INITIAL COMMENTS
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This report is a result of a supervisory review of the written report of the findings of an on-site licensure renewal inspection that was conducted on February 7, 2014 and February 10, 2014, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the supervisory review of findings from the on-site inspection, ADAPPT Outpatient Treatment 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 supervisory review.
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Plan of Correction
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document the instruction of staff in the use of a fire extinguisher upon staff employment, in one of one personnel records reviewed.
The findings included:
Three personnel records were reviewed. One record as for newly hired staff and required documentation that fire extinguisher training had been provided in accordance with the standard. The facility failed to document the completion of fire extinguisher training upon employment in personnel records # 6.
Employee # 6 was hired on July 8, 2013. The training was not documented until July 18, 2013.
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Plan of Correction
The H. R. Specialist/desginee and Training Coordinator shall ensure that all new hires receive "fire extinguisher" training within seven days of employment.
The H.R. Specialist/designee and Training Coordinator shall meet on a weekly basis to ensure and coordinate the timely occurrence of trainings.
A certificate of completed "fire extinguisher" training shall be placed in the individual's training file. |
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 upon a review of client records, the facility failed to document a psychosocial evaluation that included an assessment of the client's problems/needs, coping mechanisms, negative factors and the client's attitude toward treatment in three of three records.
The findings included:
Four client records were reviewed during the on-site inspection. Three records were reviewed for psychosocial evaluations, 9, 10 and 11.
Client # 9 was admitted on October 30, 2013. The psychosocial evaluation dated October 30, 2013, failed to document an assessment by the counselor that included the client's problems/needs, negative factors and the client's attitude toward treatment. The documentation did not include an evaluation by the clinician for the required components.
Client # 10 was admitted on October 30, 2013. The psychosocial evaluation had a date typed on the form with no signature so the date of documentation could not be verified. Additionally, the psychosocial evaluation failed to document an assessment by the counselor that included the client's coping mechanisms and negative factors that may impact treatment. The documentation did not include an evaluation by the clinician for the required components.
Client # 11 was admitted on January 22, 2014. The psychosocial evaluation dated January 22, 2014, failed to document an assessment by the counselor that included the client's coping mechanisms and negative factors that may impact treatment. The documentation did not include an evaluation by the clinician for the required components.
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Plan of Correction
Train and refresh staff in developing psychosocial evaulations that contain all the elements specified by DDAP regulations.
Provide staff with written guidelines that include all the elements specified by DDAP regulations for use in writing psychosocial evaluations.
The Clinical Supervisor shall use DDAP regulation standard based guidelines as the benchmark when reviewing psychosocial evaulations for his/her signature.
The Clinical Supervisor and Counselor shall monitor psychosocial evaluations for DDAP standards as part of monthly chart review.
The Facility Director shall hold staff accountable for compliance with DDAP regulations in the completion of psychosocial evaluations. |
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 upon a review of client records, the facility failed to document a treatment plan update which addressed progress achieved during the reporting period on the stated goals of the treatment plan in two of two records.
The findings included:
Four client records were reviewed during the on-site inspection. Two records were reviewed for treatment plan updates, 9 and 10.
Client record # 9 contained multiple treatment plan updates that were illegible.
Client record # 10 contained multiple treatment plan updates that did not contain progress achieved during the reporting period.
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Plan of Correction
The Facility Director has counseled the Clinical Supervisor/Counselor on the importance and need for legible documentation in all client files. A system has been put in place whereby client files will be spot checked for legibility.
A review of DDAP standard 709.92 (b) has been presented to both the Clinical Supervisor and Counselor.
A spot check of client files will occur to ensure that treatment plans are reviewed and updated at least every 60 days, and updates address progress achieved during reporting periods.
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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 upon a review of client records, the facility failed to document a complete client record that included record of services, progress notes, and case consultation in three of four records reviewed
The findings included:
Four client records were reviewed during the on-site inspection. Three client records did not include all of the required components, # 9, 10 and 11.
Client # 9 was admitted on October 30, 2013. The record of services provided did not include services provided during November 2013, and included pre-printed signatures that did not match the provider of the services rendered on 12/4/2013, 12/5/2013, 1/8/2014 and 1/22/2014. The progress notes for services were not documented for 12/17/2013, 12/18/2013, 12/19/2013, 12/23/2013, 12/27/2013, and 12/31/2013.
Client # 10 was admitted on October 30, 2013. The record of services provided was last entered on 12/31/2013; however, notes were documented for January 2014. The record was missing group notes from 12/16/2013 to 1/2/2014 for 7 notes. Additionally, the record contained documentation of a case consultation dated November 30, 2013, that failed to identify the staff involved.
Client # 11 was admitted on January 22, 2014. The record of services provided was last entered on 1/29/2014.
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Plan of Correction
All client records of service shall be reviewed during weekly clinical supervision. The Clinical Supervisor shall ensure that client records contain all of the required components related to DDAP standard 709.93.
Records of service with pre-printed signatures have been destroyed. All signatures shall be documented at the time of service by the facilitating counselor.
Client files shall also be reviewed by Outpatient staff to ensure that client records of progress achieved are related to the specific reporting period. |