INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 1-2, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Polaris Renewal Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
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Plan of Correction
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709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
Based on the review of client records, the facility failed to demonstrate the project's effort toward informing staff of the employee's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records and the right to submit rebuttal data or memoranda to his own records in four of four client records.
The findings include:
Five personnel records were reviewed on April 1-2, 2013. Four personnel records required documentation that the employees' were informed of their rights. The facility did not document the employees' were informed of their right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records and the right to submit rebuttal data or memoranda to his own records in personnel records # 1, 2, 3 and 4.
Employee # 1 was hired on July 1, 2012. There was no documentation provided that the employee was informed of the right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records and the right to submit rebuttal data or memoranda to his own records.
Employee # 2 was hired on February 4, 2013. There was no documentation provided that the employee was informed of the right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records and the right to submit rebuttal data or memoranda to his own records.
Employee # 3 was hired on July 30, 2012. There was no documentation provided that the employee was informed of the right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records and the right to submit rebuttal data or memoranda to his own records.
Employee # 4 was hired on July 1, 2012. There was no documentation provided that the employee was informed of the right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records and the right to submit rebuttal data or memoranda to his own records.
The Facility Director was interviewed on April 2, 2013 and confirmed the findings.
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Plan of Correction
709.26(e)
CORRECTIVE ACTION:
1.The Project Director shall develop written policies on the employee's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records and the right to submit rebuttal data or memoranda to his/her own records.
SYSTEMIC/PREVENTATIVE CHANGES:
1.Upon an employee's initial date of hire, documentation shall be generated to verify that the employee was informed of the right to request the correct or removal of inaccurate, irrelevant, outdated or incomplete information from the records and the right to submit rebuttal data or memoranda to his/her own records.
MONITORING/QUALITY ASSURANCE:
1.The Facility Director will routinely review and update policies related to employee rights on an as needed basis.
DATE OF COMPLETION: May 1st, 2013 |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on the review of client records, the facility failed to demonstrate efforts toward informing clients of the following: The project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file. The client has the right to appeal a decision limiting access to his records to the project director. The client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records and that the client has the right to submit rebuttal data or memoranda to his own records in seven of seven client records.
The findings include:
Seven client records were reviewed on April 1-2, 2013. Seven client records required documentation that the client was informed of their rights. The facility did not document that the client was informed of their rights in client records # 1, 2, 3, 4, 5, 6 and 7.
Client # 1 was admitted on September 20, 2012. There was no documentation that the client was informed that the project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file. The client has the right to appeal a decision limiting access to his records to the project director. The client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records and that the client has the right to submit rebuttal data or memoranda to his own records.
Client # 2 was admitted on December 28, 2012. There was no documentation that the client was informed that the project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file. The client has the right to appeal a decision limiting access to his records to the project director. The client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records and that the client has the right to submit rebuttal data or memoranda to his own records.
Client # 3 was admitted on August 13, 2012. There was no documentation that the client was informed that the project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file. The client has the right to appeal a decision limiting access to his records to the project director. The client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records and that the client has the right to submit rebuttal data or memoranda to his own records.
Client # 4 was admitted on November 13, 2012. There was no documentation that the client was informed that the project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file. The client has the right to appeal a decision limiting access to his records to the project director. The client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records and that the client has the right to submit rebuttal data or memoranda to his own records.
Client # 5 was admitted on December 1, 2012. There was no documentation that the client was informed that the project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file. The client has the right to appeal a decision limiting access to his records to the project director. The client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records and that the client has the right to submit rebuttal data or memoranda to his own records.
Client # 6 was admitted on September 27, 2012. There was no documentation that the client was informed that the project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file. The client has the right to appeal a decision limiting access to his records to the project director. The client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records and that the client has the right to submit rebuttal data or memoranda to his own records.
Client # 7 was admitted on August 13, 2012. There was no documentation that the client was informed that the project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file. The client has the right to appeal a decision limiting access to his records to the project director. The client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records and that the client has the right to submit rebuttal data or memoranda to his own records.
