INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 8, 2016 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 exceeded the limitations imposed in 4 Pa. Code, Subsection 255.5(b) as it pertains to the information authorized to be released per the the informed and voluntary to release information forms in nine of ten client records reviewed.
The findings include:
Limitations imposed at 4 Pa. Code, Subsection 255.5(b) specify that the release of information to insurance companies shall be restricted to whether the client is or is not in treatment, the prognosis of the client, the nature of the project, a brief description of the progress of the client, and a short statement as to whether the client has relapsed and the frequency of such relapse.
Ten client records requiring informed and voluntary consent to release information forms were reviewed on 1/8/16. The facility failed to ensure that the informed and voluntary consent to release information forms only authorized the release of information as per the restrictions within 4 Pa. Code, Subsection 255.5(b) in client records # 1, 3, 4, 5, 6, 7, 8, 9, and 10
Client # 1 was admitted into treatment on 8/13/15 and was still active at the time of the inspection. The client's consent to release information to the client's insurance company, dated 8/13/15, documented terminology that authorized the release of the client's chart contents.
Client # 3 was admitted into treatment on 8/24/15 and was still active at the time of the inspection. The client's consent to release information to the client's insurance company, dated 8/24/15, documented terminology that authorized the release of the client's chart contents.
Client # 4 was admitted into treatment on 3/2/15 and was discharged on 9/3/15. The client's consent to release information to the client's insurance company, dated 3/2/15, documented terminology that authorized the release of the client's chart contents.
Client # 5 was admitted into treatment on 6/1/15 and was discharged on 12/18/15. The client's consent to release information to the client's insurance company, dated 6/1/15, documented terminology that authorized the release of the client's chart contents.
Client # 6 was admitted into treatment on 10/2/15 and was discharged on 11/30/15. The client's consent to release information to the client's insurance company, dated 10/2/15, documented terminology that authorized the release of the client's chart contents.
Client # 7 was admitted into treatment on 7/9/15 and was discharged on 10/30/15. The client's consent to release information to the client's insurance company, dated 7/9/15, documented terminology that authorized the release of the client's chart contents.
Client # 8 was admitted into treatment on 5/8/15 and was discharged on 11/20/15. The client's consent to release information to the client's insurance company, dated 5/8/15, documented terminology that authorized the release of the client's chart contents.
Client # 9 was admitted into treatment on 2/27/15 and was discharged on 9/4/15. The client's consent to release information to the client's insurance company, dated 2/27/15, documented terminology that authorized the release of the client's chart contents.
Client # 10 was admitted into treatment on 5/11/15 and was discharged on 11/20/15. The client's consent to release information to the client's insurance company, dated 5/17/15, documented terminology that authorized the release of the client's chart contents.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Site Director will conduct a training on Confidentiality with staff members during weekly staff meeting on (1/14/16). During this meeting, Site Director will review regulations and policies regarding clienconfidentiality, 4Pa. Code 255.5.
Site Director will perform quarterly audits of 12 charts minimum 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. The current managed care consent form will be edited to utilize proper terminology and stay within the 4Pa. Code 255.5 regulation of confidentiality. The new consent form was sent out to all Rehab After Work
clinicians on January 18th, 2016 and will be utilized from that date moving forward, replacing the previous managed care consent form. |
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 a treatment plan update that was signed and dated by the primary counselor in two of ten records reviewed. Additionally, the facility failed to document a treatment plan update at least every 60 days in one of ten client records reviewed.
These findings were reviewed with facility staff during the licensing process.
Ten client records requiring documentation of a treatment plan update were reviewed during the renewal inspection on 1/8/16. The facility failed to document a treatment plan update that was signed and dated by the primary counselor in client records # 2 and 3. Additionally, the facility failed to document a treatment plan update at least every 60 days in client record # 8.
Client # 2 was admitted into treatment on 10/23/15 and was still active at the time of the inspection. A treatment plan update dated 12/16/15 was not signed and dated by the primary counselor.
Client # 3 was admitted into treatment on 8/24/15 and was still active at the time of the inspection. A treatment plan update dated 12/16/15 was not signed and dated by the primary counselor.
Client # 8 was admitted into treatment on 5/8/15 and was discharged on 11/20/15. The last two treatment plan updates for the client were completed on 7/1/15 and 9/1/15.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Site Director will conduct a training on proper documentation of treatment plan updates with staff members during weekly staff meeting on 1/14/16. During this meeting, Site Director will review regulations and policies regarding proper documentation of client treatment plan updates.
Site Director will perform monthly audits of 4 charts minimum in order to monitor compliance with proper documentation of treatment plan update regulations.
Site director will perform these audits to ensure that the appropriate measures and documentation of treatment plan updates are being utilized
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709.93(a) 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:
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Observations
Based on the review of client records, the facility failed to ensure that a complete record was documented in three of ten client records reviewed.
The findings include:
Ten client records were reviewed for documentation of a complete client record during the renewal inspection on 1/8/16. The facility failed to document a complete record in client records # 5, 8, and 10.
Client # 5 was admitted into treatment on 6/1/15 and discharged on 12/18/15. The record of service for the client indicated the client attended a group session on 7/30/15. A progress note for this group session was not documented in the client's record. Additionally, a progress note in the client's record indicated the client attended a group session on 9/15/15. This group session was not documented on the record of service.
Client # 8 was admitted into treatment on 5/8/15 and was discharged on 11/20/15. The record of service for the client indicated the client attended a group session on 10/21/15. A progress note for this group session was not documented in the client's record. A progress note in the client's record indicated the client attended a group session on 10/20/15. This group session was not documented on the record of service. Additionally, the record of service indicated the client attended an individual session on 9/9/15. A progress note for this individual session was not documented in the client's record.
Client # 10 was admitted into treatment on 5/11/15 and was discharged on 11/20/15. The record of service for the client indicated the client attended an individual session on 9/15/15. A progress note for this individual session was not documented in the client's record. Additionally, a progress note in the client's record indicated the client attended an individual session on 9/8/15. This individual session was not documented on the client's record of service.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Site Director will conduct a training on maintaining a complete and accurate record of service for all clients and staff members during weekly staff meeting on 1/14/16 . During this meeting, Site Director will review regulations and policies regarding client's record of service and having accurate documentation of each recorded date of service. Site Director will perform monthly audits of 4 charts minimum in order to monitor compliance with maintaining an accurate and complete record of service for all clients.
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