INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 3 through 5, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, WPIC Center for Psychiatric and Chemical Dependency Services 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 and a plan of correction is due on October 20, 2008.
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Plan of Correction
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711.81(b)(3)(i) LICENSURE Medical History
711.81. 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 a review of four client records on September 3 through 4, 2008, the facility failed to document a medical history within the time frame stipulated in facility policy and procedure in two of three client records where required.
Findings:
Facility policy and procedure requires that medical histories be completed by the fifth group session. In client records #2 and 4 the medical history was completed after the fifth group session. The medical history in client record #2 was to be completed by August 15, 2008, but was not completed until August 26, 2008. In client record #4 the medical history was to be completed by July 18, 2008, but was not completed until August 28, 2008.
This is a repeat deficiency.
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Plan of Correction
The Director of Ambulatory Services for WPIC shall ensure through the Clinical Administrator of WPIC Addiction Medicine Services, that through supervision and quality assurance chart review, that the aspects of medical history comprises a history documenting the client's personal medical history, family medical history, and history of illness and symptoms. The information will be gathered and recorded within the required time frame as identified by policy, which is by the end of the 3rd outpatient session, and by the end of the first week of partial services. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 11/15/08 and continuing through the course of the licensing review period. |
711.81(b)(3)(ii) LICENSURE D & A History
711.81. 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
Based on a review of four client records on September 3 through 4, 2008, the facility failed to document a drug and/or alcohol history within the time frames stipulated by facility policy and procedure in two of three client records where required.
Findings:
In client records #2 and 4 the drug and/or alcohol history was completed later than the fifth group session as required by the project's policies and procedures for drug and/or alcohol histories. The drug and/or alcohol history in client record #2 was to be completed by August 15, 2008, but was not completed until August 26, 2008. In client record #4 the drug and/or alcohol history was to be completed by July 18, 2008, but was not completed until August 28, 2008.
This is a repeat deficiency.
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Plan of Correction
The Director of Ambulatory Services for WPIC shall ensure through the Clinical Administrator of WPIC Addiction Medicine Services, through supervision and quality assurance chart review, that the aspect of D & A histories comprises a complete history including, but not limited to, progression of use related to lengths/patterns and prior treatment history. In addition the Clinical Administrator will ensure that the documentation of D & A histories is completed for each client, completed on time and contains required information as to be in accordance with agency policy. Furthermore the Clinical Administrator will ensure that the D & A history documentation is updated within specified time frames. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 11/15/08 and continuing through the course of the licensing review period. |
711.81(b)(3)(iii) LICENSURE Personal History
711.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of four client records on September 3 through 4, 2008, three were required to contain a personal history. The facility failed to document a personal history within the time frames stipulated in facility policy and procedure in two of three client records where required.
Findings:
In client records #2 and 4 the personal history was completed later than the fifth group session as required by the project's policies and procedures for personal histories. The personal history in client record #2 was to be completed by August 15, 2008, but was not completed until August 26, 2008. In client record #4 the personal history was to be completed by July 18, 2008, but was not completed until August 28, 2008.
This is a repeat deficiency.
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Plan of Correction
The Director of Ambulatory Services for WPIC shall ensure through the Clinical Administrator of WPIC Addiction Medicine Services, through supervision and quality assurance chart review, that the aspects of personal history comprises a history documenting the client's historical and pertinent personal data including: family, legal, employment/vocational, educational, military, recreational, sexual and others where appropriate. The information will be gathered and recorded within the required time frame as identified by policy, which is by the end of the 3rd outpatient session, and by the end of the first week of partial services. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 11/15/08 and continuing through the course of the licensing review period. |
711.81(b)(6) LICENSURE Psychosocial Evaluation
711.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of four client records on September 3 through 4, 2008, three were required to contain a psychosocial evaluation. The facility failed to document a psychosocial evaluation within the time frames stipulated by facility policy and procedure in three of three client records where required.
Findings:
In client records #2 and 4 the psychosocial evaluation was completed later than the fifth group session as required by the project's policies and procedures for psychosocial evaluations. The psychosocial evaluation in client record #2 was to be completed by August 15, 2008, but was not completed until August 26, 2008. In client record #4 the psychosocial evaluation was to be completed by July 18, 2008, but was not completed until August 28, 2008.
