 4/29/14 reminding clinicians that when someone is readmitted and it has been only 6 months (or less) since the prior admission they can update in red pen the prior Psychosocial Evaluation, making sure to update ALL areas of the medical, drug and alcohol and personal history; and if there is no change to some areas to write "no change" so that it is clear that all areas of the Psychosocial Evaluation were addressed. The training will also remind staff that the Mental Status Examination and Initial Clinical Assessment should be redone, not just updated, at the time of readmission; and that if it has been longer than 6 months since the previous admission, the entire Psychosocial Evaluation needs to be redone. Clinical Supervisor will monitor ongoing compliance through random monthly reviews of clinical charts. Program Director will be responsible for overall compliance with this plan, and will include discussion of chart reviews at least once a month in his meetings with the Clinical Supervisor. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. 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:
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Observations
Based on the review of client records, the facility failed to document a treatment plan was developed with the client in one of one record.
The findings included:
Ten client records were reviewed during the on-site inspection. One of the client records was for the partial hospitalization activity, # 1.
Client # 1 was readmitted to the facility on November 18, 2013. The client's comprehensive treatment plan for partial hospitalization was documented on February 7, 2014, and not signed by the client so could not be verified it was developed with the client.
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Plan of Correction
Program Director will conduct a staff in-service on 4/29/14 informing staff that all treatment plans will be done with the client and will require the signature of the client to verify. The Assistant Administrator will ensure that front office/support staff schedule an individual appointment with any clients who have treatment plans due; and that this scheduled appointment will be done at least a week prior to the treatment plan due date. If the client does not show up for appointment, the no-show will be documented in the client chart and a new appointment scheduled. Clinical Supervisor will monitor for compliance through monthly review of charts and treatment plans. Program Director will be responsible for overall compliance and will monitor progress as part of his regular meetings with the Clinical Supervisor and the Assistant Administrator. |
709.82(d) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
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Observations
Based on the review of client records, the facility failed to provide counseling to a client on a regular and scheduled basis including individual counseling, at least twice weekly in one of one record reviewed in the partial hospitalization activity.
The findings included:
Ten client records were reviewed during the on-site inspection. One of the client records was for the partial hospitalization activity, # 1.
Client # 1 was readmitted to the facility on November 18, 2013. The client was transferred from intensive outpatient on February 7, 2014. Documentation of two individual sessions per week was not completed for the weeks of February 10 and 17, 2014.
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Plan of Correction
Program Director will conduct a staff in-service/in-house training on 4/29/14 reminding clinicians of the Partial Hospitalization service requirements, and the requirement that two individual sessions per week must be documented. Clinical Supervisor will monitor ongoing compliance through monthly reviews of Partial Hospitalization clinical charts. Program Director will be responsible for overall compliance with this plan, and will include discussion of chart reviews at least once a month in his meetings with the Clinical Supervisor. |
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 the review of client records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in three of seven records. The facility failed to stay within the limits imposed by 4 Pa. Code 255.5 (b) in one of seven records reviewed.
The findings included:
Ten client records were reviewed during the on-site inspection. Six outpatient records and one partial hospitalization record were reviewed for consents to release information. The facility failed to ensure that an informed and voluntary consent to release information was obtained in three of seven records reviewed, # 1, 5, and 8. The facility also failed to stay within the limits imposed by 4 Pa. Code 255.5 (b) in one of seven records, # 7.
A review of client record # 1 revealed a consent to release information to a family member that did not have a dated signature of the client.
A review of client record # 5 revealed a consent to release information to a funding source that did not include the specific information to be disclosed.
A review of client record # 7 revealed a consent to release information dated November 15, 2013, to disclose the nature of an emergency to an attorney and probation officer. The information permitted exceeded the limitations imposed by Pa Code 255.5 (b).
A review of client record # 8 revealed documentation from the Department of Public Welfare website with specific client information. The record did not contain a consent to release information regarding the client for the purpose of funding.
This is a repeat deficiency from the October 15, 2013 on-site inspection.
