INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 4, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Brighter Visions Counseling, was found to be not 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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709.28 (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
Nine client records were reviewed on January 4, 2018, the facility failed to obtain a valid consent to release information form in client records, #1-4 & 7-9. The Consent to Release Information Template failed to indicate whether the client was offered a copy of the consent.Client #1 was admitted on 8/11/17 and was an active client at the time of the licensing inspection. A consent to release information to a funding source, dated 8/11/17.Client #2 was admitted on 10/20/17 and was an active client at the time of the licensing inspection.A consent to release information to a funding source, dated 10/20/17.A consent to release information to a provider, dated 10/20/17.Client #3 was admitted on 6/16/17 and was an active client at the time of the licensing inspection. A consent to release information to a funding source, dated 6/16/17.A consent to release information to a provider, dated 6/16/17.Client #4 was admitted on 4/14/17 and was an active client at the time of the licensing inspection.A consent to release information to a funding source, dated 4/14/17. Client #7 was admitted on 6/10/17 and discharged on 8/18/17. A consent to release information to a funding source, dated 6/10/17.A consent to release information to a provider, dated 6/10/17.Client #8 was admitted on 10/20/17 and discharged on 12/16/17.A consent to release information to a funding source, dated 10/20/17.A consent to release information to a government agency, dated 10/20/17.A consent to release information to an attorney, dated 11/3/17.Client #9 was admitted on 7/11/17 and discharged on 8/22/17.A consent to release information to a funding source, dated 7/11/17.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The facility Consent to Release Information Template shall include the option offering the client a copy of the release, said copy to be accepted or declined by the client. This correction is in effect January 8, 2018.
Clients #1, #2, #3, and #4 who are active in treatment will be presented with the amended Release forms at their next attended session. Completed forms will become part of the record on that date.
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709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Nine client records were reviewed on January 4, 2018, the facility failed to document a comprehensive drug and alcohol history which specified the substances most frequently abused, the length and patterns of use, age of first use and date of last use in client records, #1, 3, 4, & 6-9.Client #1 was admitted on 8/11/17 and was an active client at the time of the licensing inspection.Client #3 was admitted on 6/16/17 and was an active client at the time of the licensing inspection. Client #4 was admitted on 4/14/17 and was an active client at the time of the licensing inspection. Client #6 was admitted on 2/25/17 and discharged on 5/26/17. Client #7 was admitted on 6/10/17 and discharged on 8/18/17. Client #8 was admitted on 10/20/17 and discharged on 12/16/17.Client #9 was admitted on 7/11/17 and discharged on 8/22/17.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Client records will document a comprehensive drug and alcohol history which specifies the substances most frequently abused, the length and patterns of use, age of first use, and date of last use in the client records.
This correction is in effect for new clients beginning January 30, 2018. Records of clients which were reviewed, (#1, #3, and #4) who are active in treatment will be revised with amended information at their next attended session after January 30, 2018.
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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
Nine client records were reviewed on January 4, 2018, the facility failed to document a psychosocial evaluation that included the counselor's assessment of the client's assets and strengths, support systems, negative factors, attitude toward treatment in client records, #6 & 7.Client #6 was admitted on 2/25/17 and discharged on 5/26/17. Psychosocial 'assessment summary' was incomplete.Client #7 was admitted on 6/10/17 and discharged on 8/18/17. Psychosocial 'assessment summary' was blank.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The client record will include the counselor's assessment of the client's assets and strengths, support systems, negative factors, and attitude toward treatment. The assessment template will be revised to ensure that these aspects of assessment are included. For active clients this assessment will be reviewed and documented by separate document if deficient at the next attended session. This practice will be reinforced by random chart audits and reviews during regular supervisory and staff meetings conducted by the facility director. This correction is in effect January 30, 2018. |
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
Nine client records were reviewed on January 4, 2018, the facility failed to update the treatment plan every 60 days in client records, #1-4, & 7.Client #1 was admitted on 8/11/17 and was an active client at the time of the licensing inspection. The comprehensive treatment plan was documented on 8/11/17; a treatment plan update was due by 10/11/17 but was not documented until 10/13/17; another treatment plan update was due by 12/13/17 but was not documented until 12/15/17.Client #2 was admitted on 10/20/17 and was an active client at the time of the licensing inspection. The comprehensive treatment plan was documented on 10/20/17; a treatment plan update was due by 12/20/17 but was not documented at the time of the licensing inspection.Client #3 was admitted on 6/16/17 and was an active client at the time of the licensing inspection. The comprehensive treatment plan was documented on 6/16/17; a treatment plan update was due by 8/16/17 but was not documented until 8/18/17; another update was due by 10/18/17 but was not documented until 10/27/17 and another update was due by 12/27/17 but was not documented at the time of the licensing inspection.Client #4 was admitted on 4/14/17 and was an active client at the time of the licensing inspection. A treatment plan update was documented on 8/4/17; a treatment plan update was due by 10/4/17 but was not documented until 10/13/17; another update was due by 12/13/17 but was not documented at the time of the licensing inspection.Client #7 was admitted on 6/10/17 and discharged on 8/18/17. A comprehensive treatment plan was documented on 6/10/17; a treatment plan update was due by 8/10/17 but was not documented at the time of the licensing inspection.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days. If a session is missed, the counselor will update the goals and interventions of the plan by the 60th day. This will be reviewed with the client at the next attended session.
A roster of active clients will be maintained in table format which chronicles required milestones of treatment including due dates for treatment plan updates. This will be reviewed by counselors daily so that said milestones are not missed. The rosters will also be reviewed by the Facility Director with the counselor on a weekly basis.
This correction is in effect January 30, 2018. |