INITIAL COMMENTS
|
This report is a result of an unannounced inspection conducted on November 16, 2010 by staff from the Division of Drug and Alcohol Program Licensure Based on the findings of the on-site inspection, B.I. Incorporated 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 December 14, 2010.
|
Plan of Correction
|
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
|
Observations
Based on the review of staff records, administrative documents and an interview with the staff, the facility failed to provide documentation of an annual training assessment for the 2010 training year.
The findings include:
An unannounced follow up inspection was conducted on November 16, 2010. During the inspection the ranking employee in the Drug and Alcohol treatment program, the lead counselor, was interviewed and asked to provide Division staff with documentation of the annual training assessment for the 2010 training year. The annual training year runs from January to December This employee stated that these documents were not accessible at the time of the inspection and that they would be forwarded by the Facility Director who was working at another facility on November 16. Attempts by Division staff were made to obtain the document on November 15, 19 and 23. Additional training materials were presented to Division staff as of November 23, 2010, however no documentation of a staff training assessment was provided.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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.
|
Observations
Based on a review of client records and interviews with facility staff, the facility failed to distinguish between the Day Reporting case management activity and the Drug and Alcohol treatment activity failed to maintain confidentiality in three of three client records.
The findings include:
On November 16, 2010 three client records and the corresponding case management records were reviewed., Three additional case management records were also reviewed.
The form entitled "Starting Point- Client Information pages 15-17 Revised 6/20/10" is used in all case management files. The form is called a Release of Information form and the stated purpose of the form is
"...to allow communication with supervising criminal justice agencies to ensure ..compliance and progress on issues that pertain to supervision requirements, treatment needs and public safety."
The information on the form which is disclosed to criminal justice agencies exceeds the limits imposed at 4 Pa. Code 2.55.5(b) by allowing such detailed information as drug and alcohol use and drug test results to be released to the criminal justice agencies involved. The next to the last bullet point on page 16 of 17 addresses the Federal Drug and Alcohol Confidentiality regulations at 42 CFR Part 2, Subparts A through E, and states that
".. recipients of this information may re-disclose it only in connection with their official duties, in a professional manner."
In fact, 42 CFR Part 2 , Subpart C subsection 2.32 specifically prohibits re-disclosure of client information without the explicit written consent of the person to whom the information pertains.
The form entitled "Client Contract & Program Rules", Section 7 addresses instances allowing for the release of client identifying information. This form is used in both the Day Reporting Center (DRC) and the Drug and Alcohol treatment components of the program. This section allows for the release of client identifying information without client consent. The Pennsylvania law at 71 P.S. subsection 1690.108(b) states that information contained in the client record may only be released with the written consent of the client. The Federal confidentiality law at 42 CFR Part 2, Subparts D & E specifically defines those situations not requiring client consent for the release of information from the record. Bullet point #6 under section 7 of the facility document incorrectly identifies elder abuse/neglect as an instance in which disclosure without the written consent of the client may occur. Bullet point # 7 under section 7 incorrectly identifies threats to others as instances which would permit disclosure without client consent. This is not consistent with 42 C.F.R. Part 2, Subpart E, Subsection 2.63
The Authorization to release information forms used in both the DRC and the Drug and Alcohol treatment records of the program incorrectly states that information could be disclosed without the client's consent.
The patient HIPAA consent form used in both the Drug and Alcohol and the DRC records states in paragraph 1 and the accompanying bullet points that:
"... I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out: treatment, obtain payment, and for the day to day healthcare operations of your practice."
This statement constitutes a general consent to release information. 4 Pa. Code 255.5 and 28 Pa. Code 709.28 (c)(2) require that the specific information to be released be identified on the consent to release information form and it is this component which makes the consent an informed consent. The HIPAA form also states that
"I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these restrictions."
This statement is incorrect. 42 CFR Part 2, Subpart A, Subsection 2.2(a)(1) states that prior written consent is required for disclosures from the client record. The only exceptions to this are listed at 42 CFR Part 2, Subparts D & E and 71 P. S . Subsection 1690.108(b)(ii).
The form entitled "Disclosure of Client Oriented Information" incorrectly states that information may be released "with or without" consent to judges and probation/parole officers. The state regulation at 4 Pa. Code Subsection 255.5 is superseded by state law at 71 P. S . Subsection 1690.108(b) and federal regulation at 42 CFR Part 2, Subpart A, Subsection 2.2(a)(1) and requires that client consent be given for all disclosures unless specifically excepted as stated above. Written facility policy correctly states that releases to judges and probation/parole officer is to occur with the consent of the client. The facility failed to follow its own policy in the development and use of this form.
