INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 3-5, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, PA Treatment and Healing 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
A review of personnel records was conducted on August 28, 2019 at the PA Treatment and Healing Scranton facility. During the review, it was discovered that employee #1 did not have an annual individual training plan.
Employee #1 was hired as the project director on June 3, 2019 and was still in the position as of the date of the onsite inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The annual training plan will be completed for all new employees within 10 days of hire and annually thereafter with the input from both employee and the supervisor.
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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
The Staffing Requirements Facility Summary Reports was completed on July 23, 2019 and reviewed on September 5, 2019. Employee #7 was hired as a counselor on September 8, 2014 and was still acting in that position at the time of the inspection. Employee #7 was reported to have 20 hours per week devoted to their 20 clients on their caseload.
The counselor Full-Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility's work week hours, which at this facility is 40 hours. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's caseload is divided by the FTE.
The FTE counselor's caseload calculation is as follows: 20/40 = .5 (FTE); 20/.5 = 40, which equals to a client counselor ratio of 40:1.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on the review of the staffing requirements facility summary reports this facility failed to comply with with ratio requirements. Employee #7's work hours per week will be increased to 30. Employee #7 is a part-time employee. |
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection on September 5, 2019, it was observed that the facility failed to ensure the safety and well-being of clients, staff and visitors. The back wooden handicap ramp has a loose floor board that sticks up higher than the surrounding boards creating a tripping hazard.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on a physical plant inspection, this facility failed to ensure the safety and well-being of clients, staff and visitors. The plan of correction is to replace the loose floor board that sticks up higher than the surrounding boards creating a tripping hazard. This was completed on 9/6/2019. The facility director and lead counselor are responsible for monitoring the physical plant. The physical plant will be inspected morning and evening on a daily basis. |
705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on a physical plant inspection on September 5, 2019, it was observed that the facility failed to store trash in covered containers. A full, open trash bag was observed outside the facility's front door.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on the physical plan inspection, it was observed that the facility failed to store trash in covered containers. A full, open trash bag was observed outside the facility's front door. The plan of correction is to check the outside surroundings on a daily basis and pick up any trash and remove trash once a week. The facility is in compliance with this as of October 1, 2019. The facility director and lead counselor are responsible for monitoring the physical plant morning and evening on a daily basis. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection conducted on September 5, 2019, it was observed that the window in counselor room #2 did not have any type of window treatments, thus allowing unobstructed visual access.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Based on the physical plan inspection, it was observed that the window in the counselor room #2 did not have any type of window treatments, thus allowing unobstructed visual access. As of 9/6/2019, in room #2, a set of blinds was placed on the window. We are in compliance as of 9/6/2019. The facility director and lead counselor are responsible for monitoring the physical plant every morning and evening on a daily basis. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection on September 5, 2019, it was observed that the facility failed to ensure exits were unobstructed for fire safety. The basement level back exit stairs was obstructed with various forms of materials and equipment being used for the facility's renovation.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Based on the physical plan inspection, it was observed that the facility failed to ensure exits were unobstructed for fire safety. The basement level back exit stairs was obstructed with various forms of materials and equipment being used for the facility's renovation. As of 9/5/2019, all materials and equipment have been removed and stored in a closet. We are in compliance as of 9/5/2019. The facility director and lead counselor are responsible for monitoring the physical plant morning and evening on a daily basis. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
A review of the October 2017 through August 2019 fire drill logs was conducted during the onsite inspection. The facility failed to conduct an unannounced drill during November 2018.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Fire log drills were reviewed and found that the facility failed to conduct an unannounced drill during November 2018. AS of 10/01/2019, PATH will conducted unannounced fire drills once a month on a different day of the month. The facility director and lead counselor will ensure a fire drill will be conducted each month. |
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.
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Observations
Based on the review of seven client records on September 3-5, 2019, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in client record #7.
Client #7 was admitted on April 27, 2018 and discharged on January 24, 2019. There were four documentation's in the client record that information was released without an informed and voluntary consent to release information form on file.
(1) A fax was sent to a doctor on February 27, 2019 without a proper release.
(2) A fax was sent on February 26, 2019 to a medical center. The release of information form on file permitted the medical center to release information to the facility but there was no form on file for the facility to release information to the medical center.
