INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 24 - 25, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, The Guidance Center 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
The facility failed to complete the treatment plan within 15 days per facility policy in three of seven client records reviewed on April 25, 2019. Client records #3, #6, #7 did not complete the treatment plan within 15 days. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Drug & Alcohol Program Director will update the Treatment Rehabilitation Management policy within the agency's Drug and Alcohol Policy manual to remove the 15 day time frame and reflect more specific treatment management practices. An initial treatment plan is completed on the day of intake and will be specified more clearly in the policy manual. The individual treatment and rehabilitation plan will be developed with the client within 60 days of admission and updated at least every 60 days thereafter. Updates to policy will be reviewed by agency Board of Directors on 5/28/19.
Any approved updates to practices and policies will be reviewed in the staff supervision meeting on 6/04/19 with Drug and Alcohol staff who will sign off on document acknowledging the review.
The D/A Program Director (Facility Director) will monitor client records to ensure that adherence to policy occurs. |
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.
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Observations
The facility failed to document an informed and voluntary consent from the client prior to the disclosure of information in one of seven client records reviewed on April 25, 2019.Client record #1 included:was disclosed to a pharmacy on September 18, 2018, but a release of information was not signed for that pharmacy until October 18, 2018.release of information to an insurance company was signed on September 13, 2018 but did not indicate the name of the person, agency or organization to whom disclosure is made.release of information for an emergency contact was signed on September 13, 2018 but did not include an appropriate purpose for disclosure.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program (Facility) Director will review Confidentiality Procedures and Regulations with Drug and Alcohol Program staff during supervision meeting on 5/14/19. Staff members include 3 therapists, program nurse and psychiatric staff. All Drug and Alcohol Program staff will sign off on the training and supervision meeting. This record will be turned into personnel department.
Audits of records which includes all consents will be completed by Program Director on all new Drug and Alcohol clients entering the program as of 6/01/19. Monthly random record audits will be completed on active clients by Program (Facility) Director to ensure consents are complete and accurate for any disclosures made. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
The facility failed to include "creed, sex, and color" in the Client Rights policy and procedure, and in the written acknowledgement signed by clients in seven of seven client records reviewed on April 25, 2019. These findings were reviewed with facilty staff during the licensing process.
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Plan of Correction
Drug and Alcohol Program (Facility) Director updated the agency's drug & alcohol policy titled Client Civil Rights and Liberties Policy to include the words creed, sex and color on 5/06/19.
Credible Form Manager, with input from Program (Facility) Director made updates to the Drug & Alcohol Client's Rights Agreement located within the Electronic Medical Record on 5/03/19. The words creed, sex and color were included in the document which is signed by clients upon admission to the Drug & Alcohol Program.
Current clients will sign off on the updated clients rights agreement by July 1, 2019. Drug and Alcohol Program (Facility) Director will monitor this completion. All clients admitted after 5/03/19 have been signing the updated agreement. Drug and Alcohol Program (Facility) Director reviews all new clients within a week of admission. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
The facility failed to include the "Project, Facility, or Clinical Director can remove portions of the client record", and the "reasons for removing sections shall be documented in the record" in the Client Rights policy and procedure, and in the written acknowledgement signed by clients in seven of seven client records reviewed on April 25, 2019. These findings were reviewed with facilty staff during the licensing process.
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Plan of Correction
The agency's current Drug and Alcohol program Client Access to Records policy approved on 4/27/16 states "Clients have the right to inspect their own records. The Executive Director or Outpatient Director may temporarily remove portions of the record prior to the inspection by the client if determined that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record." As the only difference to the policy and regulation is title differences, the titles project, facility and clinical director have been added to the policy by the D/A Program Director as of 5/06/19.
Additionally, the current D/A Clients Rights document has a section titled Access to Records. In this section the statement "Clients have the right to inspect their own records. Portions of the record may be temporarily removed prior to the inspection if it is determined that the information may be detrimental if presented to the clients. "
The Credible Form Manager with input from the D/A Program (Facility) Director made updates to the form in the Electronic Health Record to include the specific language of the regulation. These updates were made on 5/03/19 to the D/A Client's Right agreement that is signed by clients upon intake. The wording now includes the following :
I understand that I have to the right to:
Request to inspect my treatment records. I understand that the project, facility or clinical director may temporarily remove portions of the record prior to the inspection if the director determined that the information may be detrimental if presented to me. Reasons for removing sections shall be documented in the record.
Current clients will sign off on the updated clients rights agreement by July 1, 2019. Drug and Alcohol Program (Facility) Director will monitor this completion. All clients admitted after 5/03/19 have been signing the updated agreement. Drug and Alcohol Program (Facility) Director reviews all new clients within a week of admission. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
The facility failed to provide each patient an average of 2. 5 hours of therapy per month in two of three patient records reviewed on April 25, 2019. Patient records # 1 and # 4 did not document the required hours. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The D&A Program (Facility) Director provided another review of Regulation 715.19 with MAT prescribers, program nurse and counselors during the 5/07/19 supervision meeting. Methods to increase compliance with required counseling will include:
1) Program Nurse will maintain spreadsheet of individuals enrolled in the MAT program and record their monthly counseling attendance hours. This information will be reviewed during weekly meetings with prescribers and drug and alcohol program therapists and Program Director. For clients who have no showed appointments or cancelled them during the previous week, Program Nurse will call and reach out to client. At next appointment with MAT prescriber, client will only receive enough medication to last until client has attended a counseling session. For clients who do not attend regular counseling appointments, prescribers will work to provide a taper or referral to another agency.
2.)Therapists will offer group sessions to increase opportunities for clients to receive psychotherapy.
2) Prescribers' secretaries will work to schedule Suboxone maintenance visits for clients on the same day that they are receiving counseling eliminating a barrier of difficulty with transportation.
Program Director (Facility) will monitor clients' monthly attendance to determine compliance. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The facility failed to document an individual treatment plan that included the frequency of treatment services in seven of seven client records reviewed on April 25, 2019.Seven of seven client records documented "Individuals weekly to monthly as needed" and did not specify the frequency of treatment services.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The phrase Individual weekly to monthly has been removed from electronic treatment plan.
D & A Program Director (Facility Director) will provide a training to therapists on 5/14/19 on how to enter information regarding type and frequency of treatment services into the electronic drug and alcohol treatment plan during weekly supervision meeting. Therapist will sign off on this training.
Credible Form Manager with input from the D/A Program Director added free boxes to treatment plan so that information can be individualized and specific.
Program Director (Facility) beginning 6/01/19 will conduct monthly audits on treatment plans to ensure that the type and frequency is added correctly. |
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
The facility failed to document a treatment plan update every 60 days in three of seven client records reviewed on April 25, 2019. Client records #1, #5, #6 did not update the treatment plan every 60 days.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
D & A Program Director (Facility) will provide training to therapy staff on 5/14/19 regarding the requirement to update treatment plans every 60 days. This training will clarify the therapists confusion and discrepancy between the Certified Community Behavioral Health Clinic's indicator that clients must sign treatment plan for it to be effective and regulation 709.92. Clarification in policy will also be completed by Program Director.
Therapy staff will be directed to update treatment plan in time frame required even if client is not present. Therapist will sign off on the training and records of supervision meeting will be maintained in a supervision file in Program Director's office.
Program Director will complete monthly audit of clinical records to ensure compliance. |