The psychosocial evaluations documented in client records #2, 4 and 9 did not represent the counselor's evaluation of the client, but rather was a listing of comments made by the clients. The psychosocial evaluation in client records #2, 4 and 9 were missing a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation. The potential or available support systems, the client's preferred coping mechanisms and the overall conclusions regarding the client's attitude toward and ability to participate in the treatment process were also missing from the evaluations.
This is a repeat deficiency.
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Plan of Correction
The Director of Ambulatory Services for WPIC shall ensure through the Clinical Administrator of WPIC Addiction Medicine Services, through supervision and quality assurance chart review, that the aspects of the psychosocial summary will be in compliance with licensing standards. The evaluation will provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions, and causes leading to the patient's current situation. The evaluation shall also include: A clear description of the client's presenting and underlying problems; Client needs or problems that can or cannot be resolved through treatment or that might inhibit treatment; Client assets, strengths or other factors that can contribute to the resolution of identified problems; The potential or available client support systems; Negative factors that might affect treatment; The client's preferred coping mechanisms; Conclusions regarding the client's appearance, behavior and reactions during the intake process; Conclusions regarding the client's attitude toward and ability to participate in the treatment process.
The information will be gathered and recorded within the required time frame as identified by policy, which is by the end of the 3rd outpatient session, and by the end of the first week of partial services. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 11/15/08 and continuing through the course of the licensing review period.
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711.81(b)(7) LICENSURE Preliminary Tx Plan
711.81. 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 four client records on September 3 through 4, 2008, three were required to contain a preliminary treatment and rehabilitation plan. The facility failed to document a preliminary treatment and rehabilitation plan within the time frames stipulated by facility policy and procedure in two of three records where required.
Findings:
In client records #2 and 4 the preliminary treatment and rehabilitation plan was completed later than the first individual session as required by the project's policies and procedures for preliminary treatment and rehabilitation plan.
In client record #2 the preliminary treatment and rehabilitation plan was due at the first individual session on August 11, 2008, but was not completed until August 26, 2008.
In client record #4 the preliminary treatment and rehabilitation plan was due at the first individual session on July 9, 2008, but was not completed until August 28, 2008.
This is a repeat deficiency.
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Plan of Correction
The Director of Ambulatory Services for WPIC shall ensure through the Clinical Administrator of WPIC Addiction Medicine Services, through supervision and quality assurance chart review, that the aspects of the preliminary treatment plan will be in compliance with licensing standards. The Preliminary Treatment Plan shall be based upon information derived from the initial interview, psychosocial and other evaluations. This plan should also identify critical client problems and strategies for their resolution. The information will be gathered and recorded within the required time frame as identified by policy, which is by the end of the 3rd outpatient session, and by the end of the first week of partial services. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 11/15/08 and continuing through the course of the licensing review period. |
711.82(c) LICENSURE Individualized Tx Plan
711.82. 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:
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Observations
Based on a review of four client records on September 3 through 4, 2008, three were required to contain an individual treatment and rehabilitation plan. The facility failed to document an individual treatment and rehabilitation plan within the timeframe stipulated by facility policy and procedure in one of three records where required.
Findings:
In client record #9 the individual treatment and rehabilitation plan was to be completed by the end of the fifth group session as required by the project's policies and procedures for individual treatment and rehabilitation plans. The client's fifth group session occurred the week of July 28, 2008. The individual treatment and rehabilitation was not documented as of September 4, 2008.
This is a repeat deficiency.
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Plan of Correction
The Director of Ambulatory Services for WPIC shall ensure that compliance to developing individualized treatment plans in timely fashion will be evidenced by periodic quality reviews by the Clinical Administrator of Addiction Medicine Services at WPIC, combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Training about the regulations and completion of treatment plans will occur in individual supervisory sessions conducted by the Clinical Administrator. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 11/15/08 and continuing through the course of the licensing review period. |
711.82(c)(1) LICENSURE Short/Long Term Goals
711.82. 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.
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Observations
Based on a review of four client records on September 3 through 4, 2008, three were required to contain short and long-term goals in the individual treatment and rehabilitation plan. The facility failed to document short and long-term goals for treatment, as formulated by both staff and client in one of three client records where required.
Findings:
The short and long term goals were not documented on the treatment plan in client record #9.