(3) Two faxes were sent, dated January 31, 2019 and February 1, 2019, to a medical social worker without the proper release.
(4) A fax was sent to a medical professional on February 5, 2019 without a proper release.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility failed to document an informed and voluntary consent to release information from prior to the disclosure of information in client record #7. There were 4 documentation's in the client record that information was released without an informed and voluntary consent to release information form on file. Plan of correction: All staff will be trained on confidentiality, how to complete a release and what information should be identified on the release. In addition, each staff will obtain informed consent and voluntary consent to release information before sending any document to any person, medical facility, doctor, and social worker. A proper release will be completed for any release of information. As of 10/01/2019, PATH will be in compliance with information regarding releasing information to individuals. All staff are trained weekly on how to complete the release forms. All staff questions are answered regarding how to complete release forms as needed. The facility director and lead counselor will monitor on a weekly basis via auditing. |
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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on the review of seven client records on September 3-5, 2019, the facility failed to properly document the name of the person or agency to whom disclosure is made on the informed and voluntary consent to release information forms in client record #4.
Client #4 was admitted on December 11, 2018 and discharged on August 21, 2019. There were five consent to release information forms in the client's file, all dated December 11, 2018 that were missing the name of the person or agency to whom disclosure is to be made. All five consents were signed and dated by the client.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Based on the review, the facility failed to properly document the name of the person or agency to whom disclosure is made on the informed and voluntary consent to release information forms in client record #4. Plan of correction: All staff will be trained on how to complete a release. This will be done by 10/01/2019 and the facility director will ensure that staff are completing the releases correctly by randomly auditing charts. |
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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of seven client records on September 3-5, 2019, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record #'s 2 and 7. Additionally, client records #4 and 6 were missing specific information to be disclosed. In client record #7, information was released that was not permitted on the consent to release information form.
Client #2 was admitted on October 24, 2018 and discharged on January 22, 2019. Two consent to release forms were signed and dated on October 24, 2018 to government agencies that allowed for release of progress reports, medical history and physical, psychosocial evaluation, counselor recommendations, counselor discharge summary, psychological evaluation, physician discharge summary, psychiatric evaluation, aftercare plan, emergency contact, physician recommendations and "other".
Client #4 was admitted on December 11, 2018 and discharged on August 21, 2019. There were three consent to release information forms in the client's record that were missing specific information to be disclosed. One form was to a government agency and two forms did not list the name/agency to whom the information could be released. All three consents were signed and dated on December 11, 2018.
Client #6 was admitted on April 10, 2019 and was still active at the time of the inspection. A consent to release form, dated April 16, 2019, to a funding source, did not specify what information could be disclosed. There was documentation in the client's record of contact with the funding source on June 10, 2019. A second consent to release information form, dated April 16, 2019, to a government agency did not specify what information could be disclosed.
Client #7 was admitted on April 27, 2018 and discharged on January 24, 2019. A consent to release information to a government agency permitted only information on whether the client is or is not in treatment. The facility had email contact with this agency on January 28, 2019 which included information not permitted on the form and was outside the five points outlined in 4 Pa. Code 255.5 (b). In addition, a consent to release information form to the funding source permitted only information on whether the client is or is not in treatment. Facility staff verified through an interview that information was released to the funding source outside what was permitted on the consent form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on the review of client record #'s 2 and 7 facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5. In addition, client record #'s 4 and 6 were missing specific information to be disclosed. Record #7, information was released that was not permitted on the consent to release information form. Plan of correction: All staff will be trained on what they can release to whom and the specific information that needs to be identified on each release. This training will be completed by 10/01/2019 and the facility director and lead counselor will pull random charts and audit them to ensure that releases are being completed correctly. The facility director and lead counselor will monitor charts weekly. The plan for acquiring corrected release of information forms for active clients is for each counselor to review the releases with the clients and complete new releases with correct information and signatures. |
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 must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on the review of seven client records on September 3-5, 2019, the facility failed to properly document the purpose of the disclosure on the informed and voluntary consent to release information forms in client records #4 and 6.
Client #4 was admitted on December 11, 2018 and discharged on August 21, 2019. There were three consent to release information forms in the client's record that were missing the purpose of the disclosure. One form was to a government agency and two forms did not list the name/agency to whom the information could be released.
