INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 12, 2009 through January 14, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Aldie Foundation 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 and a plan of correction is due on February 14, 2009..
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records on January 13, 2009 the facility failed to make sure that all staff are trained for 6 hours in HIV/AIDS and at least 4 hours of TB/STD training in the required amount of time in two of nine records reviewed, #3 and 6. Findings:Employee # 3 was hired May 9, 2007 and was required to have HIV/AIDS training by May 9, 2008; employee #3 only received 4 hours of the required 6 hour credit for HIV/AIDS. Employee # 6 was hired December 8, 1999 and was required to have HIV/AIDS training by December 8, 2000; this was not documented in the personnel record reviewed.
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Plan of Correction
Aldie Office Manager, who executes the maintenance of staff training logs will maintain a spread sheet specific to the mandatory DOH trainings. Coordinators and applicable staff will be apprised of their training status on a quarterly basis. In addition the Quality Assurance Officer will post all training opportunities as they arise for all staff with specific attention given to the mandatory DOH trainings including the cited HIV/AIDS and TB/STD trainings. Current staff cited here have been advised of their current deficiency and were instructed to avail themselves of the next training opportunity for DOH approved HIV/AIDS training.
The Quality Assurance Officer will review all training logs semi annually to assure adherence to standards |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of the facilities fire drill record, the facility failed to document alternate exit routes used during fire drills.Findings:The fire drill record was reviewed on January 12, 2009. During the months of January 2008, February 2008, March 2008, April 2008, May 2008, June 2008, July 2008, August 2008, October 2008 and November 2008 fire drills records documented only one exit with no alternative exit routes identified.
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Plan of Correction
Quality Assurance Officer will train the Office Manager,responsible for the implementation of fire drills, in the Physical Plant standards for fire drills with specific attention to the use of alternate routes for exiting.
The Quality Assurance Officer will conduct quarterly checks of the emergency preparedness manual to insure compliance to this standard. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the facilities fire drill record, the facility failed to conduct fire drills on different times of the day and on different staffing shifts. Findings:The fire drill record was reviewed on January 12, 2009. Documentation of fire drills during the months of January 2008, February 2008, March 2008, April 2008, May 2008, June 2008, July 2008, August 2008, September, October 2008, November 2008 and December 2008 indicated the fire drills were conducted in the afternoon or the evening hours. There was no documentation of fire drills conducted during morning hours. The facility's hours of operation is Monday through Thursday 6:30 am to 9 pm, Friday 6:30 am to pm, Saturday 6:30 am to 11 am and Sunday 8 am to 10 am.
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Plan of Correction
The Quality Assurance Officer will train the Office Manager, responsible for the implementation of fire drills, in the physical plant standards, with soecific attention to conducting fire drills on different days of the week, different times of the day and on different staffing shifts. Attention will be paid in the future to include drills during morning hours in addition to the already documented afternoon and evening hour drills.
Quality Assurance Officer will conduct quarterly checks of the emergency preparedness manual to insure compliance to this standard. |
709.82(a)(1) LICENSURE Treatment and rehabilitation services
709.82. 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:
(1) Short- and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on the review of client records, the facility failed to document short and long-term goals in one client record.Findings:One client record was reviewed on January 14, 2009. Short and long-term goals were required in one client record. The facility did not document short and long-term goals with measurable action steps in client record #1.
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Plan of Correction
Further training will be provided to all clinicians by the Program Coordinators on writing treatment plans that contain short and long term goals and contain measurable action steps. Treatment Plans will be reviewed by the Program Coordinators prior to signature to insure adherence. The Compliance Officer will randomly monitor charts on a quarterly basis for adherence to this standard. |
709.82(a)(3) LICENSURE Treatment and rehabilitation services
709.82. 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:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to document support services in one client record.Findings:One client record was reviewed on January 14, 2009. Documentation of support services was required in one client record. The facility did not document support services in client record #1
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Plan of Correction
Further training will be provided to all clinicans by the Program Coordinators on the proper writing of treatment plans with specific attention to the inclusion and documentation of support services. Treatment plans will be reviewed by the Program Coordinator prior to signature to insure adherence. The Compliance officer will randomly monitor charts quarterly for adherence to this standard. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to document a complete treatment plan updates in one client record. Findings:One client record was reviewed on January 14, 2009. Treatment plan updates were required in one client record. Treatment plan updates failed to document the client's progress toward the stated goals of the treatment plan.
