INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on August 25, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site complaint investigation, New Directions Treatment Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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.
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Observations
Based on an interview with the Facility Director, the facility failed to protect the confidentiality of client identities and records. The findings include:A complaint investigation was conducted on August 25, 2015. The facility failed to protect the confidentiality of client identities and records by having clients who are seen once per month complete their treatment plan updates during group sessions.These findings were reviewed with facility staff during the complaint investigation.
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Plan of Correction
Action/ Plan: Group leaders will be instructed to protect the Identifies of group participants during group sessions. Group leaders will be informed that clients' completed MI Change Plan Worksheets will be used develop treatment plan goals after and not during the group session. participants MI Change Plan Worksheets will be completed only using first names to protected confidentiality. Ongoing compliance with the standard will be monitored by Clinical Director though quality record reviews and during individual supervision.
Person(s) Responsible: Clinical Director, Clinical Staff
Date of full compliance: May 10, 2016
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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
Based on an interview with the Facility Director, the facility failed to develop individual treatment and rehabilitation plan updates with clients. The findings include:A complaint investigation was conducted on August 25, 2015. A list of current clients was reviewed which indicated New Directions had a total of 620 active clients. The Staffing Requirements Facility Summary Report was reviewed which indicated there was 12 counselors and 293 clients. The Facility Director indicated the difference of 327 clients reflects the long-term clients seen once a month.The Facility Director indicated that treatment plan updates for clients seen once per month were completed during monthly group sessions.These findings were reviewed with facility staff during the complaint investigation.
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Plan of Correction
Action/ Plan: Group leaders will be instructed to protect the Identifies of group participants during group sessions. Group leaders will be informed that clients' completed MI Change Plan Worksheets will be used develop treatment plan goals after and not during the group session. participants MI Change Plan Worksheets will be completed only using first names to protected confidentiality. Ongoing compliance with the standard will be monitored by Clinical Director though quality record reviews and during individual supervision.
Person(s) Responsible: Clinical Director, Clinical Staff
Date of full compliance: May 10, 2016
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