INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 4 and 5, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Bucks County Council on Alcoholism and Drug Dependence, Incorporated 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 March 28, 2008.
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Plan of Correction
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on the physical plant inspection on 3/4/08, the facility failed to ensure visual privacy in the large group room on the lower level. The window allowed clients to be seen during counseling sessions.
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Plan of Correction
Muted, self-adhesive film covering will be purchased to place on window in the large group room on the lower level, which will ensure visual privacy of clients meeting in the large group room on the lower level. The clinical supervisor will complete this measure by 3/28/08.
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709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on the physical plant inspection on 3/4/08 and staff interviews, the facility failed to secure client records within locked storage containers. The active client records were stored in unlocked file cabinets in the administrative assistant's office. The closed client records were stored in unlocked file cabinets in the hallway between the lower level reception area and the large group room.
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Plan of Correction
The facility will maintain all client records within locked storage containers at all times. The filing cabinet which holds active client records in the administrative assistants' office will be re-locked each time it is accessed by the administrative assistant. The filing cabinet in the hallway which contains the closed records will be locked at all times, and will be re-locked upon accessing records. The administrative assistant will be responsible for keeping the filing cabinets locked at all times. The clinical supervisor will ensure compliance with this standard by periodically checking to see that all cabinets are locked and noting this in the supervision log. The facility will be in full compliance with this standard by 4-3-08 |
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 on 3/5/08, the facility failed to obtain an informed and voluntary consent from the client in one of five client records reviewed, #1. The client record documented telephone calls between the administrative assistant and staff in Bucks County Corrections. Written consent for the release of information to Bucks County Corrections had not been obtained from the client.
Consents to release information to emergency contacts in six of seven client records reviewed included "obtain from" language, #1, 2, 3, 4, 5, 7 and 8. The "obtain from" language must be removed from the consent form since the law and regulation does not address or regulate entities wanting to obtain information. Entities may obtain information without any procedures or requirements.
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Plan of Correction
A new release form for the consent to release confidential information to Bucks County Corrections Drug & Alcohol Department was created(on 3/5/08.) This release has been added to the Master Packet of Releases that is used by each assessor. A staff meeting held on 3/27/08 addressed the need for AOD assessors to have clients sign the release in the event that the Bucks County Corrections Drug & Alcohol Department will need to be contacted. The addition of the release was completed by the clinical supervisor.
Consents for release of information were changed on 3/5/08 eliminating the "obtain from" language. The Master Packet of Release now only contains consent for release absent of the verbiage, "obtain from". A staff meeting held on 3/26/08 by the clinical supervisor which addressed the change with all treatment employees, which includes therapists, assessors, administrative assistant staff, and the DUI manager. The change in the release form was made by the clinical supervisor.
Follow up will be achieved by the clinical supervisor by periodically reviewing charts to ensure that all needed releases are signed and present in the chart and that they contain the correct language.
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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 on 3/5/08, the facility failed to obtain an informed and voluntary consent from the client in one of seven client records reviewed, #5. The client signed a general consent to release information form to Bucks County Court System. The specific information to be disclosed was not identified on this form.
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Plan of Correction
The facility will obtain informed and voluntary consent from each client prior to the release of any confidential information. The use of a general release form was suspended immediately effective 3-6-08 by the clinical supervisor. All release forms to be utilized will include the specific person to whom the information is to be disclosed, as well as the specific information to be disclosed. The facility will be in full compliance with this standard 3-6-08. Follow up on this POC will be accomplished by the clincial supervisor through ongoign chart review. |
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 on 3/5/08, the facility failed to document complete psychosocial evaluations in six of seven client records reviewed, #1, 3, 4, 5, 7 and 8. The evaluations did not include a clinical assessment of how assets/strengths, support systems and negative factors would impact the potential for treatment
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Plan of Correction
A staff meeting held on 3/26/08, which included therapists, assessors, administrative assistant staff, and the DUI manager. The clinical supervisor addressed the changes to be made in the clinical assessment of how assets/strengths, support systems and negative factor's impact the client's potential for treatment. A handout was given to each employee outlining requirements for changes in the clinical summary. A follow up will be made in two weeks from the 3/26/08 staff meeting by the clinical supervisor individually with each assessor to ensure that assessors have begun to implement the changes to the aforementioned sections. At the time of the meeting, the assessor will present all the treatment files they have completed in the two week period to the clinical supervisor who will review them and provide any necessary feedback, clarification, or direction.