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Plan of Correction
Program Coordinators will provide aditional training to clinicians regarding the standards specific to treatment plan updates executed in a Partial Hospital level of care with specific attention given to required timeframes and the documentation of the client's progress toward each stated goal. Treatment plans moving forward will be reviewed and updated at least every 30 days and will clearly identify the clients progress in relationship to the stated goals in the previous treatment plan. The Program Coordinator will review treatment plans prior to signature to insure that the protocol is maintained. The Quality Assurance Officer will randomly review charts quarterly to insure compliance to these standards |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) 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 the review of client records, the facility failed to provide to a client on a regular and schedule basis individual counseling at least twice weekly in client record #1 Findings:One client record reviewed on January 14, 2009. Individual counseling was to be conducted at least twice weekly with client #1 who was admitted on 1/28/08. Record Documentation revealed the patient had one session weekly during the weeks of July 2, 2008, July 11, 2008, and June 12, 2008. During the months of April 2008 and May 2008 only two session were documented in each month. For the month of March 2008, only one session was documented and there were no documented counseling sessions in February 2008.
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Plan of Correction
Program Coordinators will provide additional training to all clinicans regarding the Partial Hospital Standards with specific attention to identifying the number of individual sessions required weekly. Moving forward all clients participating in a Partial Hospital level of care will receive two indivdual session per week on a regular and scheduled basis throughout their time in Partial Hospital. Coordinators will meet weekly with clinicians providing Partial Hospital Services to monitor the number and type of services being provided to insure adherence to standards.The Quality Assurance Officer will review Partial charts quarterly to assure compliance. |
709.82(d)(2) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) 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 the review of client records, the facility failed to provide documentation of regularly scheduled group counseling for client record #1. Findings:One client record reviewed on January 14, 2009. Group counseling was to be provided twice weekly with client # 1 who was admitted into treatment 1/28/08. Documentation revealed client # 1 received only one group counseling session during the weeks of May 27, 2008, May 16, 2008, and May 9, 2008, none for the week of April 28, 2008 through May 3, 2008, only one for the week of April 18, 2008, and only one for the week of April 4, 2008. There was no documentation of group counseling for patient #1 during the month of February 2008.
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Plan of Correction
Program Coordinators will provide additional training to all clinicans regarding the Partial Hospital Standards with specific attention to identifying that the number of group counseling sessions must be at least twice weekly in compliance with licensing standards for Partial Hospital.. Moving forward all clients participating in a Partial Hospital level of care will receive at minimum two group sessions per week on a regular and scheduled basis throughout their time in Partial Hospital. Coordinators will meet weekly with clinicians providing Partial Hospital Services to monitor the number and type of services being provided to insure adherence to standards.The Quality Assurance Officer will review Partial charts quarterly to assure compliance. |
709.83(a)(9) LICENSURE Client records
709.83. 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) Progress notes.
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Observations
Based on the review of client records, the facility failed to document progress notes in one client record.Findings:One client record was reviewed on January 14, 2009. Group progress notes were required in one client record. Client record # 1 contained group progress note that did not include data regarding the patient's involvement in the group as well as the counselor's assessment of the patient. Additionally, client record # 1 revealed documentation that was illegible and unreadable by the reviewer. Group progress notes were evidenced to have been copied rather than an original document.
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Plan of Correction
Further training will be provided to all clinicians by the Program Coordinators on the writing of progress notes. Specific attention will focus on the following: the timely execution of progress notes; the proper writing of a group note in a D.A. P. format which is individualized, documents participation in the data section; provides the therapists assessment within the assessment section; and indicates an individualized action plan in the final section. Staff will also be advised to produce individualized notes which are neither templated or copied. Additionally staff who are currently not utilizing electronic documentation, where applicable, will be provided with increased support to facilitate this transition. Coordinators will regularly monitor charting for legibility as part of their quarterly chart review. They will also monitor for any continued use of templating in notes. Individual staff identified as needing increased supervision in this area will receive enhanced supervision.
