INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 4-5, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare York Pharmacotherapy 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 and a plan of correction is due on December 1, 2008.
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Plan of Correction
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709.28(a)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(2) Staff access to client records.
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Observations
Based on a review of client records, the facility failed to identify the specific information to be disclosed, or exceeded the limitations specified at 4 Pa. Code subsection 255.5(b) on each consent in five of five client records.
The findings include:
Five client records were reviewed on November 4 and 5, 2008. The facility was required to adhere to the requirements at 4 Pa. Code subsection 255.5(b) in each of the five client records. Specific information was not identified on consents to release information filed in client records # 1, 2, 4 & 5. Specific information to be disclosed exceeded the limits established at 4 Pa. Code subsection 255.5(b) in client records # 1, 2 & 4 in releases of information to third party payers and/or criminal justice entities.
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Plan of Correction
Consents to release information where reviewed with all staff on 11-11-08, identifying what can and cannot be released. This area of consent forms has been added to the chart monitoring form. Weekly peer reviews are completed by counselors, and monthly chart monitors are completed by the director, so this area will be specifically checked during chart reviews. |
709.28(c)(6) 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:
(6) Expiration date of the consent.
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Observations
Based on a review of client records and an interview of the facility director, the facility failed to identify the expiration date of each consent to release information form in five of five client records.
FINDING:
Five client records were reviewed on November 4 & 5, 2008. Four of the client records reviewed, #2, 3, 4 & 5, did not clearly identify the expiration date of the consent to release information. A statement at the end of each consent reads as follows:
" This authorization expires _______ 90 days from the date of discharge OR______ 120 days from the date of request . ( for discharged clients only)."
In each of the four client records identified above, staff completing the form initialed both of these spaces with the result being that the client was unable to determine exactly when the consent would expire. A discussion with the Facility Director verified that the form was not being used correctly and that only one of the two dates is to be initialed by staff as the expiration date.
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Plan of Correction
Consents to release information were reviewed with all staff on 11-11-08. All staff were instructed to initial only the time frame that pertains to their individual client. This section of the consent forms has been added to the chart monitoring form. Weekly peer reviews are conducted by clinical staff, and monthly chart monitoring is done by the director. |
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 document a letter of termination for involuntarily discharged clients in one of two client records..
The findings include:
Five client records were reviewed on November 4 & 5, 2008. Two client records were required to document termination letters. The facility failed to document a termination letter in client record # 2.
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Plan of Correction
Effective 11-11-08 a termination letter is being sent out to all discharged clients, identifying the type of discharge and type of follow up services available. This procedure was reviewed with all staff on 11-11-08. All letters for discharged clients must be signed by the director or the medical director. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to document a letter of termination for involuntarily discharged clients which notified the client of the right to appeal involuntary termination in one of two client records.
The findings include:
Five client records were reviewed on November 4 & 5, 2008. Two client records where required to have letters of termination which informed the client of the right to appeal involuntary termination. The facility failed to document that the client had been informed of his/her right to appeal the involuntary termination in client record #2.
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Plan of Correction
Effective 11-11-08, a termination letter is being sent out to all discharged clients. The letter must include the type of discharge, follow up services available, and rights to appeal if it is an involuntary termination. All letters must be signed off by the director or the medical director. |
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 on a review of client records, the facility failed to document treatment plan updates or failed to document complete treatment plan updates in 2 of 4 client records.
The findings include:
Five client records were reviewed on November 4 and 5, 2008. Four records were required to document treatment plan updates. Client record # 5 did not have a treatment plan update documented as required. Client record # 2 had a treatment plan update, but the content of the document did not address progress on the previously stated goals of the treatment plan.
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Plan of Correction
Due dates for reviews were reviewed with all staff on 11-11-08. A clinical tracking log including all treatment due dates for reviews must be kept by each counselor for all of their clients. The log must be submitted to the director on a weekly basis for review. Content of treatment plan reviews were reviewed on 11-11-08, and checking content of the reviews has been added to the clinical weekly chart monitor for counselors and the monthly chart monitor for the director. Counselors will conduct a peer review of 2 charts per week for content, and the director will review 4 charts per month. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations in two of four client records.
The findings include:
Five client records were reviewed on November 4 & 5, 2008. Four client records were required to have case consultations documented. Case consultations were not documented in client records # 2 and 5.
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Plan of Correction
Due dates for case consults were reviewed with all staff on 11-11-08. A clinical tracking log including the due dates for all case consults must be kept by each counselor for all of their clients. The log must be submitted to the director for review weekly. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up with discharged clients.
The findings include:
Five client records were reviewed on November 4 and 5, 2008. Three of five client records reviewed required documentation of follow up contacts. Two of three client records, # 2 & 4, did not include documentation of follow up attempts..
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Plan of Correction
Follow up due dates were reviewed with all staff on 11-11-08. A clinical tracking log, including due dates for follow up contacts must be kept by each counselor for all of their clients. The log must be submitted weekly to the director for review. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records during the on site licensing inspection, the facility failed to document physician signatures in treatment plans and treatment plan updates.
The findings include:
Five client records were reviewed on November 4 & 5, 2008. Two of these records were funded through Medical Assistance funding streams. Two of two client records did not document physician signatures on treatment plans and treatment plan updates filed in client records # 1 &2.
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Plan of Correction
This area of deficiency was already corrected, prior to this licensing visit, with the addition of a signature line for the medical director to sign the treatment plans and reviews. The records identified in this observation were older records and had the old form. All current records are signed by the medical director on the new form. |