INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 8, 2006 to June 9, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on July 13, 2006.
|
Plan of Correction
|
711.91(b)(3)(i) LICENSURE Medical History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
|
Observations
In 5 out of 16 clinical charts reviewed, specifically #9, 11, 12, 13 and 15, the medical histories were completed late according to facility policy and procedure. In addition, 15 out of 16 clinical charts, specifically #1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14, 15 and 16, the medical history did not include the client's symptoms and/or illnesses.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.91(b)(3(ii) LICENSURE D & A History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
|
Observations
In 12 out of 16 clinical charts reviewed, specifically #1, 2, 3, 4, 5, 6, 8, 10, 11, 12, 13 and 14, the drug and alcohol history was missing lengths and patterns of use. In addition to the clinical charts above, charts #9, 15 and 16 did not include the client's perception of use in the drug and alcohol history. Lastly, the drug and alcohol history in clinical charts #7, 9, 11, 12 and 15 were completed late according to facility policy and procedure.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.91(b)(3)(iii) LICENSURE Personal History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
In 16 out of 16 clinical charts reviewed, specifically #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16, the personal history was missing 3 or more of the following components: legal, employment, education, recreation and sexual. In addition, the personal history was completed late according to facility policy and procedure in clinical charts #9, 11, 12 and 15.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
In 8 out of 16 clinical charts reviewed, specifically #2, 5, 6, 8, 10, 13, 14 and 16, the psychosocial evaluations were missing. In 4 out of 16 clinical charts reviewed, specifically #9, 11, 12 and 15, the psychosocial evaluation was completed late according to facility policy and procedure. In all clinical charts reviewed, the psychosocial evaluation was missing multiple required areas.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.92(a)(3) LICENSURE Mngt of Treatment Services
711.92. Treatment and rehabilitation services.
(a) The project shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the development, approval and ongoing management of treatment/rehabilitation services for clients.
|
Observations
Multiple, conflicting policies were identified in the manual regarding timeframes for the completion of clinical documentation.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
In 8 out of 15 clinical charts reviewed, specifically #1, 2, 3, 4, 5, 6, 10 and 11, the individual treatment plan was late according to facility policy and procedure.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.92(c)(1) LICENSURE TX Plan Goals
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment, as formulated by both staff and client.
|
Observations
The short and long -term goals, objectives and/or actionsteps were not realistic or measurable in clinical charts #3, 4, 6, 7, 9, 10, 11, 12, 13, 14, 15 and 16.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.92(c)(3) LICENSURE Support Service
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
|
Observations
In clinical charts #6, 9, 10, 11, 12, 13, 14, 15 and 16, the individual treatment plans did not include support services.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
In 11 out of 14 clinical charts reviewed, specifically #1, 2, 3, 4, 5, 7, 9, 12, 13, 14 and 16, the treatment plan update did not address the client's progress in the past 60 days as it relates the goals on the individual treatment plan. In addition, in clinical chart #15, the treatment plan update was missing.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) 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:
|
Observations
In 16 out of 16 clinical charts reviewed, the patient's rights form contained a signature line for the parent/guardian. In addition, in clinical charts #1, 2, 3, 4, 5, 12 and 14, the consent to release protected health information form contained a parent signature line and wording that stated that the privacy rule is not in effect for the re-disclosure of information. In clinical charts #9 and 13, the PCPC's released to the insurance provider indicated specific medications and amount of drug use and route used.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.93(c)(2)(ii) LICENSURE Specific Info. Disclosed
711.93. Client records.
(c) Confidentiality.
(2) 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:
(ii) The specific information disclosed.
|
Observations
In clinical chart #11, the consent to release information form to probation included the release of lab reports and/or tests. This information exceeds the limits imposed at 4 Pa. Code subsection 255.5(b).
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.95(b) LICENSURE Efficient Retrieval of Data
711.95. Uniform Data Collection System.
(b) A data collection system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance.
|
Observations
The current data collection system does not allow for the efficient retrieval of data in order to measure the project's performance.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |