INITIAL COMMENTS
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This report is a result of an on-site inspection to follow up on a 'Notice of Intent To Issue Order to Show Cause' conducted on October 2 through 4, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Services of Beaver Valley 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 November 6, 2007.
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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 administrative and training documentation it was determined that the facility failed to document HIV/AIDS training for employees #3 and 4 within two years of their employment dates.
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Plan of Correction
The project was not in compliance with the standard because one employee's training history did not have a proper certificate; the second person was out of compliance because her HIV/Aids training was issued in Ohio (employees # 3&4).
Both employees are registered to receive the required HIV/Aids training on January 15, 2008. (Note: an earlier training on Nov. 14, 2007, was full and they couldn't register for this
training.)
The Operations Manager will monitor all employees' attendance at required trainings and will take appropriate action to ensure compliance with this standard.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of administrative and training documentation it was determined that the facility failed to ensure that employees # 1 and 7 obtained the mandatory 25 hours of training for counselors during the previous training year.
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Plan of Correction
The project was not in compliance because employees # 1 & 7 did not attend the required 25 hours of training in the last calendar year.
After reviewing all employees' training plan for our training year (July 1- June 30), all training plans were rewritten to ensure required training hours were reflected in each plan. All employees were required to sign their revised individual training plan.
The Clinical Supervisor will monitor the attendance of all clinicians and the operations manager will monitor all non-clinical personnel's attendance in order to ensure full compliance.
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709.22(c)(1) LICENSURE Governing Body
709.22. Governing body.
(c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:
(1) A method of selection for membership.
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Observations
Based on a review of the corporate By Laws for this not for profit, charitable organization it was determined that the corporate board of directors failed to comply with Section 4.2 of the By Laws pertaining to membership on the board of directors. Section 4.2 of the corporate By Laws establishes a limit of two consecutive three year terms per board member. A review of the current board members revealed that six current members have exceeded the two term limit. One board member is in his sixth consecutive term. The current board president and one other member are in their fifth consecutive term. The former board president is in his fourth consecutive term and two others are in their third consecutive terms.
Section 4.3 of the corporate By Laws states "...no person will be permitted to serve on the Board of Directors who has a relative employed by this agency...". One board member had served on the board, during the year in review, while his son was a full time employee of the corporation.
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Plan of Correction
On August 15 when the current Director was hired, the existing Board of Directors was out of compliance with the project's bylaws: "A review of the current board members revealed that six current members have exceeded the two term limit."
The Project Director responded to learning of this deficiency by requesting and receiving the resignations of 5 members of the Board of Directots (October 15th, 2007). The final resignation will be received on November 19, 2007, and the BOD will be in compliance at that time. (In order to have a quorum --necessary to function, it was essential to retain one non-compliant member of the BOD until this next meeting when another member had been replaced.) The Project Director is responsible for seeing that the BOD is in compliance in future. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the policy and procedures manual it was determined that the written procedures for the management of treatment/rehabilitation services for clients was incomplete. The written procedures were missing procedures for the preliminary treatment plans; treatment plan updates; medication records; records of services; referral contacts; progress notes; client related correspondence; case consultations; aftercare planning and discharge summaries.
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Plan of Correction
In reviewing the DASBV Policies and Procedures Manual, licensing staff noted that the written procedures for the management of treatment and rehabilitation were incomplete; specifically missing procedures for many aspects of patient care. (709.24)
The Project Director is in the process of rewriting the policies and reestablishing procedures for carrying out the policies.
The project will be in compliance with the standard on 11/15/2007.
The mechanisms for coming into compliance include: 1)examining and rewritng the P&P manual, creating documentation that drives the procedures, training the staff to carry out the procedures correctly and supervising the changes to confirm that they are carried out correctly.
The Project Director bears final responsibility for the process and has created an administrative team to supervise and follow-up on the changes. Various members of the DASBV staff meet several times a week to review and follow up on the new processes. |
709.26(a)(11) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(11) Employe accidents and safety.
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Observations
Based on a review of of the policy and procedure manual it was determined that the facility failed to include policy and procedure for reporting unsafe conditions that would impact on physical plant safety.
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Plan of Correction
709.26 (a)(11) Licensure staff found that the P&P Manual failed to include policy and procedure for reporting unsafe conditions that would impact on physical plant safety.
Remediation of this problem includes:
1) The Project Director has rewritten the policy.
2)The rewritten policy includes a procedure for instructing all DASBV staff that if any staff member sees an unsafe condition to report it immediately to the Operations Manager. If the Operations Mangager is out of the building the report should be made to the Project Director or the Clinical Supervisor.
3)It is the responsibility of the Operations Manager to investigate any unsafe condition and report it to the Project Director immediately if possible and minimally within 24 hours. It is the responsibility of the Operations Manager to develop a plan to correct the situation within 24 hours with the help and supervision of the Project Director.
4) Staff have been notified of this policy by email, by memo, and in staff meetings.
The project is in compliance as of today (11/2/2007). |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of facility documentation it was determined that the facility failed to make appropriate use of the Qualified Service Organization Agreements (QSOA) with other entities. The facility had executed QSOA forms with schools, other treatment facilities, insurance companies, criminal justice entities and the single county authority. Releases of information are required for releases to any of these entities and the use of QSOA documents instead of releases of information would be contrary to the regulations.
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Plan of Correction
Department staff determined that the facility failed to make appropriate use of the Qualified Service Organization Agreements, utilizing QSOAs instead of releases of information in inappropriate situations.
The project will be in compliance no later than November 15, 2007.
The DASBV policy and procedures manual now states:
All project staff are responsible for the protection of client confidentiality.
Any request for information that involves a specific client requires a Release of Information.
No staff member should use any Release of Information or other document regarding client privacy without review by the Clinical Supervisor or the Project Director or both.
Maintenance of client records in the direct responsibility of counselors. Supervision of counselors is the responsibility of the Clinical Supervisor, who is in turn supervised by the Project Director.
In order to come into compliance, the Project Director has instructed staff as to the appropriate use of Releases of Information and is responsible for follow-up. The Project Director has instructed staff that for the next 60 days, no documents relative to confidentiality (releases, contracts, QSOAs) should be utilized without review by the Operations Manager or the Clinical Supervisor and the Project Director. Following this process will insure that confidentiality is protected and that every staff person is monitored until the standard is well understood.
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709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records it was determined that the facility failed to ensure that informed and voluntary consents to release information were consistently executed. The consent to release information forms documented in client records # 1, 2, 3, 4, 5, 6, 9, 10, 11, 12, 13, 14 and 15 failed to include the specific information that was to be released, the purpose for the release of information and some did not include who was to be the recipient of the information.
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Plan of Correction
DOH Staff found that DASBV failed to ensure that informed and voluntary consents to release information were consistently executed.
DASBV will be in compliance no later than 11/15/2007.
The Project Director is responsible for bringing the agency into compliance with the confidentiality regulations and ensuring compliance into the future.
The policy manual now states:
The project will obtain an informed and voluntary consent from the client for the
disclosure of information contained in the client record. The consent shall be in writing
and include
(1) Name of the person, agency or organization to whom disclosure is made.
(2) Specific information disclosed.
(3) Purpose of disclosure.
(4) Dated signature of client or guardian.
(5) Dated signature of witness.
(6) Expiration date of the consent (reflecting the date, time event or condition under which the consent expires.
The procedure for insuring compliance is as follows:
1) The Release of Information form has been rewritten to make the specifics of the content of the disclosure more clear.
2) The Project Director has instructed staff as to the appropriate content of Releases of Information and has instructed staff that for the next 60 days, no releases should be used without review by the Operations Manager or the Clinical Supervisor and the Project Director. Following this process will insure that confidentiality is protected and that every staff person is monitored until the standard is well understood.
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709.28(c)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records it was determined that several client records contained consent to release information forms that were missing the specific information to be disclosed. Client records # 1, 2, 3, 4, 9, 10, 11, 12, 13, 14 and 15 contained consent to release information forms that failed to include the specific information that would be released.
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Plan of Correction
The licensing staff found that client records contained consents that were missing the specific information to be disclosed.
DASBV will be in compliance no later than 11/15/2007.
The Project Director is responsible for bring the agency into compliance with the confidentiality regulations. The Clinical Supervisor will assist the Director in monitoring releases of information to see that the specific information to be disclosed is clear and accurate.
The procedure for insuring compliance is as follows:
1) The Release of Information form has been rewritten to make the specific information to be disclosed more clear.