This is a repeat deficiency.
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Plan of Correction
The Director of Ambulatory Services for WPIC shall ensure that compliance to developing individualized treatment plans in timely fashion will be evidenced by periodic quality reviews by the Clinical Administrator combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Particular attention will be paid to the development of realistic and measurable short and long-term goals. Training about the regulations and completion of treatment plans will occur during individual supervisory sessions conducted by the Clinical Administrator. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 11/15/08 and continuing through the course of the licensing review period. |
711.82(c)(2) LICENSURE Type/Frequency of Treatment
711.82. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of four client records on September 3 through 4, 2008, three were required to contain the type and frequency of treatment in the individual treatment and rehabilitation plan. The facility failed to document the type and frequency of treatment in two of three client records where required.
Findings:
In client record #4 the frequency of treatment was not documented in the individual treatment and rehabilitation plan.
In client record #9 the type and frequency of treatment was not documented in the individual treatment and rehabilitation plan.
This is a repeat deficiency.
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Plan of Correction
The Director of Ambulatory Services for WPIC shall ensure through the Clinical Administrator of WPIC Addiction Medicine Services, through supervision and quality assurance chart review, that the treatment plans in the partial program shall include the frequency of individual, group, and family sessions. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 11/15/08 and continuing through the course of the licensing review period. |
711.82(c)(3) LICENSURE Support Service - Tx Plan
711.82. 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.
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Observations
Based on a review of four client records on September 3 through 4, 2008, three were required to contain proposed support services in the individual treatment and rehabilitation plan. The facility failed to document the proposed support services in two of three client records where required.
Findings:
In client records #4 and 9 the proposed support services were not documented in the individual treatment and rehabilitation plan.
This is a repeat deficiency.
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Plan of Correction
The Director of Ambulatory Services for WPIC shall ensure that compliance to developing individualized treatment plans in timely fashion will be evidenced by periodic quality reviews by the Clinical Administrator combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Training about the regulations and completion of treatment plans will occur in individual supervisory sessions conducted by the Clinical Administrator. Particular focus shall be placed upon including the patient's participation appropriate support services, including 12-step fellowships among other activities as part of the plan of recovery.
Program leadership will develop a resource manual that contains community resources and will be geared specifically to the issues experienced by individuals participating in the program. The manual will be available for staff use by 11/1/08. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later that 11/15/08 and continuing through the course of the licensing review period.
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711.82(d) LICENSURE Tx Plan Updates
711.82. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of four client records on September 3 through 4, 2008, two were required to contain treatment plan updates at least every 30 days. The facility failed to document individualized treatment plan updates in one of two client records where required.
Findings:
In client record #4 the treatment plan was completed on July 9, 2008. The individualized treatment plan update was to be completed by August 9, 2008. The update was not documented as of September 4, 2008.
This is a repeat deficiency.
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Plan of Correction
The Director of Ambulatory Services for WPIC shall ensure that compliance to developing individualized treatment plan updates in timely fashion will be evidenced by periodic quality reviews by the Clinical Administrator combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Training about the regulations and completion of treatment plan updates will occur in individual supervisory sessions conducted by the Clinical Administrator. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 11/15/08 and continuing through the course of the licensing review period. |
711.82(e) LICENSURE Provision of Services re: TX Plan
711.82. Treatment and rehabilitation services.
(e) 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 four client records on September 3 through 4, 2008, three were required to contain progress notes and records of services demonstrating that counseling services were provided according to the individual treatment and rehabilitation plan. The facility failed to demonstrate that counseling services were provided in accordance with the treatment plan in three of three client records where required.
Findings:
In client record #2 the individual treatment and rehabilitation plan indicated that counseling services were to be provided in the form of group therapy five times a week and individual therapy two times a week. Documentation in the progress notes and record of services indicated the client received one individual session for the week of August 25, 2008.
In client record #4 the individual treatment and rehabilitation plan indicated that counseling services were to be provided in the form of group therapy five times a week and individual therapy two times a week. Documentation in the progress notes and record of services indicated the client received four group therapy sessions and one individual session the week of July 14, 2008. In addition, the client received no treatment services the week of August 11, 2008.