Client #6 was admitted on April 10, 2019 and was still active at the time of the inspection. A consent to release form to a government agency did not list the purpose of disclosure.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility failed to properly docuemnt the purpose of the disclosure on the informed and voluntary consent to release information forms in client records #4 and 6. All staff will be trained on how to complete releases providing all information needed. The purpose of the disclosure and the name/agency to whom the information is released to will be completed on all release forms and all staff will be trained to complete forms that provide all the necessary information. The training will be help on 10/01/2019 and the facility director will audit charts weekly to see if the releases are completed correctly in the charts. If they are not completed correctly the staff member will need to contact the client to complete a correct release. Client #6 will re-sign the accurately completed consents to release information and it was completed on 10/14/2019. |
709.28 (c) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on the review of seven client records on September 3-5, 2019, the facility failed to obtain a dated signature from the client on the informed and voluntary consent to release information form in client record #5.
Client #5 was admitted on June 26, 2019 and was still active at the time of the inspection. A consent to a medical testing facility was not signed and dated by the client. A urine drug screen was sent to the medical testing facility on July 3, 2019.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
We failed to obtain a dated signature from the client on the informed and voluntary consent to release information for in client record #5. A consent to a medical testing facility was not signed and dated by the client. All staff were trained on how to complete release of information documents on 10-01-2019. The facility director and lead counselor will audit random charts once a week and review releases once a week. Client 5 will sign an updated, accurate consent to release information form by 11/30/2019. |
709.28 (c) (5) 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 must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
Based on the review of seven client records on September 3-5, 2019, the facility failed to obtain a dated signature from a witness on the informed and voluntary consent to release information form in client record #5.
Client #5 was admitted on June 26, 2019 and was still active at the time of the inspection. A consent to a medical testing facility was not signed and dated by a witness. A urine drug screen was sent to the medical testing facility on July 3, 2019.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility failed to obtain a dated signature from a witness on the informed and voluntary consent to release information form in client record #5. A consent to medical testing facility was not signed and dated by a witness. All staff have been trained on how to accurately complete release forms on 10/01/2019. The facility director and lead counselor will pull random charts weekly to ensure that releases are completed accurately. Client 5 will sign an updated, accurate consent to release information form by 11/30/2019. |
709.28 (c) (6) 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 must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on the review of seven client records on September 3-5, 2019, the facility failed to properly document an expiration date on the informed and voluntary consent to release information forms in client records #4 and 6.
Client #4 was admitted on December 11, 2018 and was discharged on August 21, 2019. There were four consent to release information forms in the client's record that were missing the expiration information. One form was to a government agency and three forms did not list the name/agency to whom the information could be released.
Client #6 was admitted on April 10, 2019 and was still active at the time of the inspection. There were three consent to release information forms in the client's record that were missing the expiration information. One form was to a government agency, one form was to a funding source, and one form was to a medical testing facility.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
We failed to properly document an expiration date on the informed and voluntary consent to release information forms in client records #4 and 6. There were four consent to release information forms in the client's record that were missing the expiration information. The name/agency was not completed. Staff have been trained on 10/01/2019 how to accurately complete release forms. The facility director and lead counselor will randomly audit charts once a week and will review releases to ensure that they are completed correctly. Client 6 will sign an updated, accurate consent to release form by 11/30/2019. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on the review of seven client records on September 3-5, 2019, the facility failed to properly document if the client was offered a copy of the informed and voluntary consent to release information forms in client records #1, 5 and 6.
Client #1 was admitted on February 21, 2019 and discharged on July 30, 2019. A consent to a medical testing facility and a government agency, both dated February 21, 2019, did not include whether a copy was offered to the client.
Client #5 was admitted on June 26, 2019 and was still active at the time of the inspection. A consent to a medical testing facility, did not include whether a copy was offered to the client. A urine drug screen was sent to the medical facility on July 3, 2019.
