INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from April 30, 2013 through May 1, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Family Services of Warren County, 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.
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Plan of Correction
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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.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in two of two client records.
The findings include:
Nine client records were reviewed on April 30-May 1, 2013. Four client records were reviewed as discharged clients. Two of the discharged clients reviewed were successfully discharged and required an aftercare plan. There was no documentation of an aftercare plan in client records # 6 and 8.
Client # 6 was admitted to treatment on February 23, 2012 and was successfully discharged on December 26, 2012. There was no documentation of an aftercare plan.
Client # 8 was admitted to treatment on September 25, 2012 and was successfully discharged on December 20, 2012. There was no documentation of an aftercare plan.
The Facility Director was interviewed on May 1, 2013 and confirmed the findings.
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Plan of Correction
With regards to client records # 6 and 8 where no documentation of an aftercare plan was found the following measures have been taken to assure the facility will be in compliance:
- Supervisor of the Substance Abuse Program (Facility Director) met with each counselor to review the Licensing Regulation on an Aftercare Plan in a client's record if applicable. In addition, each counselor was instructed to take extreme care in paying attention to assure an aftercare plan is completed at the time of discharge with a client completing treatment.
- The Supervisor of the Substance Abuse Program will perform quality assurance check of the client's records at the time of the Discharge Summary being signed to assure compliance with the law.
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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.
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Observations
Based on a review of client records, the facility failed to document follow-up information in two of four client records.
The findings include:
Nine client records were reviewed on April 30-May 1, 2013. Four client records were reviewed as discharged clients. Four client records required follow-up information. Per agency policy, follow-up is to be completed within 30 days of discharge for non referred clients. There was no documentation of follow-up information in client records # 6 and 8.
Client # 6 was admitted to treatment on February 23, 2012 and was successfully discharged on December 26, 2012. Follow-up information was due by January 26, 2013. There was no documentation of follow-up information.
Client # 8 was admitted to treatment on September 25, 2012 and was successfully discharged on December 20, 2012. Follow-up information was due by January 20, 2013. There was no documentation of follow-up information.
The Facility Director was interviewed on May 1, 2013 and confirmed the findings.
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Plan of Correction
With regards to client records # 6 and 8 where no documentation of follow-up information was found the following measures have been taken to assure the facility will be in compliance:
- Supervisor of the Substance Abuse Program (Facility Director) met with each counselor to review the Licensing Regulation on Follow-Up in a client's record. In addition, each counselor was instructed to take extreme care in paying attention to assure that Follow-Up is completed at the time of discharge especially for those that have completed treatment.
- The following procedure was constructed to assure that every client that completes D&A Counseling must have a D/C Follow-up letter and survey sent out to them after 30 days according to agency policy: 1. Complete the letter and attach the survey to the letter during the D/C of the client. 2. Date the letter one month in advance since we send them out 30 days after D/C. 3. Place the D/C Follow-up Letter and Survey in the SAS Program Cabinet in the Archive Room under the Outcome Survey folder marked Outgoing Surveys. The Outcome Survey folder will have 3 folders in it ?Blank Surveys, Outgoing Surveys and Returned Surveys. 4. Supervisor of the Substance Abuse Program will send D/C Follow-up letters and surveys out when needed and make copies of the D/C Follow-up letters for the clients' records placing it in the folder marked Returned Surveys. 5. All returned surveys will be given to the Supervisor of the Substance Abuse Program who then will attach them to the D/C Follow-up letter in the Returned Surveys Folder 6. Supervisor of the Substance Abuse Program will document the letter and survey was sent and document whether the survey was returned or not after a 2 week period in the client's record.
- The Supervisor of the Substance Abuse Program will perform quality assurance check of the client's record at the time of the Discharge Summary being signed to assure compliance with the law.
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