In client record #9 the individual treatment and rehabilitation plan indicated that counseling services were to be provided in the form of group therapy five times a week and individual therapy two times a week. Documentation in the progress notes and record of services indicated the client received three group therapy sessions and one individual session the week of July 28, 2008, one group therapy session and one individual session the week of August 4, 2008, one group therapy session and one individual session the week of August 11, 2008 and one individual session the week of August 18, 2008.
This is a repeat deficiency.
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Plan of Correction
The Director of Ambulatory Services for WPIC shall ensure through the Clinical Administrator of WPIC Addiction Medicine Services, through supervision and quality assurance chart review, that a minimum of 2 individual sessions are provided on a weekly basis to all members of the partial program. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 11/15/08 and continuing through the course of the licensing review period. |
711.82(f)(1) LICENSURE Ind Counseling - 2X WK
711.82. Treatment and rehabilitation services.
(f) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of four client records reviewed September 3 through 4, 2008, three were required to contain documentation demonstrating the client received individual counseling at least twice weekly. The facility failed to demonstrate that individual counseling occurred at least twice weekly in three of three client records where required.
Findings:
In client record #2 the progress notes and record of services revealed the client received one individual session the week of August 25, 2008.
In client record #4 the progress notes and record of services revealed the client received one individual session the week of July 14, 2008.
In client record #9 the progress notes and record of services revealed the client received one individual session the weeks of July 28, August 4, August 11 and August 18, 2008.
This is a repeat deficiency.
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Plan of Correction
The Director of Ambulatory Services for WPIC shall ensure through the Clinical Administrator of WPIC Addiction Medicine Services, through supervision and quality assurance chart review, that a minimum of 2 individual sessions are provided on a weekly basis to all members of the partial program. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 11/15/08 and continuing through the course of the licensing review period. |
711.82(f)(2) LICENSURE Group Counseling - 2X WK
711.82. Treatment and rehabilitation services.
(f) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(2) Group counseling, at least twice weekly.
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Observations
Based on a review of four client records on September 3 through 4, 2008, three were required to contain documentation demonstrating the client received weekly group counseling in accordance with the facility's policy and procedure . The facility failed to demonstrate that weekly group counseling was provided in accordance with the facility's policy and procedure in two of three client records where required.
Findings:
In client records #4 and 9 the facility was to provide group therapy sessions to each client at least five times a week as required by the facility's policies and procedures for partial hospitalization.
In client record #4 the progress notes and record of services revealed the client received four group therapy sessions the week of July 14, 2008.
In client record #9 the progress notes and record of services revealed the client received three group therapy sessions the weeks of July 28, 2008 and one group therapy session each week for August 4 and August 11, 2008.
This is a repeat deficiency.
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Plan of Correction
The Director of Ambulatory Services for WPIC shall ensure through the Clinical Administrator of WPIC Addiction Medicine Services, through supervision and quality assurance chart review, that the number of group sessions agreed upon in the treatment plan are provided on a weekly basis to all members of the program. This would include the minimum of two group sessions to members of the partial program. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 11/15/08 and continuing through the course of the licensing review period. |
711.83(a)(4) LICENSURE Progress Notes
711.83. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(4) Progress notes.
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Observations
Based on a review of four client records on September 3 through 4, 2008, three were required to contain complete progress notes. The facility failed to document complete progress notes within stipulated timeframe in three of three client records where required.
Findings:
In client records #2, 4 and 9 the group progress notes did not include a comment relative to each individual's response or participation in the group session.
In client record #2 a number of progress notes were completed more than 24 hours after the treatment session, though facility policy and procedure requires progress notes be completed within 24 hours of the treatment session. Group sessions conducted on August 12, August 14, August 18, August 19, August 25 and August 26, 2008 were documented on August 26, August 28, August 28, August 26, September 2, September 2, and September 2, 2008, respectively.
This is a repeat deficiency.
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Plan of Correction
The Clinical Administrator of WPIC Addiction Medicine Services will ensure, through supervision and quality assurance chart review, that all clinical documentation within the patient record meet all licensing standards, as well as standards for best practices in clinical documentation. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 11/15/08 and continuing through the course of the licensing review period. |
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.
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Observations
Based on a review of twelve client records on September 3 through 4, 2008, six were required to contain a medical history. The facility failed to document a medical history within the timeframe stipulated by facility policy and procedure in five of six client records where required.