2) The Project Director has instructed staff as to the appropriate content of Releases of Information. 3) For the next 60 days, no releases should be used without review by the Operations Manager or the Clinical Supervisor AND the Project Director. Following this process will insure that confidentiality is protected and that every staff person is monitored until the standard is well understood.
After that time, the Clinical Supervisor will continue to review releases for accuracy and the protection of confidentiality. The agency has also set up a procedure for regular chart review that is in addition to the review by the Clinical Supervisor
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709.28(c)(3) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records it was determined that the facility failed to ensure that the consent to release information documents always included the purpose for the release of information. The purpose for the release of information listed on the consent to release information forms in client records # 1, 2, 3, 4, 11, 12 and 13 was either missing or was inconsistent with the function of the recipient of the information.
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Plan of Correction
The licensing staff found that client records contained consents that did not always included the purpose of the disclosure or in some cases included a purpose tht was inconsistent with the fuctions of the recipient of the information.
DASBV will be in compliance no later than 11/15/2007.
The Project Director is responsible for bring the agency into compliance with the confidentiality regulations. The Clinical Supervisor will assist the Director in monitoring releases of information to see that the purpose of the disclosure is clear and accurate.
The procedure for insuring compliance is as follows:
1) The Release of Information form has been rewritten to make the purpose of the disclosure more clear.
2) The Project Director has instructed staff as to the appropriate content of Releases of Information and has instructed staff that for the next 60 days, no releases should be used without review by the Operations Manager or the Clinical Supervisor and the Project Director. In this case the counselors and reviewers are to ensure that the purpose of the disclosure is consistent with the tasks/needs of the recipeint of the disclosure. Following this process will insure that confidentiality is protected and that every staff person is monitored until the standard is well understood.
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709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
Based on the work done over the period of this inspection it was determined that the electronic data collection and record-keeping system did not allow for the efficient retrieval of data. Information provided during the inspection was not always accurate and was not separate from data that belonged to the private practice of the former director. Accurate census counts were difficult to obtain.
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Plan of Correction
709.31 (b)
Uniform Data Collection System
Licensing staff found that the clinical information system had records of the former director and there was concern that the private practice patients were intermixed with DASBV patients, making accurate census information difficult to obtain.
The project is in compliance as of 11/2/2007.
The responsibility for correcting this deficiency rests with the Project Director. The primary staff person who monitors the UCDS is the records manager and billing specialist; this person's work is monitored by the director.
DASBV staff who work with the UCDS have purged the system of all patients associated with the former director and have taken process steps to insure that the information put into the system accurately reflects all of the work we are currently doing. The project director and DASBV staff have sought technical assistance in order to do the above and will continue to monitor and improve data collection.
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709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records it was determined that the facility failed to document the disclosure of the criteria for admission, treatment, completion and discharge in client records # 2, 4, 5, 6, and 7. Some of the elements were missing in client records # 9, 10, 11, 12, 13, 14 and 15.
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Plan of Correction
709.91(b) Intake and Admission
Licensing specialists found that DASBV failed to document the disclosure of the criteria for admission, treatment, completion and discharge in client records.
We will be in compliance no later than 11/15/2007.
Intake and counseling staff are responsible for communicating admission, treatment, completion and discharge criteria to clients. They have been given the means to do so more accurately by new patient information materials. The intake process itself is documented in part by means of a patient and staff sign off checklist.
DASBV began a new intake process (designed to get clients to treatment more quickly) on November 1, 2007. The new process includes daily chart review and staff discussions which allows the administrative team to follow up on the new process and on the documentation of same.
The administrative team (Operations Manager, Lead Counselor, Clinical Supervisor and Director)is responsible for the follow-up supervision. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records it was determined that the facility failed to document the clients orientation to project policies in client records # 2, 4, 5, 6, 7, 9, 10, 11, 12, 13, 14 and 15.
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Plan of Correction
709.91(b) (2)(i)
Licensing specialists found that DASBV failed to document orientation to the project which includes familiarization with project policies.
The project will be in compliance by November 15, 2007
The Clinical Supervisor is responsible for ensuring that staff counselors orient patients to the project and document that they have done so. The Project Director is responsible for setting the policy and following up to see that it is carried out.
The project instituted a new intake procedure on November 1, 2007 which is being very closely followed. The process includes new patient information and other documents as well as new procedures designed to facilitate the orientation of the patient to the project policies and treatment.
