INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 10, 2016 by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, St. John Vianney 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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709.123(b)(1)(ii) LICENSURE Tx type & frequency
709.123. Treatment and rehabilitation.
(b) Treatment and rehabilitation services.
(1) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(ii) Type and frequency of treatment and rehabilitation services.
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Observations
Ten client records were reviewed on August 10, 2016. Based on this review, the facility failed to document the frequency of individual treatment on the comprehensive treatment plan in ten of ten client records.
Client records #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 contained comprehensive treatment plans that called for the provision of individual therapy session but the frequency of the individual treatment was not specified on the plan.
This information was reviewed with facility staff.
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Plan of Correction
Staff involved in treatment plan development will complete training around treatment plan requirements on 8/31/2016 as facilitated by the Clinical Director. Treatment plan updates will be audited by the Director of MIS, Quality & Regulatory Compliance on a monthly basis to ensure plans reflect the frequency of services provided.
Monthly data collection results will be reviewed monthly by the Performance Improvement Committee who may recommend further staff training should compliance not be met. Auditing will cease once a compliance rate of 90%, over 6 consecutive months, is met. |
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
During a review of client records and a conversation with the facility staff on August 10, 2016, the facility failed to utilize an informed and voluntary consent form that included the name of the person, agency or organization to whom disclosure is made, and the specific information to be disclosed in client records #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
Additionally, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in client record #1.
Client #1 was admitted on February 13, 2016 and was an active client at the time of the licensing inspection. A fax cover sheet dated July 25, 2016 indicated the release of client identifying information to another healthcare provider but a consent to release information to this entity was not documented in the client record.
This information was reviewed with the facility staff.
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Plan of Correction
To protect confidentiality, any request for resident information to be disclosed will only be fulfilled after a consent for Release of Information Form has been completed, signed and dated by the resident. This will include all clinical information/reports, billing information/invoices, and all correspondences discussing resident care. The Director of MIS, Quality and Regulatory Compliance will audit a sample of completed release of information requests on a monthly basis to ensure the disclosures have a corresponding release of information. Monthly data collection results will be reviewed monthly by the Performance Improvement Committee. Auditing will cease once a compliance rate of 90%, over 6 consecutive months, is met.
The facility will revise the Release of Information to Third Party Payors Form to clarify financial/billing information will be both sent and received by Saint John Vianney Center. All current residents and new admissions will complete the revised consent form.
Regarding resident record #1, a Release of Information Form was completed and signed by the resident as of 8/12/2016 to allow for future disclosure of information with the service provider. |