Client #6 was admitted on April 10, 2019 and was still active at the time of the inspection. There were three consent to release information forms in the client's file that were missing documentation that the client was offered a copy of the form. The forms were to a government agency, a funding source and a medical testing facility.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
We failed to properly document if the client was offered a copy of the informed and voluntary consent to release information forms in client records #1, 5 and 6. All staff were trained on how to accurately complete releases with offering the client a copy of the signed release. The staff were trained to have the client initial whether or not that they wanted a copy or they refused a copy. This training was completed on 10/01/2019. The facility director and lead counselor will ensure that the releases are accurately completed by randomly auditing charts once a week. Client 5 and 6 will sign the updated consent to release forms by 11/30/2019. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of seven client records on September 3-5, 2019 and the policy and procedures manual on August 26-27, 2019, the facility failed to ensure that the client had been made aware of their client rights in client record #'s 1, 2, 3, 4, 5, 6 and 7. In addition, the facility's client rights policy failed to include all parts of the client rights regulation. In both the client record documentation and the policy and procedures manual, the project failed to include that a client may not be discriminated against based on color, marital status and handicap.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We failed to ensure that the client had been made aware of their client rights in client record's 1,2,3,4,5, 6, and 7. The facility's client rights policy failed to include all parts of the client rights regulation. All staff were trained to have the client sign the client rights and put in chart as well as give the client a copy on 10/3/2019. The rights did not include color, marital status, and handicap. In addition, the project director revised our rights policy that added color, marital status, and handicap. This will be revised and active clients sign the client rights form by November 30, 2019. |
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 seven client records on September 3-5, 2019, the facility failed to document a psychosocial evaluation in client record #'s 6 and 7. In addition, client #4's biopsychosocial was completed but was not dated by the counselor. According to the facility's policy and procedure manual, "Upon completion of the Bio-Psycho-Social Summary, the clinical staff person and the physician (if applicable) will sign and date the document".
Client #4 was admitted on December 11, 2018 and discharged on August 21, 2019.
Client #6 was admitted on April 10, 2019 and was still active at the time of the inspection.
Client #7 was admitted on April 27, 2018 and was discharged on January 24, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We failed to document a psychosocial evaluation in client record #'s 6 and 7. Client number 4 biopsychosocial was completed but not dated by the counselor. All staff were trained on what is needed on the biopsychosocial documentation on 10/03/2019. The facility director and lead counselor will audit charts on a weekly basis to ensure the bio's are completed accurately. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of seven client records on September 3-5, 2019, the facility failed to document a preliminary treatment plan in client record #'s 4, 5 and 6.
Client #4 was admitted on December 11, 2018 and discharged on August 21, 2019.
Client #5 was admitted on June 26, 2019 and was still active at the time of the inspection.
Client #6 was admitted on April 10, 2019 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
We failed to document a preliminary treatment plan in client record's #4, 5, and 6. All staff were trained to complete the preliminary treatment plan on the day of intake on 10/03/2019. Facility director and lead counselor will pull random charts weekly in order to ensure that preliminary treatment plans are being completed. |
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 on a review of seven client records on September 3-5, 2019, the facility failed to provide documentation in the form of a signed and dated treatment plan, that the treatment plan was developed with the client in client records #2 and 4. In addition, the facility failed to follow their policy and procedures manual timeline for developing the master treatment plan with the client in client record #1. The "Coordination of Outpatient Drug & Alcohol Treatment Services" section of the policy and procedures manual states "it is the clinical staff person's responsibility to develop the Preliminary Treatment Plan with the client during the Intake Session and the Master Treatment Plan with fifteen (15) days of the date of the Intake Session."
Client #1 was admitted on February 21, 2019 and discharged on July 30, 2019. Intake was completed on February 21, 2019 and the master treatment plan was signed by the client on July 23, 2019.
Client #2 was admitted on October 24, 218 and discharged on January 22, 2019. The master treatment plan was signed by the counselor on November 1, 2018 but was not signed and dated by the client.
Client #4 was admitted on December 11, 2018 and discharged on August 21, 2019. The master treatment plan was not signed and dated by the counselor and client.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
We failed to provide documentation in the form of a signed and dated treatment plan, that the treatment plan was developed with the client in client records #2 and 4. The facility also failed to follow their policy and procedures manual timeline for developing the master treatment plan with the client in client record #1. All staff have been trained on 10/03/2019 to complete the master treatment plan within 15 days of intake and to ensure that the treatment plan is signed and dated with all necessary signatures including the counselor, client, supervisor, and doctor. The facility director and lead counselor will audit charts on a weekly basis to ensure that the master treatment plan is being completed correctly. |
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 on a review of seven client records on September 3-5, 2019, the facility failed to document treatment plan updates within the regulatory timeframe in client record #'s 2, 4 and 6.