Findings:
In client records #5, 6 and 12 the medical history was completed later than the third individual session as required by the project's policies and procedures for medical histories.
Client record #5, the client's third individual session occurred on June 25, 2008, but the medical history was completed on June 30, 2008.
Client record #6, the client's third individual session occurred on August 12, 2008, but the medical history was completed on August 20, 2008.
Client record #12, the client's third individual session occurred on June 18, 2008, but the medical history was completed on June 26, 2008.
In client records #3 and 11 the medical history was not documented.
This is a repeat deficiency.
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Plan of Correction
The Director of Ambulatory Services for WPIC shall ensure through the Clinical Administrator of WPIC Addiction Medicine Services, that through supervision and quality assurance chart review, that the aspects of medical history comprises a history documenting the client's personal medical history, family medical history, and history of illness and symptoms. The information will be gathered and recorded within the required time frame as identified by policy, which is by the end of the 3rd outpatient session, and by the end of the first week of partial services. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 11/15/08 and continuing through the course of the licensing review period. |
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.
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Observations
Based on a review of twelve client records on September 3 through 4, 2008, six were required to contain a drug and/or alcohol history. The facility failed to document a drug and/or alcohol history within the timeframe stipulated by facility policy and procedure in five of six client records where required.
Findings:
In client records #5, 6 and 12 the drug and/or alcohol history was completed later than third individual session as required by the facility's policies and procedures for drug and/or alcohol histories.
Client record #5, the client's third individual session occurred on June 25, 2008, but the drug and/or alcohol history was completed on June 30, 2008.
Client record #6, the client's third individual session occurred on August 12, 2008, but the drug and/or alcohol history was completed on August 20, 2008.
Client record #12, the client's third individual session occurred on June 18, 2008, but the drug and/or alcohol history was completed on June 26, 2008.
In client records #3 and 11 the drug and/or alcohol history was not documented.
This is a repeat deficiency.
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Plan of Correction
The Director of Ambulatory Services for WPIC shall ensure through the Clinical Administrator of WPIC Addiction Medicine Services, through supervision and quality assurance chart review, that the aspect of D & A histories comprises a complete history including, but not limited to, progression of use related to lengths/patterns and prior treatment history. In addition the Clinical Administrator will ensure that the documentation of D & A histories is completed for each client, completed on time and contains required information as to be in accordance with agency policy. Furthermore the Clinical Administrator will ensure that the D & A history documentation is updated within specified time frames. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 11/15/08 and continuing through the course of the licensing review period. |
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.
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Observations
Based on a review of twelve client records on September 3 through 4, 2008, six were required to contain a personal history. The facility failed to document a personal history within the timeframe stipulated by facility policy and procedure in five of six records where required.
Findings:
In client records #5, 6 and 12 the personal history was completed later than third individual session as required by the facility's policies and procedures for personal histories.
Client record #5, the client's third individual session occurred on June 25, 2008, but the personal history was completed on June 30, 2008.
Client record #6, the client's third individual session occurred on August 12, 2008, but the personal history was completed on August 20, 2008.
Client record #12, the client's third individual session occurred on June 18, 2008, but the personal history was completed on June 26, 2008.
In client records #3 and 11 the personal history was not documented.
This is a repeat deficiency.
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Plan of Correction
The Director of Ambulatory Services for WPIC shall ensure through the Clinical Administrator of WPIC Addiction Medicine Services, through supervision and quality assurance chart review, that the aspects of personal history comprises a history documenting the client's historical and pertinent personal data including: family, legal, employment/vocational, educational, military, recreational, sexual and others where appropriate. The information will be gathered and recorded within the required time frame as identified by policy, which is by the end of the 3rd outpatient session, and by the end of the first week of partial services. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 11/15/08 and continuing through the course of the licensing review period. |
711.91(b)(4) LICENSURE Consent to Treatment
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of twelve client records on September 3 through 4, 2008, six were required to have a consent to treatment form signed by both the client and staff person at intake. The facility failed to have a consent to treatment form completed in two of six records where required.
Findings:
There was no documentation of consent to treatment forms in client records #11 and 12.
This is a repeat deficiency.