All clinicians will also utilize a check off system on their daily widgets to identify completion of all notes on a daily basis. Data techs will then monitir that all notes are included in the staff envelopes the next day and the office manager will weekly monitor that all notes are being filed in a timely manner.
The Quality Assurance Officer will randomly monitor charts quarterly for adherence to this standard. |
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 client records, the facility failed to complete psychosocial evaluations in eight of eight client records.Findings:Fifteen client records were reviewed on January 14, 2009. Psychosocial evaluations were required in eight client records. The psychosocial evaluations failed to document a clinical composite of the client to include identification of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, client attitude toward treatment and the counselor's impression of the client in client records #1, 2, 3, 5, 6 and 7. Also, client records #4 and 8 did not have documentation of psychosocial evaluations. In accordance with policy, the facility has 30 days from the date of admission to complete the psychosocial evaluations. Client record #4 was admitted on 11/25/08; there is no documentation of a psychosocial evaluation in the client record. Client record #8 was admitted on 7/29/08; there is no documentation of a psychosocial evaluation in the client record.
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Plan of Correction
Program coordinators will provide additional training on how to interpret factual information into a clinical analysis of the patients problems/needs,assets/strengths, support systems,coping mechanisms, negative factors, attitude toward treatment and overall impressions. A new document was also introduced which will better support this and staff have been oriented to its use.The psychosocial evaluation/clinical assessment will be reviewed by the Program Coordinator for adherence of a more clinical analysis rather than a historical documentation of the clients presentation prior to signature. Peer chart review will be conducted on a monthly basis. In addition, each clinician will now retain a spreadsheet/checklist which will track initial admit/intake date, psychosocial evaluation due dates and other key benchmarks in order to better track documentation due dates. The client spread sheet and client chart will be reviewed by the Program Coordinator and the clinician in individual supervision on a monthly basis to insure compliance to this standard.
Quarterly chart reviews will be conducted by the Program Coordinators and the Quality Assurance Officer to review for adherence to standards. |
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 the review of client records, the facility failed to document treatment plans in three of eight client records.Findings:Fifteen client records were reviewed on January 14, 2009. Treatment plans were required in eight client records. The facility did not document treatment plans in client records #1, 6 and 8. In accordance with the facility' policy and procedure, all treatment plans are to be developed within 30 days of admission. Client #1 was admitted on 10/31/08; there was no documentation of a treatment plan in the client record. Client #6 was admitted on 10/2/08; there was no there was no documentation of a treatment plan in the client record. Client #8 was admitted on 7/29/08; there was no there was no documentation of a treatment plan in the client record.
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Plan of Correction
Every client record will include treatment plan documentation within the timeframes identified within the standards. Each clinician will now retain a spreadsheet/checklist which will track initial admit/intake date, treatment plan due dates and other key benchmarks in order to better track documentation due dates. This client spreadsheet and cient charts will be reviewed by the Program Coordinator and the clinician in individual supervision on a monthly basis to insure compliance to this standard. Similarly the Quality Assurance Officer will randomly monitor charts quarterly for adherence to this standard. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on the review of client records, the facility failed to document short and long-term goals in three of eight client records.Findings:Fifteen client records were reviewed on January 14, 2009. Short and long-term goals were required in eight client records. The facility did not document short and long-term goals with measurable action steps in client records # 2, 3 and 4.
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Plan of Correction
Further training will be provided to all clinicians by the Program Coordinators on writing treatment plans that address both short term and long term goals and contain measurable action steps. Treatment plans will be reviewed by the Program Coordinator prior to signature to insure adherence. The Compliance Officer will randomly monitor charts for adherence to this standard. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to document support services in four of eight client records.Findings:Fifteen client records were reviewed on January 14, 2009. Documentation of support services were required in eight client records. The facility did not document support services in client records #1, 3, 6 and 8.