The Facility Director was interviewed on April 2, 2013 and confirmed the findings.
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Plan of Correction
709.30
CORRECTIVE ACTION:
1.The Project Director shall develop written policies on the client's right and access to his/her file that informs the client that the Project Director may temporarily remove portions of the client's records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. The written policies shall also inform the client of his/her right to appeal a decision limiting access to his/her records to the Project Director and the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his/her records and that the client has the right to submit rebuttal data or memoranda to his/her own records.
SYSTEMIC/PREVENTATIVE CHANGES:
1.Upon a client's initial treatment start date, documentation shall be generated to verify that the client was informed that the Project Director may temporarily remove portions of the client's records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client; however, it shall also be documented that the client was informed that he/she has the right to appeal a decision limiting access to his/her records to the Project Director and the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his/her records and their right to submit rebuttal data or memoranda to his/her own records. For those clients already participating in the treatment program, the client's therapist shall review the newly introduced policies with the client and documentation shall be recorded in the client's clinical file.
MONITORING/QUALITY ASSURANCE:
1.The Project Director will routinely review and update policies related to client rights on an as needed basis.
DATE OF COMPLETION: May 1st, 2013 |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in one of two client records.
The findings include:
Seven client records were reviewed on April 1-2, 2013. Three of the client records reviewed were that of discharged clients. Two of the discharged clients was involuntarily terminated from treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client record # 7.
Client # 7 was admitted into treatment on August 13, 2012 and was involuntarily terminated from the project on December 17, 2012. There was no documentation that the facility notified the client, in writing, of a decision to involuntarily terminate the client's treatment at the project.
The Facility Director was on April 2, 2013 and confirmed the findings.
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Plan of Correction
709.33 (a)
CORRECTIVE ACTION:
1.The Project Director shall develop written policies on the client's right to be notified of their reason for involuntary termination of treatment at the project in writing. Furthermore, the policy shall also state that the client will also have the opportunity to request reconsideration of a decision terminating treatment.
SYSTEMIC/PREVENTATIVE CHANGES:
1.A client shall be notified of their reason for involuntary termination of treatment at the project prior to the day of discharge in writing either by being provided a written letter in person or being mailed a written notice to the address maintained in the client's clinical file. A copy of the letter provided in person to the client, or a copy of the letter mailed to the client, along with the addressed envelope, shall be maintained in the client's records. If a client requests that Project staff reconsider the termination of their treatment, a case consultation shall be held to discuss the client's request, which the client will be permitted to attend.
MONITORING/QUALITY ASSURANCE:
1.The Project Director will routinely review and update policies related to client rights and notification of involuntary termination on an as needed basis.
DATE OF COMPLETION: May 1st, 2013 |
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 the review of patient records, the facility failed to document psychosocial evaluations that provided a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation in four of four client records.
The findings included:
Seven client records were reviewed on April 1-2, 2013. Four of the records were reviewed for the content of the psychosocial evaluation. The psychosocial evaluation did not include a clinical assessment of the client's assets and strengths, coping mechanisms, support systems, the negative factors that might inhibit treatment, and the counselor's impressions regarding the patient in client records # 1, 2, 3 and 4.
Client # 1 was admitted on September 20, 2012. The psychosocial evaluation, completed on December 7, 2012 included the repeat of the patient reported information and did not include a clinical assessment of the client's assets and strengths, coping mechanisms, support systems, the negative factors that might inhibit treatment, and the counselor's impressions regarding the patient.
Client # 2 was admitted on December 28, 2012. The psychosocial evaluation, completed on January 28, 2013, included the repeat of the patient reported information and did not include a clinical assessment of the client's assets and strengths, coping mechanisms, support systems, the negative factors that might inhibit treatment, and the counselor's impressions regarding the patient.
Client # 3 was admitted on August 13, 2012. The psychosocial evaluation, completed on September 21, 2012, included the repeat of the patient reported information and did not include a clinical assessment of the client's assets and strengths, coping mechanisms, support systems, the negative factors that might inhibit treatment, and the counselor's impressions regarding the patient.