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Plan of Correction
The Director of Ambulatory Services for WPIC shall ensure through the Clinical Administrator of WPIC Addiction Medicine Services, through supervision and quality assurance chart review, that the consents utilized in addiction medicine programs include neither a signature line for parental consent, nor that parental consent is offered to the family of a minor who is seeking services at the program. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 11/15/08 and continuing through the course of the licensing review period. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of twelve client records on September 3 through 4, 2008, six were required to contain a psychosocial evaluation. The facility failed to document a psychosocial evaluation within the timeframe stipulated by facility policy and procedure in six of six client records where required.
Findings:
In client records #5, 6 and 12 the psychosocial evaluation was completed later than third individual session as required by the facility's policies and procedures for psychosocial evaluations.
Client record #5, the client's third individual session occurred on June 25, 2008, but the psychosocial evaluation was completed on June 30, 2008.
Client record #6, the client's third individual session occurred on August 12, 2008, but the psychosocial evaluation was completed on August 20, 2008.
Client record #12, the client's third individual session occurred on June 18, 2008, but the psychosocial evaluation was completed on June 26, 2008.
In client records #1, 6 and 12 the psychosocial evaluation was not based on the counselor's assessment of the client, but rather the clients' reported comments. The psychosocial evaluations were missing a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation.
In client records #3 and 11 the psychosocial evaluation was not documented.
This is a repeat deficiency.
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Plan of Correction
he Director of Ambulatory Services for WPIC shall ensure through the Clinical Administrator of WPIC Addiction Medicine Services, through supervision and quality assurance chart review, that the aspects of the psychosocial summary will be in compliance with licensing standards. The evaluation will provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions, and causes leading to the patient's current situation. The evaluation shall also include: A clear description of the client's presenting and underlying problems; Client needs or problems that can or cannot be resolved through treatment or that might inhibit treatment; Client assets, strengths or other factors that can contribute to the resolution of identified problems; The potential or available client support systems; Negative factors that might affect treatment; The client's preferred coping mechanisms; Conclusions regarding the client's appearance, behavior and reactions during the intake process; Conclusions regarding the client's attitude toward and ability to participate in the treatment process.
The information will be gathered and recorded within the required time frame as identified by policy, which is by the end of the 3rd outpatient session, and by the end of the first week of partial services. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 11/15/08 and continuing through the course of the licensing review period.
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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:
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Observations
Based on a review of nine client records on September 3 through 4, 2008, six were required to contain an individual treatment and rehabilitation plan. The facility failed to document an individual treatment and rehabilitation plan in two of six client records where required.
Findings:
In client records #5 and 11 the individual treatment and rehabilitation plan was not documented.
This is a repeat deficiency.
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Plan of Correction
The Director of Ambulatory Services for WPIC shall ensure that compliance to developing individualized treatment plans in timely fashion will be evidenced by periodic quality reviews by the Clinical Administrator of Addiction Medicine Services at WPIC, combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Training about the regulations and completion of treatment plans will occur in individual supervisory sessions conducted by the Clinical Administrator. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 11/15/08 and continuing through the course of the licensing review period. |
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.
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Observations
Based on a review of twelve client records on September 3 through 4, 2008, six were required to contain short and long-term goals in the individual treatment and rehabilitation plan. The facility failed to document individualized short and long-term goals for treatment, as formulated by both staff and client in six of six client records where required.
Findings:
In client records #1, 2, 6 and 12 the short and long-term goals in the individual treatment and rehabilitation plan were generic and identical. The goals stated were for the client to explore skills for dealing with substance use and for staying away from identified people, places and things. In addition, the client records had no documentation of the clients' histories and psychosocial evaluations prior to establishing the short and long-term goals in the individual treatment and rehabilitation plan as required by the facility's policies and procedures for short and long-term treatment goals.
In client records #5 and 11 the short and long-term goals were not documented.
This is a repeat deficiency.
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Plan of Correction
The Director of Ambulatory Services for WPIC shall ensure that compliance to developing individualized treatment plans in timely fashion will be evidenced by periodic quality reviews by the Clinical Administrator combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Particular attention will be paid to the development of realistic and measurable short and long-term goals. Training about the regulations and completion of treatment plans will occur during individual supervisory sessions conducted by the Clinical Administrator. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 11/15/08 and continuing through the course of the licensing review period. |
711.92(c)(2) LICENSURE Type & Frequency of TX
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of twelve client records on September 3 through 4, 2008, six were required to document the type and frequency of treatment in the individual treatment and rehabilitation plan. The facility failed to document the type and frequency of treatment in three of six client records where required.