The new process is monitored through daily chart review and staff discussions to ensure that the changes are taking place. We expect to have the new process well in hand and to be compliant within two weeks.
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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
Based on a review of client records it was determined that the facility failed to include the lengths and patterns of abuse as it relates to the progression of use and the client's perception of the impact of substance abuse in client records #1, 2, 3, 4, 9, 10, 13, 14 and 15.
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Plan of Correction
Department staff found "that the facility failed [in the patient history] to include the lengths and patterns of abuse as it relates to the progression of use and the client's perception of the impact of substance abuse in client records."
The Project Director and staff have developed a new Psychosocial Evaluation (including a patient history) based on the BDAP regulations and drafted from a psychosocial used in another Pennsylvania D&A program. This evaluation has 2 plus pages which inquire as to the lengths and patterns of abuse as well as the client's perception of the impact of substance abuse on his or her life. The new evaluation was put into place on November 1, 2007.
The administrative team is performing chart review daily in order to immediately address any failures in documentation on the part of the clinical staff.
Long-term goal is for the Clinical Supervisor to review charts regularly to ensure clinical quality. The Project Director is responsible for ensuring that this occurs. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. 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 client records it was determined that the facility failed to provide for complete personal histories. The personal history was missing from client record #1. The personal histories were incomplete in client records #2, 3, 5, 9, 10, 12 and 15, having incomplete family, legal and employment histories and missing educational, military, sexual and recreational histories.
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Plan of Correction
Licensing Staff found incomplete personal histories missing categories such as family history, legal, educational and military history among others.
Our plan for remediation is as follow:
1)The Project Director and staff have designed a new psychosocial evaluation based on BDAP and DOH Licensure requirements and drawn from agencies where the psychosocial has been reviewed and found satisfactory. This was introduced for use on November 1, 2007.
2) The clinical staff has been challenged to provide better documentation and in order to do that the staff has been provided with a copy of the PA DOH Client Record Keeping Outline. Staff is reminded daily that they are to review their charting by comparing it to what is requested in the DOH outline.
3) The administrative team is conducting daily chart review in order to ensure that the documentation is brought to a higher standard.
4) The Clinical Supervisor is directly responsible for clinical care and charting, and she is supervised by the Project Director. Short-term the Clinical Supervisor is being provided with additional support by the administrative team so that every client session is reviewed every day. In this way we are able to train the staff very directly in real time.
We will be in compliance by November 15, 2007.
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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
Based on a review of client records it was determined that the facility failed to provide for complete and evaluative psychosocial evaluations in all the records reviewed. The psychosocial evaluation was missing from client record #1. The psychosocial evaluation was incomplete and non-evaluative in client records # 2, 3, 5, 9, 10, 12 and 15, with incomplete composite pictures, support systems and coping mechanisms.
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Plan of Correction
Again, department staff found incomplete psychosocial evaluations in a large number of records.
1)The Project Director and staff have designed a new psychosocial evaluation based on BDAP and DOH Licensure requirements and drawn from agencies where the psychosocial has been reviewed and found satisfactory. This was introduced for use on November 1, 2007.
2) Clinical staff have been provided with materials which explain how to document accurately and completely.
3) We are attempting to train the staff to raise the quality of their charting by giving them immediate feedback on a daily basis. For that reason the administrative team is conducting daily chart review.
4) The Clinical Supervisor is directly responsible for clinical care and charting, and she is supervised by the Project Director. Short-term the Clinical Supervisor is being provided with additional support by the administrative team so that every client session is reviewed every day.
We will be in compliance by November 15, 2007.
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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 a review of client records it was determined that the facility failed to provide for individualized treatment plan goals that were realistic and measurable. The treatment plan goals and objectives were not individualized in client records # 1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13, 14 and 15. Treatment plan objectives were missing in client records # 1, 10, 11 and 12.
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Plan of Correction
709.92 a 1
Treatment Plan
Department staff found that DASBV failed to provide for individual treatment plans that were realistic and measurable.
The plan for coming into compliance includes:
1) The Project Director has designed a new treatment plan designed to provide better documentation of treatment planning. The new treatment plan was brought into service on 11/12007.
2) Clinical staff have been provided with a DOH outline for developing and documenting treatment plans.