Client #2 was admitted on October 24, 2018 and discharged on January 22, 2019. A master treatment plan was completed on November 1, 2018 and an update was due no later than December 30, 2018; however, there was no updates documented in the record at the time of the inspection.
Client #4 was admitted on December 11, 2018 and discharged on August 21, 2019. A treatment plan update was completed on April 2, 2019 and the next update was due no later than June 1, 2019; however, there was no updates documented in the record at the time of the inspection.
Client #6 was admitted on April 10, 2019 and was still active at the time of the inspection. There was no documentation in the record of any updates being completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We failed to document treatment plan updates within the regulatory time-frame in client record #'s 2, 4 and 6. All staff were trained on 10/03/2019 of the time-frame that treatment plan reviews should be completed. They were trained to complete them within 60 days of date of the master treatment plan and every 60 days thereafter. The facility director and lead counselor will audit charts to ensure that the treatment plan reviews are completed within the 60 day time-frame. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of seven client records on September 3-5, 2019, there was no documentation that the clients received counseling services according to their individual master treatment plan in client record #'s 2, 4 and 7.
Client #2 was admitted on October 24, 2018 and discharged on January 22, 2019. The master treatment plan, dated November 1, 2018, indicated biweekly individual sessions and group sessions two times per week. There was no documentation of any counseling sessions after December 3, 2018.
Client #4 was admitted on December 11, 2018 and discharged on August 21, 2019. The treatment plan updates, dated February 5, 2019 and April 2, 2019, indicated biweekly individual sessions. The record of service and progress notes indicated that the client did not receive individual sessions between February 1-24, March 14- April 14, April 16 - May 15, and May 17 - June 4, 2019.
Client #7 was admitted on April 27, 2018 and discharged on January 24, 2019. The master treatment plan, dated May 10, 2018, indicated weekly individual counseling sessions. The record of service and progress notes indicated that the client did not receive individual sessions between June 8 - June 20, and July 11 - August 1, 2019. The client's last documented session was on August 7, 2018. Facility staff stated that the client's chart was kept open for medical reasons, but there was no documentation in the chart to support the information.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
We failed to document the clients received counseling services according to their individual master treatment plan in client record #'s 2, 4, and 7. All staff were trained to follow the treatment plan and document progress or lack of progress accordingly. Staff were trained on 10/03/2019. Facility director and lead counselor will ensure that the clients is receiving the best services by reviewing progress notes and comparing them to the treatment plan. |
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 a review of client records on September 3-5, 2019, the facility failed to provide a complete client record, which is to include progress notes, individual treatment plans, aftercare plans, discharge summaries and documentation of follow-up information, in client record #'s 3, 4, 5, 6 and 7.
Client #3 was admitted on October 8, 2018 and was discharged on July 16, 2019. The client record did not contain documentation of follow-up information.
Client #4 was admitted on December 11, 2018 and discharged on August 21, 2019. The client record did not contain documentation of an aftercare plan and discharge summary.
Client #5 was admitted on June 26, 2019 and was still active at the time of the inspection. The client record did not contain documentation of an individual treatment plan.
Client #6 was admitted on April 10, 2019 and was still active at the time of the inspection. The client record did not contain documentation of an individual treatment plan.
Client #7 was admitted on April 27, 2018 and was discharged on January 24, 2019. The client record did not contain documentation of progress notes, an aftercare plan, discharge summary and follow-up information. Progress notes were missing for sessions occurring on May 10, May 17, May 24, May 31, June 7, June 21, July 5 and August 7, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We failed to provide a complete client record, which is to include progress notes, individual treatment plans, aftercare plans, discharge summaries and documentation of the follow-up information, in client record #;s 3, 4, 5, 6, and 7. All staff were trained on how to complete a whole chart with the proper documentation on 10/03/2019. This included what the progress notes should include in each section, what the individual treatment plans should include, what the aftercare plan should include, what the discharge summary should include, and that each client should have a follow up information of proof that there was follow up after discharge or referral. Facility director and lead counselor will audit charts weekly to ensure that the all of the information that is needed in the charts is accurately completed in the clients file. |