(Section of handout to treatment employees at the staff meeting:
- "CLINICAL SUMMARY: How will assets/strengths, support systems and negative factors impact client's AOD tx experience? Ex. It appears the client will be engaged and maintain sobriety during treatment, but his social and family support system will not be a good source of sober support for the client because of their alcohol use. Or, the client's social support system meets every Friday at a bar, so the client's social support system will be detrimental to the client's AOD treatment experience.")
To prevent recurrence of this deficiency, the clinical supervisor will conduct periodic record review at least once a month to review all new files. At that time, psychosocial evaluations will be reviewed by the clinical supervisor to ensure they address the client's strengths/assets, support systems and negative factors that would impact the client's treatment. If at the time of review, the files do not contain this information, these files will be returned to the assessor and deficencies will be corrected. The clinical supervisor will provide 1:1 training to any counselor/assessor that turns in charts that do not meet this standard, until which time that all charts contain complete psychosocial evaluations. The facility will be in full compliance with this standard as of 4-4-08
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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 a review of client records on 3/5/08, the facility failed to complete individualized treatment plans in six of six client records reviewed, #1, 2, 3, 4, 7 and 8. The treatment plans had identical goals and action steps.
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Plan of Correction
A staff meeting held on 3/26/08, which included therapists, assessors, administrative assistant staff, and the DUI manager, and the clinical supervisor. The clinical supervisor addressed the corrective changes to be made on individualized treatment plans. The clinical supervisor discussed the importance of the development of a solid clinical summary which identifies elements to be included in an individualized treatment plan. Assessors are required to put a minimum of 3 individualized clinical goals that client needs to address while in treatment under the "Prognosis for Treatment" section of the clinical summary. Each therapist will include individualized action steps for each goal. The therapist will address the clinical issues in the "Prognosis for Treatment" section with the client during the one-on-one orientation with the client. At that time, the therapist and the client will develop the individualized treatment plan to be signed the following group session.
On 4/9/08 the clinical supervisor will meet with each therapist individually to review all new individualized treatment plans to ensure changes have been implemented. During that meeting constructive feedback will be given and monthly meetings will be held to ensure continued compliance with regulatory statues on individualization of treatment plans.
To ensure that this deficiency does not recurr, periodic record review will take place once a month by the clinical supervisor, who will review all new files. At that time, individual treatment plans will be reviewed by the clinical supervisor to ensure they are individualized to the client. If at the time of review, the files are determined to not be individualized, charts will be returned to the facilitator for corrections. The clinical supervisor will provide 1:1 training with any facilitator that fails to provide individualized treatment plans, until which time all treatment plans are individualized. This will occur at the time the deficiencies are noted and also be addressed with the facilitator during monthly meetings between the clinical supervisor and facilitator.
The facility will be in full compliance with the statute on 4/4/08
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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 on 3/5/08, the facility failed to document treatment plan goals stated in terms of measurable criteria in six of six client records reviewed, #1, 2, 3, 4, 7 and 8.
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Plan of Correction
The facility will correct this deficiency through staff training and through monitoring of charts to ensure that treatment plan goals contained measurable criteria. The clinical supervisor held a staff training on 3/26/08, which included the clinical supervisor, therapists and assessors. The clinical supervisor trained all present to develop measurable criteria for each treatment plan goal and instructed therapists that these changes were to be implemented effective 3-26-08. The plan for follow up is that the clincal supervisor will do ongoing review of treatment plans to ensure that staff are including measurable treatment plan goals. The facility will be in full compliance with this standard as of 3-27-08 |
709.44(a)(3) LICENSURE Psychosocial evaluation
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(3) Psychosocial evaluation.
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Observations
Based on a review of client records on 3/5/08, the facility failed to document a complete psychosocial evaluation in one of one client records reviewed, #1. The evaluation did not include a clinical assessment of how assets/strengths, support systems and negative factors impact the potential for treatment.
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Plan of Correction
The facility will correct this deficiency through staff training and through monitoring of charts by the clinical supervisor. On 3/26/08 the clincial supervisor held a training which was attended by the clinical supervisor, the therapists, and the assessors. All present were trained on the need to include within the psychosoical evaluation an assessment of how the client's individual assets and strengths, support systems, and negative factors might impact the client's treatment. Mutliple examples were given and staff indicated understanding of the need to include these elements in the psychosocial evaluation. Follow up will be accomplished by the ongoing monitoring of psychosocial evaluations by the clinical supervisor. The facility will be in full compliance with this statute as of 3/27/08 |