INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 10, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, White Deer Run Of York 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 April 5, 2009.
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Plan of Correction
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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 the review of client records, the facility failed to document consents to release in one of five client records.
The findings include:
Seven client records were reviewed on March 10, 2009. Consents to release information were required in five of seven client records. The facility did not document a consent to release information before a release was made to a government agency in client record # 2.
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Plan of Correction
The facility will ensure that appropriate Consents to Release are completed for all clients. Re-fresher training will be provided to all staff having responsibility for completion of the Consent forms by the Facility Clinical Supervisor. Training will be completed by 5/1/2009. The Clinical Supervisor and Nurse Coordinator will also conduct on-going file audits to inspect client files for compliance with the regulation. A staff meeting will also be scheduled to review the confidentiality policy with all facility staff to include the requirement that staff inspect the client file prior to making a contact and ensuring that a Consent to Release is completed before any information is shared. A staff meeting will be scheduled prior to 5/1/2009. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document complete psychosocial evaluations in two of four client records.
The findings include:
Four detoxification client records were reviewed on March 10, 2009. Psychosocial evaluations were required in three of four client records. The facility did not document complete psychosocial evaluations in client records # 2 and 5. Client record # 2 and 5 were missing assets and strengths, support systems, copping mechanisms, client's attitude toward treatment and counselor conclusions and impressions.
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Plan of Correction
While the Psychosocial Evaluation was completed on all clients, there is a concern that the information contained in the Evaluation does not contain sufficient detail. The facility Administrator, Clinical Supervisor, and Nurse Manger, will develop and conduct a training and an on-going review process for the Clinical and Nursing staff to ensure the level of quality and content of the client file meets regulatory requirements. A re-training program will be developed by 5/1/2009 and implemented by 5/15/2009. Re-training will consist of how to properly and completely document: composite picture of the client; assets and strengths; support systems; coping mechanisms; negative factors; client attitude toward treatment; and counselor conclusions/impressions. The Nursing Coordinator and Clinical Supervisor will also conduct on-going reviews of client clinical files and address any quality concerns through the clinical supervision process.
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709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document follow up information in one of two client records.
The findings include:
Four client records were reviewed on March 10, 2009. Follow up information was required in two of four client records. The facility did not document follow up information in client record # 7.
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Plan of Correction
The facility will ensure that the appropriate follow-up documentation is completed for all clients to include appropriate documentation of aftercare services. Re-fresher training will be provided to all staff having responsibility for completion of follow-up documentation by the Facility Administrator and Clinical Supervisor. Training will occur before 5/15/2009. The Clinical Supervisor and Nurse Coordinator will also conduct on-going file audits to inspect client files for continued compliance with the regulation.
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