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Plan of Correction
Program Director will conduct a staff in-service/in-house training on 4/29/14 reviewing the parameters, requirements and constraints of informed and voluntary consents. The training will include the requirement that the consent must have a dated client signature; the requirement that the specific information to be disclosed must be indicated; the limitations on disclosure mandated by PA Code 255.5; and the requirement of a consent for any and all funding sources, including the Department of Public Welfare. Clinical Supervisor will monitor ongoing compliance through random monthly reviews of clinical charts. Program Director will be responsible for overall compliance with this plan, and will include discussion of chart reviews at least once a month in his meetings with the Clinical Supervisor and with the Assistant Administrator. |
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 upon a review of client records, the facility failed to document a psychosocial evaluation that included an assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, client's attitude toward treatment and the counselor's conclusions/impressions in two of six records.
The findings included:
Ten client records were reviewed during the on-site inspection. Nine were outpatient records. Six records were reviewed for psychosocial evaluations. Two records failed to document a psychosocial evaluation that contained all areas, # 7 and 9.
Client #7 was admitted on November 15, 2013. The psychosocial evaluation dated November 15, 2013, failed to document an assessment by the counselor that included the client's assets/strengths, coping mechanisms, negative factors, client's attitude toward treatment and counselor conclusions/impressions. The documentation did not include an evaluation by the clinician for the required components.
Client # 9 was admitted on October 16, 2013. The psychosocial evaluation documented on October 16,2013, included a composite picture of the client. The documentation did not include an evaluation by the clinician for the required components to include the client problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, client's attitude toward treatment and the counselor's impressions/conclusions. The documentation did not include an evaluation by the clinician for the required components.
This is a repeat deficiency from the October 15, 2013 on-site inspection.
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Plan of Correction
Program Director will conduct a staff in-service/in-house training on 4/29/14 reviewing the required elements of the Psychosocial Evaluation and the counselor's assessment. The training will address the requirement that the Psychosocial Evaluation must include an evaluation by the clinician of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, client's attitude toward treatment and the counselor's impressions/conclusions. Clinical Supervisor will monitor ongoing compliance through random monthly reviews of clinical charts. Program Director will be responsible for overall compliance with this plan, and will include discussion of chart reviews at least once a month in his meetings with the Clinical Supervisor. |
709.92(a) 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:
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Observations
Based upon a review of client records, the facility failed to develop individual treatment and rehabilitation plans with the client in three of six client records.
The findings included:
Ten client records were reviewed during the on-site inspection. Nine were outpatient records. Six records were reviewed for individual treatment and rehabilitation plans. Three records, # 6, 7, and 9 did not contain individual treatment and rehabilitation plans that were developed with the client.
Client # 6 was admitted to outpatient treatment on October 10, 2013. An individual treatment and rehabilitation plan was due to be developed with the client by November 10, 2013. The individual treatment and rehabilitation plan was developed on December 6, 2013.
Client # 7 was admitted to outpatient treatment on November 15, 2013. An individual treatment and rehabilitation plan was due to be developed with the client by December 15, 2013. The individual treatment and rehabilitation plan was not developed at the time of the review.
Client # 9 was admitted to outpatient treatment on October 16, 2013. An individual treatment and rehabilitation plan was due to be developed with the client by November 16, 2013. The individual treatment and rehabilitation plan was developed on January 29, 2014.
Client # 10 was admitted to outpatient treatment on October 7, 2013. An individual treatment and rehabilitation plan was due to be developed with the client by November 7, 2013. The individual treatment and rehabilitation plan was developed on November 14, 2013.
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Plan of Correction
Program Director will conduct a staff in-service on 4/29/14 informing staff of the mandatory time-frames for completion of individual treatment plans. The Assistant Administrator will ensure that front office/support staff schedule an individual appointment with any clients who have treatment plans due; and that this scheduled appointment will be done at least a week prior to the treatment plan due date. If the client does not show up for appointment, the no-show will be documented in the client chart and a new appointment scheduled. Clinical Supervisor will monitor for compliance through monthly review of charts and treatment plans. Program Director will be responsible for overall compliance and will monitor progress as part of his regular meetings with the Clinical Supervisor and the Assistant Administrator. |
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.
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Observations
Based upon a review of client records, the facility failed to document treatment plan updates in two of four client records.
The findings included:
Ten client records were reviewed during the on-site inspection. Nine were outpatient records. Four records required treatment and rehabilitation plans to be reviewed and updated at least every 60 days. Treatment and rehabilitation plans were not updated at least every 60 days in client records # 8 and 10.