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Plan of Correction
Further training will be provided to all clinicians by the Program Coordinators on the proper writing of treatment plans with specific attention to the inclusion and documentation of support services. Treatment plans will be reviewed by the Program Coordinator prior to signature to insure adherence. The Compliance Officer will randomly monitor charts for adherence to this standard |
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 client records, the facility failed to document complete treatment plan updates in six of seven client records. Findings:Fifteen client records were reviewed on January 14, 2009. Treatment plan updates were required in seven client records. Treatment plan updates did not include the client's progress in relationship to the stated goals specific to each client's progress in treatment in records #2 and 5. Also, client records #1, 3, 6 and 8 did not contain documentation of treatment plan updates.
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Plan of Correction
Program Coordinators will provide additional training to clinicians regarding the standards specific to treatment plan updates executed in outpatient programming with specific attention given to required timeframes and the documentation of the clients progress toward each stated goal. Treatment plans moving forward will be reviewed and updated at least every 60 days and will clearly identify the clients progress in relationship to the stated goals in the previous treatment plan. The Program Coordinator will review treatment plans prior to signature to insure that the protocol is maintained. The Quality Assurance Officer will randomly review charts quarterly to insure compliance to these standards |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on the review of client records, the facility failed to document progress notes in five of eight client records.Findings:Fifteen client records were reviewed on January 14, 2009. Group progress notes were required in eight client records. The group progress notes did not have the data of the client's participation in group and an assessment of the client from the therapist in records #3, 4, 5, 7 and 8.
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Plan of Correction
Further training will be provided to clinicians by the Program Coordinators on the writing of progress notes. Specific attention will focus on both the timely execution of progress notes and the proper writing of a group note in D.A.P. format which is individualized , documents participation in the data section; provides the therapist's assessment within the assessment section; and indicates an individualized action plan in the final section. Also a check and balance system will be implemented to insure timeliness. All clinicians will utilize a check off system on their daily widgets to identify completion of all notes on a daily basis. Data techs will then monitor that all notes are included in the staff envelopes the next day and the Office Manager will weekly monitor that all notes are being filed in a timely manner. Quarterly chart reviews will be completed by Program Coordinators to insure compliance to this standard. Similarly the Compliance Officer will randomly monitor charts for adherence to thsi standard. |
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 the review of client records, the facility failed to document aftercare plans in six of six records.Findings:Fifteen client records were reviewed on January 14, 2009. Aftercare plans were required in six client records. Record #9 did not have documentation of an aftercare plan. Client record #9 was discharged on 9/3/08; there is no documentation of the aftercare plan in the client record. Client records #10, 11, 12 and 13 did not have time frames for goals identified and client record #12 did not have support services included in the aftercare plan.
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Plan of Correction
Further training will be provided to all clinicians by the Program Coordinators on the execution, inclusion and proper writing of aftercare plans as part of the discharge protocols with specific attention to the inclusion of support services and the identification of specific timeframes for the clients future goals. As a partof this training licensing standards 709.93(a) (9) will be reviewed with all clinicians specific to identifying that aftercare plans are not required where clients have left treatment against project advise and as such will not require an aftercare plan. Aftercare Plans will be reviewed with all discharge paperwork by the Program Coordinators prior to signature to insure adherence. The Compliance Officer will randomly monitor charts for adherence to this standard. |
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 six of six client records.Findings:Fifteen records were reviewed on January 14, 2009. Follow-up information was required in six client records. In accordance with facility's policy and procedure manual, the facility has 30 days to complete a follow-up for a client discharged without a referral. Client record #9 was discharged on 9/3/08 and the follow-up was conducted on 10/30/08. Client record #10 was discharged on 10/8/08 and the follow-up was conducted on 12/22/08. Client record #11 was discharged on 9/26/08 and the follow-up was conducted on 12/26/08. Client record #12 was discharged on 9/29/08 and the follow-up was conducted on 1/13/09. Client record #13 was discharged on 7/14/08 and the follow-up was conducted on 11/26/08. Client record #14 was discharged on 9/5/08 and the follow-up was conducted on 12/22/08.
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Plan of Correction
The Quality Assurance Officer will provide training to staff responsible for the execution of discharge follow up with specific attention to the adherence to identified timeframe standards. The Quality Assurance Officer will then conduct a quarterly review of discharged charts to insure that follow up is being completed within 30 days. |