3) The staff is being trained through direct and immediate supervision of each client's treatment plan as soon as it is in development so that feedback is immediate and corrections can be completed that day.
4) The Clinical Supervisor is directly responsible for treatment planning and is supervised in that regard by the Project Director.
5) Short term the Clinical Supervisor is part of an administrative team that is focused on improving documentation dramatically and quickly.
DASBV will be in full compliance by 11/15/2007.
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709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records it was determined that the facility failed to include the type and frequency of treatment and rehabilitation services on the treatment plans in client records #1, 2, 10, 11 and 12.
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Plan of Correction
709.92 (a)(2) Type and Frequency of Rehabilitation Services
The plan for coming into compliance includes:
1) The Project Director has designed a new treatment plan that has a section that specifically asks for type and frequency of treatment. The new treatment plan was brought into service on 11/1/2007.
2) The staff is being trained through direct and immediate supervision of each client's treatment plan as soon as it is in development so that feedback is immediate and corrections can be completed that day.
3) The Clinical Supervisor is directly responsible for treatment planning and is supervised in that regard by the Project Director.
4) Short term the Clinical Supervisor is part of an administrative team that is focused on improving documentation dramatically and quickly.
DASBV will be in full compliance in this regard by 11/15/2007
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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 it was determined that the facility failed to ensure that the treatment plan updates included an assessment of the client's progress or lack of progress on the previously stated goals in client record #4, 12, 13 and 15, which represents four of four client records reviewed where the treatment plan update was due.
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Plan of Correction
709.92 (b)
The Department of Licensure staff found that treatment plan updates did not include an assessment of the client's progress of lack thereof with previously stated treatment goals.
The plan for coming into compliance includes:
1) The Project Director has designed a new treatment plan with a section that asks for progress on previous treatment goals. The new treatment plan was brought into service on 11/1/2007.
2) As with the rest of the chart, the administrative team is reviewing drafts of treatment plans as they are written in order to be able to respond immediately to poor documentation. We are essentially re-training the staff to document more accurately and well in real time.
3)We also meet weekly with all of the Clinical Staff to discuss documentation as a group.
4) Long-term responsibility for clinical documentation rests with the Clinical Supervisor with overall responsibility residing with the Project Director.
We expect to be in full compliance by 11/15/2007 |
709.93(a) 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:
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Observations
Based on a review of client records it was determined that the facility failed to ensure that complete client records were maintained. Treatment plans were missing in client records # 1, 10, 11 and 12. A personal history was missing in client record #1. Client related correspondence was missing from client records # 1, 4, 10, 11 and 12. A record of service was missing in client record #1 and follow up documentation was missing in client record #8.
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Plan of Correction
709.93 (a) Complete client record
Department staff found that DASBV failed to ensure that complete client records were maintained.
We will be in compliance on 11/15/2007.
The plan for correction includes:
1) Regular communication with the DASBV staff that their documentation has not met the standard of quality rightfully required by licensing. (This has already begun.)
2) Instruction as to proper documentation. This has begun.
3) Program documents that support effective and accurate documentation. These are being developed.
4) Regular supervision to ensure proper documentation. The process of daily review by a team of readers began on November 1, 2007 to provide immediate feedback and correction.
5) Long-term, the responsibility for supervising treatment and documentation lies with the Clinical Supervisor and the Project Director.
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709.93(a)(2) 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:
(2) Medication records.
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Observations
Based on a review of client records it was determined that medication records were incomplete in four of six client records where required. Client records # 3, 8, 9 and 12 were missing the dosage and frequency of use of the medications listed.
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Plan of Correction
709.93 (a)(2)
Medication Records were found to be incomplete in four of six client records.
The plan of correction includes:
1) The creation of a medication record that speaks to regulations as to medication, dosage, and frequency.
2) Instruction to staff about the correct use of the medication record and its' importance (for example in an emergency).
3) Regular review of charting to ensure that medication records are done correctly.
4) The Clinical Supervisor is responsible for reviewing medication records.
5) The Project Director is responsible for supervising the Clinical Supervisor.
DASBV will be in compliance by 11/15/2007
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709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of client records it was determined that six of thirteen client records reviewed had incomplete records of service. The facility failed to indicate who provided the service on the records of service found in client records # 1, 2, 3, 4, 6 and 9.