Client # 8 was admitted to outpatient treatment on November 18, 2013. A treatment and rehabilitation plan was documented on December 16, 2013. A review and update was not documented at the time of the review.
Client # 10 was admitted to outpatient treatment on October 7, 2013. A treatment and rehabilitation plan was documented on November 14, 2013. A review and update was not documented at the time of the review.
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Plan of Correction
Program Director will conduct a staff in-service on 4/29/14 informing staff of the mandatory time-frames for completion of individual treatment plan review and updates; and the requirement that the review be documented as well as the updated treatment plan. The Assistant Administrator will ensure that front office/support staff schedule an individual appointment with any clients who have treatment plans due; and that this scheduled appointment will be done at least a week prior to the treatment plan due date. If the client does not show up for appointment, the no-show will be documented in the client chart and a new appointment scheduled. Clinical Supervisor will monitor for compliance through monthly review of charts, treatment plan reviews and treatment plans. Program Director will be responsible for overall compliance and will monitor progress as part of his regular meetings with the Clinical Supervisor and the Assistant Administrator. |
709.93(a) 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:
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Observations
Based on the review of client records, the facility failed to document a complete client record that included case consultation and follow up information in five of nine records reviewed
The findings included:
Ten client records were reviewed during the on-site inspection. Nine were outpatient records. Five client records did not include all of the required components, # 2, 4, 6, 7 and 10.
Client # 2 was admitted to outpatient treatment on March 18, 2011, and discharged on December 5, 2013. The record did not contain follow up information at the time of the review.
Client # 4 was admitted to outpatient treatment on May 31, 2013, and discharged on November 1, 2013. The record did not contain follow up information at the time of the review.
Client # 6 was admitted to outpatient treatment on October 10, 2013. A case consultation was due at 90 days in treatment by January 10, 2014. A case consultation was documented on January 14, 2014.
Client # 7 was admitted to outpatient treatment on November 15, 2013. A case consultation was due at 90 days in treatment by February 15, 2014. The record did not contain a case consultation at the time of the review.
Client # 10 was admitted to outpatient treatment on October 7, 2013. A case consultation was due at 90 days in treatment by January 7, 2014. The record did not contain a case consultation at the time of the review.
This is a repeat deficiency from the October 15, 2013 on-site inspection.
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Plan of Correction
Program Director will conduct a staff in-service on 4/29/14 informing staff of the mandatory time-frames for case consultations and follow-up information; and the required documentation for case consultations and follow-up information. Assistant Administrator will direct front office support staff to provide clinical staff with timely reminders of upcoming case consultations due. Clinical Supervisor will monitor for compliance through monthly review of charts. Program Director will be responsible for overall compliance and will monitor progress as part of his regular meetings with the Clinical Supervisor and Assistant Administrator. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of the client records, the facility failed to provide a physician signature on a treatment plan and a treatment plan update in two of three client records.
The findings included:
Ten client records were reviewed during the on-site inspection. Nine were outpatient records with one for partial hospitalization activity. Three client records documented funding through the office of medical assistance and were required to include documentation of a physician's signature on the initial treatment plan. There was no documentation of the physician's signature on the initial treatment plan in client records #1 and 6.
Client # 1 was readmitted to the facility on November 18, 2013. A treatment plan was documented on February 7, 2014. There was no documentation of the physician signature on the treatment plan.
Client # 6 was admitted to outpatient treatment on October 10, 2013. The individual treatment and rehabilitation plan was developed on December 6, 2013, with an update on February 3, 2014. There was no documentation of the physician signature on the treatment plan or update.
This is a repeat deficiency from the October 15, 2013 and August 22-23, 2012, on-site renewal inspection.
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Plan of Correction
Program Director will conduct a staff in-service on 4/29/14 informing staff of the requirements related to physician signature on initial and updated treatment plans for all clients funded through the Department of Public Welfare. Whenever physician is unable to attend regularly scheduled monthly client staffing/reviews, Assistant Administrator will ensure that alternative arrangements are made with physician to ensure timely review and documentation of physician signature. Clinical Supervisor will monitor ongoing compliance through monthly review of charts and treatment plans. Program Director will be responsible for overall compliance and will monitor progress as part of his regular meetings with the Clinical Supervisor and the Assistant Administrator. |