INITIAL COMMENTS
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This report is a result of an on-site inspection to this recently licensed facility following the admission of clients for treatment. The inspection was conducted on June 17, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of this on-site follow up inspection, St. Joseph Institute 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 August 4, 2010.
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Plan of Correction
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709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records and an interview with the facility director, facility staff failed to include the specific information that would be released on the client's consent to release information forms documented in five of five client records.
The findings include:
Five client records were reviewed on June 17, 2010. Written consent to release information forms signed by the clients and documented in the client records failed to include documentation of the specific information that would be disclosed in five client records reviewed.
Client # 1 was admitted on 4/19/10 and discharged on 4/30/10. Consent to release information forms documented in the client record and signed by the client and an employee acting as witness, did not include documentation of the specific information that would be released.
Client # 2 was admitted on 5/3/10 and discharged on 5/17/10. Consent to release information forms documented in the client record and signed by the client and an employee acting as witness, did not include documentation of the specific information that would be released.
Client # 3 was admitted on 3/29/10 and discharged on 4/26/10. Consent to release information forms documented in the client record and signed by the client and an employee acting as witness, did not include documentation of the specific information that would be released.
Client # 4 was admitted on 4/29/10 and discharged on 5/15/10. Consent to release information forms documented in the client record and signed by the client and an employee acting as witness, did not include documentation of the specific information that would be released.
Client # 5 was admitted on 4/19/10 and discharged on 4/30/10. Consent to release information forms documented in the client record and signed by the client and an employee acting as witness, did not include documentation of the specific information that would be released.
This was discussed with the Facility Director on June 17, 2010 who concurred with the findings.
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Plan of Correction
This POC will address the specific findings of five client records that reviewed on June 17, 2010. If was noted that written consent to release information forms signed by the clients and documented in the client records failed to include documentation of the specific information that would be disclosed.
The clinical supervisor will be responsible for training intake/admission staff, nursing staff and all clinical staff that will be responsible for written consents. This in-service training will be conducted by the week ending August 20, 2010. The training will address the need of specific information for
disclosure i.e. bio/psycho/social history, H & P information, progress/status updates, etc. Specific language will be addressed and general terms/language will be noted as unacceptable for disclosure.
The clinical supervisor will be required to monitor all active files with weekly review of all consents for complaince. This issue will continue to be on-going training in regular supervision of clinical staff from clinical supervisor.
The facility director will be responsible for the oversight. The facility director will at random audit resident files to ensure complaince. This audit will be completed/documented monthly and will include the audit of 20% of the daily census.
Additional trainings will be explored outside the agency. |
709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records and an interview with the facility director, facility staff failed to include the purpose for the release of information on the client's consent to release information forms documented in five of five client records.
The findings include:
Five client records were reviewed on June 17, 2010. Written consent to release information forms signed by the clients and documented in the client records failed to include documentation of the purpose for the release of information in five client records reviewed.
Client # 1 was admitted on 4/19/10 and discharged on 4/30/10. Consent to release information forms documented in the client record and signed by the client and an employee acting as witness, did not include documentation of the purpose for the release of information.
Client # 2 was admitted on 5/3/10 and discharged on 5/17/10. Consent to release information forms documented in the client record and signed by the client and an employee acting as witness, did not include documentation of the purpose for the release of information.
Client # 3 was admitted on 3/29/10 and discharged on 4/26/10. Consent to release information forms documented in the client record and signed by the client and an employee acting as witness, did not include documentation of the purpose for the release of information.
Client # 4 was admitted on 4/29/10 and discharged on 5/15/10. Consent to release information forms documented in the client record and signed by the client and an employee acting as witness, did not include documentation of the purpose for the release of information.
Client # 5 was admitted on 4/19/10 and discharged on 4/30/10. Consent to release information forms documented in the client record and signed by the client and an employee acting as witness, did not include documentation of the purpose for the release of information.
