INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 17, 2009 through August 20, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Self Help Movement, 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 September 18, 2009.
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Plan of Correction
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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, a review of the agency treatment manual and staff interviews, the facility failed to document dates of physical examinations in four of seven closed client records.
Findings:
Four of seven closed client records reviewed on August 19, 2009 failed to include the date of the physical examination. Facility policy and procedure requires the physical examination be completed within seven days of admission. A review of the four records with the intake coordinator and clinical supervisor on August 19, 2009 provide further verification of the inability to determine the date of the physical examination.
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Client record #8 - Admitted October 20, 2008 and discharged on February 20, 2009. The physical examination documented in the record did not have the date of examination.
Client record # 10 - Admitted October 7, 2008 and discharged on March 24, 2009. The physical examination documented in the record did not have the date of examination.
Client record # 12 - Admitted October 31, 2008 and discharged on April 20, 2009. The physical examination documented in the record did not have the date of examination.
Client record # 14 - Admitted August 20, 2008 and discharged on February 2, 2009. The physical examination documented in the record did not have the date of examination.
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Plan of Correction
Effective 8/19/09, the Director of Intake will ensure that all physical examinations take place within seven days of admission and also ensure that the physician has written the date of the examination on the physical form to verify the date of examination. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, a review of the agency treatment manual and staff interviews, the facility failed to document case consultation notes in the three of four client records.
Findings:
Six client records were reviewed on August 18, 2009. Four of the six client records required documentation of case consultation notes on a 90 day basis. Three of the records reviewed on August 19, 2009 failed to include documentation of case consultation notes. Facility policy and procedure requires that case consultation notes be completed every 90 days from the date of admission. A review of the three client records with the intake coordinator and clinical supervisor on August 19, 2009 provided further verification of the lack case consultation notes.
Client record #1 - Admitted February 24, 2009. A review of the record on August 19, 2009 failed to provide documentation of case consultation notes which were due on May 28, 2009.
Client record # 2 - Admitted March 3, 2009. Case consultation notes were due in the record by June 4, 2009. Case consultation notes were entered on August 7, 2009. Case consultation notes were not entered into the client record until more than 60 days past the due date of June 4, 2009
Client record # 3 - Admitted May 14, 2009. Case consultation notes were due in the client record by August 16, 2009. No case consultation notes were entered in the client record as of August 19, 2009.
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Plan of Correction
Effective 8/19/09, a process will be set in place by the Director of Treatment Services, along with the counseling unit that all clients will receive a case consultation between the counselor and the Director of Treatment services after the completion of a comprehensive treatment plan, or if the client has special needs or nees reinforcemnt of behavior. The note will be completed within 30 days of the client's admittance to treatment and reviewed by the Director of Treatment Services. Two weeks prior to the client's completion of treatment a consultation and note will be completed with the appropriate aftercare follow up plan and status. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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, a review of the agency treatment manual and staff interviews, the facility failed to document follow-up information in six of seven closed client records.
Findings:
Six of seven closed client records reviewed on August 20, 2009 failed to include documentation of client follow-up activities. Facility policy and procedure requires the follow-up contacts be completed thirty-days post discharge. A review of the six client records with the intake coordinator and clinical supervisor on August 20, 2009 provided further verification of the lack of follow-up activities.
Client record #9 - Admitted October 23, 2008 and discharged on May 8, 2009. There was no documentation of a follow-up attempt.
Client record # 10 - Admitted October 7, 2008 and discharged on March 24, 2009. There was no documentation of a follow-up attempt.
Client record # 11 - Admitted February 9, 2009 and discharged on April 10, 2009. There was no documentation of a follow-up attempt.
Client record # 12 - Admitted October 31, 2008 and discharged on April 20, 2009. There was no documentation of a follow-up attempt.
Client record # 13 - Admitted December 1, 2008 and discharged on April 8, 2009. There was no documentation of a follow-up attempt.
Client record # 14 - Admitted August 20 2008 and discharged on February 4, 2009. There was no documentation of a follow-up attempt.
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Plan of Correction
Effective 9/1/09, The Director of Treatment Services, along with the counseling unit will ensure that follow up documentation and contact will be placed in the treatment file and completed within 30 days of the discharge date. A list of follow up contacts will be given to the administrative assistant who will then follow up with the counselor to ensure that contact was made by the counselor. |