Findings:
In client records #5, 6 and 11 the type and frequency of treatment was not documented in the individual treatment and rehabilitation plan.
This is a repeat deficiency.
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Plan of Correction
The Director of Ambulatory Services for WPIC shall ensure through the Clinical Administrator of WPIC Addiction Medicine Services, through supervision and quality assurance chart review, that the treatment plans in the partial program shall include the frequency of individual, group, and family sessions. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 11/15/08 and continuing through the course of the licensing review period. |
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.
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Observations
Based on a review of twelve client records on September 3 through 4, 2008, six were required to contain proposed support services in the individual treatment and rehabilitation plan. The facility failed to document proposed support services in four of six client records where required.
Findings:
In client records #1, 5, 6 and 11 the proposed support services in the individual treatment and rehabilitation plan were not documented.
This is a repeat deficiency.
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Plan of Correction
The Director of Ambulatory Services for WPIC shall ensure that compliance to developing individualized treatment plans in timely fashion will be evidenced by periodic quality reviews by the Clinical Administrator combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Training about the regulations and completion of treatment plans will occur in individual supervisory sessions conducted by the Clinical Administrator. Particular focus shall be placed upon including the patient's participation appropriate support services, including 12-step fellowships among other activities as part of the plan of recovery.
Program leadership will develop a resource manual that contains community resources and will be geared specifically to the issues experienced by individuals participating in the program. The manual will be available for staff use by 11/1/08. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later that 11/15/08 and continuing through the course of the licensing review period.
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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.
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Observations
Based on a review of twelve client records on September 3 through 4, 2008, six were required to contain a treatment and rehabilitation plan update. The facility failed to document a treatment and rehabilitation plan update within the timeframe stipulated by facility policy and procedure in five of six client records where required.
Findings:
In client records #3, 10, 11, 12 and 14 the treatment and rehabilitation plan updates were completed later than 60 days from the date of the established individual treatment and rehabilitation plan. In addition, the treatment and rehabilitation updates failed to document an assessment of the client's progress as it relates to the goals stated in the plan. There was no way to determine if goals were revised, treatment strategies or action steps were modified or if goals were achieved.
This is a repeat deficiency.
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Plan of Correction
The Director of Ambulatory Services for WPIC shall ensure that compliance to developing individualized treatment plans in timely fashion will be evidenced by periodic quality reviews by the Clinical Administrator combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Training about the regulations and completion of treatment plans will occur in individual supervisory sessions conducted by the Clinical Administrator. Particular focus shall be placed upon including the patient's participation appropriate support services, including 12-step fellowships among other activities as part of the plan of recovery.
Program leadership will develop a resource manual that contains community resources and will be geared specifically to the issues experienced by individuals participating in the program. The manual will be available for staff use by 11/1/08. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later that 11/15/08 and continuing through the course of the licensing review period.
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711.92(e) LICENSURE Provision of TX RE: TX Plan
711.92. Treatment and rehabilitation services.
(e) 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 twelve client records on September 3 through 4, 2008, the facility was required to provide counseling services according to the individual treatment and rehabilitation plan. The facility failed to assure that counseling services were provided in accordance with those treatment plans in five of nine client records where required.
Findings:
In client record #3 the client had not received any counseling services since August 12, 2008. There was no documentation in the client record indicating the reason.
In client record #5 the client had not received any counseling services since July 17, 2008. There was no documentation in the client record indicating the reason.
In client record #8 the client had not received any counseling services since August 8, 2008. There was no documentation in the client record indicating the reason.
In client record #10 the client had not received any counseling services between June 6, 2008 and August 7, 2008. There was no documentation in the client record indicating the reason.
In client record #11 the client had not received any counseling services between May 19, 2008 and July 24, 2008. There was no documentation in the client record indicating the reason.
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Plan of Correction
The Director of Ambulatory Services for WPIC shall ensure through the Clinical Administrator of WPIC Addiction Medicine Services, through supervision and quality assurance chart review, that a minimum of 2 individual sessions are provided on a weekly basis to all members of the partial program. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 11/15/08 and continuing through the course of the licensing review period. |
711.92(f) LICENSURE Couns. Prov.- Reg & Sched.