This was discussed with the Facility Director on June 17, 2010 who concurred with the findings.
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Plan of Correction
This POC will address the specific findings of five client records that reviewed on June 17, 2010. If was noted that written consent to release information forms signed by the clients and documented in the client records failed to include the purpose for the release of information on the client's consent to release.
The clinical supervisor will be responsible for training intake/admission staff, nursing staff and all clinical staff that will be responsible for written consents. This in-service training will be conducted by the week ending August 20, 2010. This training will address the purpose for the release of information on the client's consent to release information. Specific language will be addressed and general terms/language will be noted as unacceptable for disclosure. The clinical supervisor will be required to monitor all active files with weekly review of all consents for complaince. This issue will continue to be on-going training in regular supervision of clinical staff from clinical supervisor.
The facility director will be responsible for the oversight. The facility director will at random audit resident files to ensure complaince. This audit will be completed/documented monthly and will include the audit of 20% of the daily census. Additional trainings will be explored outside the agency. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of client records and an interview with the facility director, the Facility Director failed to provide written policies and procedures consistent with the regulations and failed to advise clients of client rights consistent with Pennsylvania Code.
The findings include:
A follow up inspection was conducted on June 17, 2010. The written policies and procedures that had been approved during the pre survey process which culminated on March 4, 2010 were not available during the follow up inspection conducted on June 17, 2010. An interview with the Facility Director on June 17, 2010 confirmed that the previously approved policies and procedures were not in the manual and were not in the client orientation handbook. The previously approved policies and procedures were not posted on client bulletin boards and there was no documentation in five of five client records reviewed on June 17, 2010 to demonstrate that the clients had been advised of the Department of Health approved client rights.
This was discussed with the Facility Director on June 17, 2010 who concurred with the findings.
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Plan of Correction
This POC will address the specific findings of client records that were reviewed on June 17, 2010. If was noted that the Facility will provide written policies and procedures consistent with the regulations and to advise clients of client rights consistent with Pennsylvania Code.
After follow up inspection, the Facility Director researched all updated and apporvied policies & procedures documents. The approved polices & procedures from March 4, 2010 were never updated in the current manuals. All manuels will be purged of outdated policies and procedures and updated with the previously approved policies and procedures. The completion date is August 20, 2010. This will be completed by business office staff and supervised by Facility Director.
Effective, Ausgust 3, 2010 this information has been added into the new resident handbook for client orientation. Awaiting management approval - complete with implementation by August 20, 2010.
The approved policies and procedures from March 4, 2010 have been posted on all client bulletin boards.
The client rights signature line demonstrate that the clients have been advised of the Department of Health approved client rights. A signature line has been added indicating that the client was asked if they wished to have a copy or not.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and an interview with the facility director, facility staff failed to document complete psychosocial evaluations in four of five client records reviewed.
The findings include:
Five client records were reviewed during a follow up inspection on June 17, 2010. The psychosocial evaluations documented in four of five client records were incomplete and non evaluative.
Client # 1 was admitted on 4/19/10 and discharged on 4/30/10. The psychosocial evaluation documented in the record failed to include evaluations of the client's assets/strengths, support systems and coping mechanisms.
Client # 2 was admitted on 5/3/10 and discharged on 5/17/10. The psychosocial evaluation documented in the record failed to include evaluations of the client's assets/strengths, support systems and coping mechanisms.
Client # 3 was admitted on 3/29/10 and discharged on 4/26/10. The psychosocial evaluation documented in the record failed to include evaluations of the client's assets/strengths, support systems and coping mechanisms.
Client # 5 was admitted on 4/19/10 and discharged on 4/30/10. The psychosocial evaluation documented in the record failed to include evaluations of the client's assets/strengths, support systems and coping mechanisms.
This was discussed with the Facility Director on June 17, 2010 who concurred with the findings.