Client # 4 was admitted on November 13, 2012. The psychosocial evaluation, completed on December 13, 2012 included the repeat of the patient reported information and did not include a clinical assessment of the client's assets and strengths, coping mechanisms, support systems, the negative factors that might inhibit treatment, and the counselor's impressions regarding the patient.
The Facility Director was interviewed on April 2, 2013 and confirmed the findings.
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Plan of Correction
709.91 (b)(6)
CORRECTIVE ACTION:
1.The Facility/Clinical Director will meet with clinical staff to reeducate on the regulatory requirements for the completion of biopsychosocials. The director will complete a 100% review of existing cases to determine if there were any other affected charts.
SYSTEMIC/PREVENTATIVE CHANGES:
1.The Facility/Clinical Director will review the file of each active patient within 48 hours of contact with counseling staff to review for completeness of the DAP, treatment plans and any other relevant case content.
MONITORING/QUALITY ASSURANCE:
1.The clinical staff will conduct periodic peer review of charts to assist in maintaining completeness and timeliness.
DATE OF COMPLETION: May 1st, 2013 and Ongoing
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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 the proposed type of support service in four of four client records.
The findings include:
Client # 1 was admitted on September 20, 2012. The individual treatment and rehabilitation plan completed on October 20, 2012 did not include the proposed type of support services.
Client # 2 was admitted on December 28, 2012. The individual treatment and rehabilitation plan completed on January 28, 2013 did not include the proposed type of support services.
Client # 3 was admitted on August 13, 2012. The individual treatment and rehabilitation plan completed on October 20, 2012 did not include the proposed type of support services.
Client # 4 was admitted on November 13, 2012. The individual treatment and rehabilitation plan completed on November 18, 2012 did not include the proposed type of support services.
The Facility Director was interviewed on April 2, 2013 and confirmed the findings.
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Plan of Correction
709.92 (a)(3)
CORRECTIVE ACTION:
1.The Facility/Clinical Director will meet with clinical staff to reeducate on the regulatory requirements for the completion of individual treatment and rehabilitation plans. The director will complete a 100% review of existing cases to determine if there were any other affected charts.
SYSTEMIC/PREVENTATIVE CHANGES:
1.The Facility/Clinical Director will review the file of each active patient within 48 hours of contact with counseling staff to review for completeness of the DAP, treatment plans and any other relevant case content.
MONITORING/QUALITY ASSURANCE:
1.The clinical staff will conduct periodic peer review of charts to assist in maintaining completeness and timeliness.
DATE OF COMPLETION: May 1st, 2013 and Ongoing
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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 the review of client records, the facility failed to document a discharge summary in two of three client records.
The findings include:
Seven client records were reviewed on April 1-2, 2013. Three client records were reviewed as discharged clients. There was no documentation of a discharge summary in client records # 5 and 7.
Client # 5 was admitted on December 1, 2012 and discharged on December 26, 2012. There was no documentation of a discharge summary.
Client # 7 was admitted on August 13, 2012 and discharged on December 17, 2012. There was no documentation of a discharge summary.
The Facility Director was interviewed on April 2, 2013 and confirmed the findings.
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Plan of Correction
709.93 (a)(10)
CORRECTIVE ACTION:
1.The Facility/Clinical Director will meet with clinical staff to reeducate on the regulatory requirements for the completion of the discharge summary. The director will complete a review of recent discharges within the past ninety (90) days to determine if there were any other affected charts.
SYSTEMIC/PREVENTATIVE CHANGES:
1.The Facility/Clinical Director will review the file of each discharged patient within 48 hours of discharge to review for completeness of the discharge summary and any other relevant case content.
MONITORING/QUALITY ASSURANCE:
1.The clinical staff will conduct periodic peer review of charts to assist in maintaining completeness and timeliness.
DATE OF COMPLETION: May 1st, 2013 and Ongoing
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