INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 14, 2012 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:
|
Plan of Correction
|
709.28(a)(1) 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:
(1) Confidentiality of client identity and records.
|
Observations
Based on a review of the facility policy and procedure manual, the facility failed to document a confidentiality policy and procedure compliant with 4 Pa. Code subsection 255.5.
The findings included:
4 Pa. Code subsection 255.5 (a)(6), states: "Projects may disclose with the consent of a client, in writing, the information to employers of a client to further the rehabilitation of a client; or, to a prospective employer who affirmatively expresses that information is sought to enable the employer to engage the client as an employee. Such information shall be limited to whether the client has or is receiving treatment with the project."
The facility policy and procedure manual was reviewed as part of the annual onsite licensing inspection of March 5 - 6, 2012. Policy # 60,006, section C, subsection 2, letter f, exceeded 4 Pa. Code subsection 255.5 (a)(6), as it allowed for the following: "Life Management may disclose with the client's consent, the information to employers of a client to further the client's rehabilitation; or, to a prospective employer who affirmatively expresses that information is sought to enable the employer to engage the client as an employee. Information released shall be limited to that provided for in subsection 4.a. in this section."
Subsection 4.a. states: " Nature of Client Information to be Disclosed. a. Information released to judges, probation or parole officers, insurance company, health or hospital plan or government officials, pursuant to section C.2.a-i of this section, is for the purpose of determining the advisability of continuing th client in treatment with Life Management and shall be restricted to the following:
i. Whether or not the client isn't in therapy
ii. The prognosis of the client
iii. The nature of the project
iv. A brief description of the client's progress
v. A short statement as to whether the client has relapsed into drug or alcohol abuse and the
frequency of such relapse."
The project's Confidentiality policy permits for the release of information under ii, iv, and v, which is restricted under 4 PA Code 255.5(a)(6).
|
Plan of Correction
The Executive Director of Rehab After Work will change the policy & procedure section in our manual (#66006) to reflect that "information specifically released to employers will be limited to whether a client has or is receiving treatment with the project." This will be circulated to all offices.
All staff will be required to attend a 6-hour training on Confidentiality(255.5) on 4/13/12 presented at our Phoenixville location. This policy addendum will be reviewed for all staff as part of the training.
Site directors will perform random, monthly chart audits to ensure that the policy change is being reflected by all clinicians. |
709.92(a)(3) 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:
(3) Proposed type of support service.
|
Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document treatment plans to include proposed types of supportive services.
The findings include:
The project's policy titled Treatment Management; 60,029; Section C. Comprehensive Treatment Plan (709.92.a), Effective 1/10/11 states:
The Comprehensive Treatment Plan is an individual treatment and rehabilitation plan developed in collaboration with each patient and their assigned Primary Counselor. The plan shall include, but not be limited to, written documentation of:
a.defined
b.defined
c. Proposed type of support services. Services may include medical, psychiatric or mental health services, financial, legal, AA, NA, etc. (709.9.2a.3.).
On March 14, 2012 five client records were reviewed for comprehensive treatment plans, that included support services. Four out of five client records lacked documentation of a treatment plan that included a proposed type of support service, specifically client records # 2, 3, 4, and 5.
Client #2 was admitted on November 21, 2011. The comprehensive treatment plan was documented on November 21, 2011; however it did not include a proposed type of support service for client #2.
Client #3 was admitted on June 18, 2011 and discharged on August 20, 2011. The comprehensive treatment plan was documented on June 18, 2011; however it did not include a proposed type of support service for client #3.
Client #4 was admitted on November 23, 2011 and discharged on January 20, 2011. The comprehensive treatment plan was documented on November 23, 2011; however it did not include a proposed type of support service for client #4.
Client #5 was admitted on October 26, 2011 and discharged on December 19, 2011. The comprehensive treatment plan was documented on October 26, 2011; however it did not include a proposed type of support service for client #5.
The findings were confirmed by the Site Director during the exit interview.
|
Plan of Correction
The Site Director of the York office will conduct an In-service training in which he will review company policy and state standards regarding Master Treatment Planning, specifically ensuring that clinicians are identifying support services in the treatment plan, by 4/27/12. Each clinician will sign that they understand the documentation procedure and intend to comply. The Site Director will conduct random, monthly chart audits to ensure compliance. |
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.
|
Observations
Based on a review of client records and the facility ' s policies and procedures, the facility failed to document case consultations according to the facility ' s policies and procedures.
The findings include:
The project ' s policy in reference to case consultations states:
It is a policy of Life Management that a case conference consisting of representatives from the various patient service components be held for each active patient at least every 90 days.
On March 14, 2012 one client record was reviewed for a case consultation. One out of one client record lacked documentation of a case consultation within 90 days, specifically client record # 2.
Client #2 was admitted on November 21, 2011. A case consultation was due by February 21, 2012. At the time of inspection there was no documentation of a case consultation.
The findings were confirmed by the Site Director during the exit interview
|
Plan of Correction
The Site Director of the York office will conduct an in-service training pertaining to Case Consultations, specifically discussing that Case Consults must be completed a minimuum of every 90 days for all active clients, before 4/20/12. All staff will sign off that they attended the training and understand company policy. The Site Director will conduct monthly, random chart audits to ensure that all clinicians are in compliance. The clinician for Client #2 conducted the Case Consultation on March 14, 2012. |