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Plan of Correction
709.93 (a)
Record of services. "Based on a review of client records, it was determined that the six of thirteen records reviewed has incomplete records of service"
Plan of Correction is as follows:
1) DASBV has created a new document to record services which has specific sections for the date, units provided, counselor initials, description of service and client signature.
2) We began using the new Record of Service on November 1, 2007.
3) We are instructing counselors as to how to use the new document in email and weekly clinical team meetings as well as daily direct supervision of charting.
4) We are reviewing the new document in our daily chart reviews, which is the most direct form of instruction and review.
5) The Clinical Supervisor is responsible for ensuring that the charts are complete and accurate. The Project Director is responsible for supervising and assisting the Clinical Supervisor in this regard.
6) We will be in compliance by November 15, 2007.
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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 a review of client records it was determined that the facility failed to provide for complete progress notes in 10 of 14 client records reviewed. The progress notes in client records 2, 3, 4, 11 and 12 did not include plans for the next treatment session. The progress notes in client records #1, 2, 3, 4, 6, 13 and 14 did not provide for data, assessment and plans and were brief, failing to describe the treatment provided during the session.
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Plan of Correction
709.93 (a) (5) Progress Notes
Department of D&A Program Licensure staff found that "the facility failed to provide for complete progress notes and that the DAP format is not used."
The Plan of Correction is as follows:
1) The Project Director has created a new document for progress notes which spells out the DAP format as well as content of DAP.
2) We began using the new Progress Note on 11/1/07.
3) We are instructing counselors on writing a more comprehensive note in the DAP format in team meetings and in daily chart review. We have provided the DOH Record Keeping Outline as a reference for each counselor.
4) The Clinical Supervisor is responsible for ensuring that Progress Notes are in the proper format and contain enough information to describe the treatment more accurately. The Project Director is responsible for backing up the Clinical Supervisor and for communicating project expectations with respect to the provision and documentation of treatment.
5) We will be in compliance on November 15, 2007
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709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records it was determined that the facility failed to ensure that aftercare plans were complete in 2 of the 3 client records reviewed where they were required. The criteria for re entry and the aftercare goals were missing in client records #7 and 9. The aftercare goals were not measurable in client records #7, 9 and 14.
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Plan of Correction
709.93 (a) Aftercare Plans
Department of Health found that the facility failed to ensure that aftercare plans were complete in client records reviewed.
The plan to rectify this deficiency is as follows:
1) DASBV has drafted a new Aftercare Plan document.
2) The document is under review by all staff and will be completed by 11/9/07.
3) The counselors will be provided with the DOH Outline for Client Record Keeping and other materials which address aftercare planning and documentation.
4) The issue of aftercare planning and documentation is being addressed in weekly clinical meetings and in-service training.
5) The charts are being reviewed daily by the Clinical Supervisor, the Operations Manager, the Lead Counselor and the Project Director in order to address deficiencies in real time and amend them immediately.
6) Long-term, the Clinical Supervisor and Lead Counselors are responsible for chart review and accuracy.
7) The Project Director supervises the Lead Counselor and the Clinical Supervisor.
8) We will be in compliance by 11/31/2007.
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records it was determined that the facility failed to include the reasons for treatment and the client's response to treatment on the discharge summaries documented in client records # 6, 8 and 9. The response to treatment documented in the discharge summaries in client record # 14 and 15 did not describe the treatment provided to those clients.
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Plan of Correction
709.93 (a) (10)
Discharge Summaries
Licensure staff found that the facility failed to provide complete discharge summaries;several summaries were lacking information about the reason for treatment, response to treatment and description of treatment provided.
The plan of compliance is as follows:
1) Project Director has created a new Discharge Summary.
2) The new Discharge Summary is being used as of 11/1/2007.
3) The counselors will be provided with the DOH Outline for Client Record Keeping and other materials which address aftercare planning and documentation.
4) The issue of documentation is being addressed in weekly clinical meetings and in-service training.
5) The charts are being reviewed daily by the Clinical Supervisor, the Operations Manager, the Lead Counselor and the Project Director in order to address deficiencies in real time and amend them immediately.
6) Long-term, the Clinical Supervisor and Lead Counselors are responsible for chart review and accuracy.
7) The Project Director supervises the Lead Counselor and the Clinical Supervisor.
8) We will be in compliance by 11/24/2007.
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