INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 5, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Rehab After Work 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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709.28(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, the facility failed to obtain an informed and voluntary consent that includes all of the required content required by regulation in one of ten client records reviewed.
The findings include:
Ten client records requiring informed and voluntary consent to release information forms were reviewed on 2/5/2015. The facility failed to document the specific information to be disclosed and the purpose of disclosure on an informed and voluntary consent to release information form in client record # 8.
Client # 8 was admitted to treatment on 4/21/2014. Client # 8's informed and voluntary consent to release information to the Student Assistance Program dated 4/21/2014 did not specify the information to be released and the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation. The facility was previously cited for non-compliance with this standard during the 2/26/2014 inspection.
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Plan of Correction
Site Director will conduct a training on Confidentiality with staff members during weekly staff meeting on 3/19/15. During this meeting, Site Director will review regulations and policies regarding client confidentiality, 4Pa. Code 255.5. Site Director will perform random chart audits every other month in order to monitor compliance with confidentiality regulations. Site director will perform these audits to ensure that the appropriate measures and documentation of confidentiality is being utilized in all consent forms on Rehab After Work paperwork, specifically stating the purpose for the release at hand. |
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 facility in one of three client records reviewed.
The findings include:
Three client records requiring written notification to the client of the facility's decision to involuntarily terminate the client's treatment were reviewed on 2/5/2015. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the facility in client record # 10.
Client # 10 was admitted into treatment on 10/20/2014 and was involuntarily terminated from the facility on 1/15/2015. There was no documentation of written notification of the facility's decision to involuntarily terminate the client's treatment as of the on-site inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #10 was provided a new official discharge letter stating the client's specific date of termination from treatment and the reason for termination, this letter was sent out on February 6, 2015.
Clinicians will also engage in a training about creating discharge/termination letters to clients on March 19, 2015 during York staff meeting to address the appropriate components of a termination letter including the name of client, address of client, date of termination, reason for termination, and how to return to treatment if needed in the future.
Project staff shall notify all clients moving forward, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination, date letter was sent, and termination date, informing the client of their specific termination from the facility.
The Site Director of York will conduct random chart audits every other month to ensure that the standard is in full compliance.
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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, the facility failed to maintain documentation that individual treatment and rehabilitation plans were developed with the client in ten of ten client records reviewed. Furthermore, the facility failed to document the type and/or frequency of treatment services on the individual treatment and rehabilitation plans in four of ten client records reviewed.
The findings include:
Ten client records requiring documentation that individual treatment and rehabilitation plans were developed with the client and documentation of the type and frequency of treatment services on the individual treatment and rehabilitation plans were reviewed on 2/5/2015. There was no documentation that individual treatment plans were developed with the client in client records # 1 - 10. Furthermore, the individual treatment and rehabilitation plans contained in client records # 1, 4, 8 and 9 did not include the type and/or frequency of treatment services.
Client # 1 was admitted to treatment on 10/27/2014. There was no documentation that the client's individual treatment and rehabilitation plan dated 11/5/2014 was completed with the client. Additionally, the client's individual treatment and rehabilitation plan dated 11/5/2014 did not specify the frequency of individual and group counseling therapy.
Client # 2 was admitted to treatment on 11/5/2014. There was no documentation that the client's individual treatment and rehabilitation plans dated 11/5/2014 and 1/5/2015 were completed with the client.
Client # 3 was admitted to treatment on 9/9/2014. There was no documentation that the client's individual treatment and rehabilitation plans dated 9/11/2014, 11/10/2014 and 1/5/2015 were completed with the client.
Client # 4 was admitted to treatment on 4/7/2014. There was no documentation that the client's individual treatment and rehabilitation plan dated 4/7/2014, 6/7/2014 and 8/7/2014 were completed with the client. Additionally, the client's individual treatment and rehabilitation plan dated 6/7/2014 did not specify the frequency of group counseling therapy.
Client # 5 was admitted to treatment on 10/14/2014. There was no documentation that the client's individual treatment and rehabilitation plan dated 10/20/2014 was completed with the client.
Client # 6 was admitted to treatment on 7/14/2014. There was no documentation that the client's individual treatment and rehabilitation plan dated 1/13/2015 was completed with the client.
Client # 7 was admitted to treatment on 4/7/2014. There was no documentation that the client's individual treatment and rehabilitation plans dated 4/4/2014, 6/11/2014 and 8/11/2014 were completed with the client.
Client # 8 was admitted to treatment on 4/21/2014. There was no documentation that the client's individual treatment and rehabilitation plan dated 6/26/2014 was completed with the client. Additionally, the client's individual treatment and rehabilitation plans dated 4/29/2014 and 6/26/2014 did not specify the frequency of individual counseling therapy.
Client # 9 was admitted to treatment on 9/22/2014. There was no documentation that the client's individual treatment and rehabilitation plan dated 11/21/2014 was completed with the client. Additionally, the client's individual treatment and rehabilitation plan dated 11/21/2014 did not specify the type and frequency of individual and group counseling therapy.
Client # 10 was admitted to treatment on 10/20/2014. There was no documentation that the client's individual treatment and rehabilitation plan dated 12/8/2014 was completed with the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Site Director of York conducted an in-service training during staff meeting before 3/4/15, informing staff that each client must sign off or document client's participation in the creation and discussion of the Master Treatment Plan and Treatment Plan Updates via progress note. In-service training also reviewed and educated York staff on the proper documentation of the type and frequency of treatment on Master Treatment Plans and Treatment Plan Updates.
York staff will bring three charts to staff meeting on 4/2/15 to ensure that the appropriate protocol and documentation is being utilized and that they understand this documentation represents the client's involvement in the development of the Master Treatment Plan and Treatment Plan Updates and the modality and type of treatment services is identifiable. The Site Director of York will conduct random chart audits every other month to ensure that the standard is in full compliance.
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