INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 18, 2009 through March 19, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Horsham Clinic 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 April 9, 2009.
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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 on March 19, 2009, the facility failed to obtain an informed and voluntary consent from the client for disclosure of information contained in the client record in six of six client records.
The findings include:
Six client records were reviewed on March 19, 2009. Six client records were required to have an informed and voluntary consent from the client for disclosure of information contained in the client record. The consent forms included language to release or obtain information in client records #1, 2, 3, 4, 5 and 6. The consent forms also included language that permitted the "complete medical record" to be released, which constituted a general consent, in client records #1, 2, 3, 4, 5 and 6.
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Plan of Correction
The Release of Information Form will be redesigned by the Project Director to eliminate the "obtain" section of information requests. The form will also eliminate the language "complete medical record" and will be redesigned with more specific requests for information. The form will be presented to the Health Information Management Committee and Medical Executive Committee for approval. All program staff will receive training from the Clinical Supervisor on the new form and the requirements for informed and voluntary consent from the client for the disclosure of information. The training will be mandatory for all clinical staff and is scheduled for May 6th or May 20th. A performance improvement monitor will be completed by the Project Director and Clinical Supervisor auditing 25 charts monthly. The monitor will continue until 90% compliance is maintained for 2 consecutive quarters. Results of the audits will be presented to the Performance Improvement Council quarterly.
The clients whose records were identified have been discharged from the program. As a result, the deficient consent forms have been voided. If any requests are made for information, the client will be contacted to complete a new consent form with the correct information allowed. |
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 on March 19, 2009, the facility failed to obtain an informed and voluntary consent from the client that included the specific information to be disclosed in four of six client records.
The findings include:
Six client records were reviewed on March 19, 2009. Six client records were required to have an informed and voluntary consent from the client for disclosure of information that included the specific information to be disclosed. The specific information to be disclosed was missing in client records #2 and 5. The specific information to be disclosed was identified as "complete medical record"in client records #1 and 3. The specific information to be disclosed was identified as "verbal communication" in client record #5.
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Plan of Correction
The Release of Information Form will be redesigned by the Project Director to eliminate the language "complete medical record" and will be revised to include more options for specific information to be disclosed. The form will be presented to the Health Information Management Committee and Medical Executive Committee for approval. All program staff will receive training from the Clinical Supervisor on the new form and the requirements for informed and voluntary consent from the client for the disclosure of information. The training will be mandatory for all clinical staff and is scheduled for May 6th or May 20th. Staff will be trained on the types of information for disclosure that would be noncompliant with the required standards for confidentiality, i.e. "verbal communication". A performance improvement monitor will be completed by the Project Director and the Clinical Supervisor auditing 25 charts monthly. The monitor will continue until 90% compliance is maintained for 2 consecutive quarters. Results of the audits will be presented to the Performance Improvement Council quarterly.
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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 on March 19, 2009, the facility failed to obtain an informed and voluntary consent from the client that included the specific purpose for the disclosure in six of six client records.
The findings include:
Six client records were reviewed on March 19, 2009. Six client records were required to have an informed and voluntary consent from the client for disclosure of information that included the specific purpose for the disclosure. The specific purpose for the disclosure was missing in client record #5. The specific purpose for the disclosure was identified as "continuity of care" in client records #1, 2, 3, 4 and 6 with no additional documentation specific to the reason for disclosure.
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Plan of Correction
The Release of Information Form will be redesigned by the Project Director to include more options for specific purpose of disclosure. The form will be presented to the Health Information Management Committee and Medical Executive Committee for approval. All program staff will receive training from the Clinical Supervisor on the new form and the requirements for informed and voluntary consent from the client for the disclosure of information. The training has been scheduled for May 6th or May 20th and is mandatory for all clinical staff. Staff will be trained on the regulatory requirements regarding the documentation of the purpose of disclosure. A performance improvement monitor will be completed by the Project Director and the Clinical Supervisor auditing 25 charts monthly. The monitor will continue until 90% compliance is maintained for 2 consecutive quarters. Results of the audits will be presented to the Performance Improvement Council quarterly.
The clients whose records were identified have been discharged from the program. As a result, the deficient consent forms have been voided. If any requests are made for information, the client will be contacted to complete a new consent form with the correct information allowed. |
709.123(b)(2) LICENSURE Tx Plan Update
709.123. Treatment and rehabilitation.
(b) Treatment and rehabilitation services.
(2) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regimen is less than 30 days, the treatment and rehabilitation plan review and update shall occur at least every 15 days.
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Observations
Based on a review of client records on March 19, 2009, the facility failed to document treatment plan updates that included the client's progress on the treatment plan goals in two of four client records.
The findings include:
Six client records were reviewed on March 19, 2009. Four client records were required to have a treatment plan update. A treatment plan update was missing in client record #6. The treatment plan update did not include documentation of the client's progress on the stated treatment plan goals in client record #3.
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Plan of Correction
All program staff will receive training from the Clinical Supervisor regarding the timely review and completion of treatment plan updates, which includes documentation of the client's progress on the treatment plan goals. The training will be mandatory for all clinical staff and is scheduled for April 29, 2009. The Clinical Supervisor will audit 20 charts each month for compliance with treatment planning. Monitors will continue until two consecutive months of compliance have been achieved.
The treatment plans for client records #3 and #6 were updated including the client's progress on 3/20/2009. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records on March 19, 2009, the facility failed to ensure that all counselors hired met the educational qualifications for the counselor position.
The findings include:
Five personnel records were reviewed on March 19, 2009. One counselor did not meet the educational qualifications for the counselor position. Personnel record #4 indicated this staff person was hired as a counselor. However, this staff person did not have a qualifying bachelor's degree or a CAC. Personnel record #4 had an AAC II certification, which did not qualify for the position of counselor.
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Plan of Correction
The identified staff member has been re-assigned as a Counselor Assistant. He has a staff development plan to complete the required training for a Counselor Assistant. He is currently receiving supervision from the Clinical Supervisor. He has a plan to move toward promotion as a Counselor. |