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Plan of Correction
The POC will address the psychosocial evaluation documentation in the client record. It indicated that the facility failed to include evaluations of the client's assets/strengths, support systems and coping mechanisms.
The psychosocial evaluation does include areas of client's assets/strengths, support systems and coping mechanisms.
The clinical supervisor will be responsible for training intake/admission staff, nursing staff and all clinical staff that will be responsible for intake/admissions. This in-service training will be conducted by the week ending August 20, 2010. This training will address the purpose for identification of assets, coping skills, support systems plus any additional information for the purpose of evaluation. All areas identified will be specific to identified issues/components/tools to utilize or develop by the client. These will be utilized as part of the overall treatment plan.
This information will be included in the psychosocial summary note summarizing the evaluation and assets/defiencies that the client will address in treatment.
The clinical supervisor will be required to monitor all active files with weekly review of all documented areas for complaince. This issue will continue to be on-going training in regular supervision of clinical staff from clinical supervisor.
The facility director will be responsible for the oversight. The facility director will at random audit resident files to ensure complaince. This audit will be completed/documented monthly and will include the audit of 20% of the daily census.
Additional trainings of data collection and motivational interviewing will be explored outside the agency.
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709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records and an interview with the facility director, facility staff failed to include the type and frequency of treatment services on the treatment plans documented in two of five client records.
The findings include:
Five client records were reviewed on June 17, 2010. The type and frequency of treatment was not documented on the treatment plans in two of five client records reviewed.
Client # 3 was admitted on 3/29/10 and discharged on 4/26/10. The type and frequency of treatment was not documented on the treatment plan.
Client # 4 was admitted on 4/29/10 and discharged on 5/15/10. The type and frequency of treatment was not documented on the treatment plan.
This was discussed with the Facility Director on June 17, 2010 who concurred with the findings.
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Plan of Correction
This POC will address the specific findings of two of five client records that reviewed on June 17, 2010. If was noted that facility staff failed to include the type and frequency of treatment services on the treatment plans.
The clinical supervisor will work directly with the clinical team - RN, Director of Wellness, Intake/Admissions, Counselor(s)to update the treatment plan to include type and frequency of treatment. It will be documented on the treatment plan. The Record of Service will support the type & frequency of services identified on the treatment plan. This change will be completed by August 20, 2010.
A weekly review will be conducted by the clinical team under the supervision of the clinical supervisor during treatment team meetings on Thursdays. Any changes or updates will be noted in chart. This will ensure proper complaince.
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709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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 and an interview with the facility director, facility staff failed to include documentation of case consultations in four of four client records where due.
The findings include:
Five client records were reviewed on June 17, 2010. Documentation of case consultations were due to be documented in four of those client records.
Client # 1 was admitted on 4/19/10 and discharged on 4/30/10. There was no documentation of a case consultation as of June 17, 2010.
Client # 2 was admitted on 5/3/10 and discharged on 5/17/10. There was no documentation of a case consultation as of June 17, 2010.
Client # 3 was admitted on 3/29/10 and discharged on 4/26/10. There was no documentation of a case consultation as of June 17, 2010.
Client # 4 was admitted on 4/29/10 and discharged on 5/15/10. There was no documentation of a case consultation as of June 17, 2010.
This was discussed with the Facility Director on June 17, 2010 who acknowledged the findings.
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Plan of Correction
This POC will address the specific findings of client records that were reviewed on June 17, 2010. If was noted that the facility staff failed to include documentation of case consultations in four of four client records.
After follow up inspection, the Facility Director researched and interviewed the clinical supervisor at the time of the inspection. It was noted that the case consultation/follow up is an on-going, daily, weekly and monthly log that is maintained in an electronic, secured, and password protected file accessable by clinical staff.
Personally, I have reviewed this tracking/monitoring file for case consultation notes and see no need to change this procedure. This procedure will continue to be supervised by clinical supervisor and oversight provided by the Facility Director.
During the next site visit the inspector can be given the password to explore the documentation.
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