711.92. Treatment and rehabilitation services.
(f) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of twelve client records on September 3 through 4, 2008, the facility was required to provide counseling services to all clients on a regular and scheduled basis. The facility failed to assure that counseling services were provided on a regular and scheduled basis in five of nine client records where required.
Findings:
In client record #3 the client had not received any counseling services since August 12, 2008. There was no documentation in the client record indicating the reason.
In client record #5 the client had not received any counseling services since July 17, 2008. There was no documentation in the client record indicating the reason.
In client record #8 the client had not received any counseling services since August 8, 2008. There was no documentation in the client record indicating the reason.
In client record #10 the client had not received any counseling services between June 6, 2008 and August 7, 2008. There was no documentation in the client record indicating the reason.
In client record #11 the client had not received any counseling services between May 19, 2008 and July 24, 2008. There was no documentation in the client record indicating the reason.
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Plan of Correction
The Director of Ambulatory Services for WPIC shall ensure through the Clinical Administrator of WPIC Addiction Medicine Services, through supervision and quality assurance chart review, that a minimum of 2 individual sessions are provided on a weekly basis to all members of the partial program. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 11/15/08 and continuing through the course of the licensing review period. |
711.93(a)(4) LICENSURE Progress Notes
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(4) Progress notes.
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Observations
Based on a review of twelve client records on September 3 through 4, 2008, eight were required to contain complete progress notes. The facility failed to document complete progress notes in four of eight client records where required.
Findings:
In client records #3, 5, 10 and 14 the individual progress notes did not include the counselor's assessment based upon new and previous information, nor did they contain the counselor's analysis of the client's current situation or status. The progress notes did not include a plan for the next treatment session.
In client record #3 a number of progress notes were completed more than 24 hours after the treatment session, though facility policy and procedure require that progress notes be completed within 24 hours of the treatment session. Individual sessions conducted on July 29 and August 12, 2008 were not documented until August 4, 2008 and August 20, 2008, respectively.
In client record #14 a number of progress notes were completed more than 24 hours after the treatment session, though facility policy and procedure requires that progress notes be completed within 24 hours of the treatment session. Individual sessions conducted on May 27, June 17, June 26, July 10, August 7, August 14 and August 27, 2008 were not documented until June 10, June 24, July 1, July 18, August 26, August 28 and September 2, 2008, respectively.
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Plan of Correction
The Director of Ambulatory Services for WPIC shall ensure through the Clinical Administrator of WPIC Addiction Medicine Services, through supervision and quality assurance chart review, that all clinical documentation within the patient record meet all licensing standards, as well as standards for best practices in clinical documentation. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 11/15/08 and continuing through the course of the licensing review period. |
711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of twelve client records on September 3 through 4, 2008, one client record was required to contain an aftercare plan. The facility failed to document an aftercare plan in one of one client record where required.
Findings:
In client record #11 there was no documentation of the aftercare plan.
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Plan of Correction
The Director of Ambulatory Services for WPIC shall ensure that compliance will be evidenced by reviews of all files pending discharge for thoroughly completed Aftercare Plans when applicable during individual supervision by the Clinical Administrator. Reentry guidelines and contact procedures will be documented consistently when an Aftercare Plan is completed. Staff training about completion of Aftercare Plans will be provided by the Facility Director and Clinical Supervisors. This will be conveyed to staff by the Facility Director; and by the Clinical Supervisors at a staff meeting held by 11/15/08. The reviews and supervision will begin immediately. |
711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based on a review of twelve client records on September 3 through 4, 2008, two were required to contain follow-up information. The facility failed to document follow-up information in one of two client records where required.
Findings:
In client record #11 there was no documentation of follow-up information.
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Plan of Correction
The Director of Ambulatory Services for WPIC shall ensure through the Clinical Administrator of Addiction Medicine Services that each clinician pursues the act of follow-up contacts on each patient who is discharged from services. Staff training about completion of Aftercare Plans will be provided by the Facility Director and Clinical Supervisors. This will be conveyed to staff by the Facility Director; and by the Clinical Supervisors at a staff meeting held by 11/15/08. The reviews and supervision will begin immediately. |