The facility confidentiality policy on page 115 under policy 709.28(a) (2) states that the following persons may have access to client records: " project and facility Directors, Clinical Supervisors, Counselors , Adjunct Drug and Alcohol and Day Reporting Center personnel...". The policy incorrectly authorizes adjunct staff to have access to the client's Drug and Alcohol treatment records. Adjunct personnel (those who are not employees of B.I., Inc. and Day Reporting Center staff) may not access the D&A treatment records without the client's written consent.
The issues were reviewed onsite with agency staff and they did not dispute them.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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.
|
Observations
Based on the review of client records and staff interviews, the facility failed to insure that the limits on the specific information disclosed under the consent to release information forms signed by the client and/or the limits imposed at 4 Pa. Code Subsection 255.5(b) were adhered to in four of six client records reviewed.
The findings included:
On November 16, 2010 three client records were reviewed and an additional three client records were reviewed to confirm the findings. Each record was required to adhere to the limitations imposed at 4 Pa. Code Subsection 255.5(b) and the limits established on the consents to release information forms signed by the client. In addition to the record reviews, an interview was conducted with case management staff and clinical staff. Staff disclosed in the interviews that positive drug and alcohol results are routinely released to Probation Officers and to a representative from the Single County Authority who acts as a liaison between the County Prison and the facility. These violations of client confidentiality were discussed with facility staff. The findings was not disputed.
Record # 2- The client was admitted on 9/14/10. Positive urine results were noted in the case management record on 8/16/10 and 8/17/10 for the client's drug of choice. Based on staff interviews these results were disclosed to the client's Probation Officer and the SCA representative who acts a the liaison with the Luzerne County Correctional Facility. Two individual progress notes in the client treatment record dated 11/1/10 documented that the client's refusal to sign a release of information to her physician regarding Suboxone treatment was communicated to the SCA case manager involved who acts as the liaison with the Luzerne County Correctional Facility.
Record # 3- The client was admitted on 8/18/10. Positive results were obtained on drug tests conducted on 9/3/10, 9/20/10 and 9/29/10 and were documented in the case management record.. Based on the staff interviews, these results were released to the Probation Officer involved and the SCA case manager involved who acts as the liaison with the Luzerne County Correctional Facility.
Record # 4 - The client was admitted on 9/30/10. Positive results were obtained on drug tests conducted on 10/20/10 and 10/27/10 and were documented in the case management record. Based on the staff interviews, these results were released to the Probation Officer involved and the SCA case manager involved who acts as the liaison with the Luzerne County Correctional Facility.
Record # 5- The client was admitted on 8/20/10. One progress note in the treatment record was not signed or dated. The content of this individual progress note indicated that the client's Probation Officer and the SCA Case Manager, who acts as the liaison with the Luzerne County Correctional Facility, were involved in the counseling session involving discussion around the issue of the client's suicidal ideation and drug use. An individual progress note in this treatment record dated 10/7/10 included the SCA Case Manager, who acts a the liaison with the Luzerne County Correctional Facility, as participating in the individual counseling session which discussed stressors in the client's life and counseling around this issue with the client. Issues surrounding the clients Drug and Alcohol use were also discussed in this counseling session.
The consents to release information in place for these individuals only permitted releases of information consistent with the limitations imposed at 4 Pa. Code subsection 255.5(b). The releases of information and the participation of the SCA Case Manager and the Probation Officer in the counseling sessions exceeded the limitations imposed at 4 Pa. Code subsection 255.5(b).
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on the review of client records during the unannounced onsite licensing inspection, the facility failed to document a psychosocial evaluation which provided a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation in three of three client records reviewed.
The findings include:
On November 16, 2010, three client records were reviewed. Each was required to include documentation of a psychosocial evaluation which included identification of relationships, conditions and causes contributing to the client's current condition. Facility policy mirrors the requirements of the regulation regarding the content of the psychosocial evaluation. The standardized form used for the evaluation is constructed in the format stated in the regulation.
Client record # 1- The client was admitted on 11/4/10. The content of the psychosocial evaluation in this record was not constructed to identify the individual treatment needs of the client. The language in the document included rote phrases written in generic language. An example of this is as follows: "..Client needs to appropriately learn positive coping skills in order to gain techniques to aid in recovery...to avoid people places and things..become involved in a sober support network". The document was not specific to the client, was not individualized and was not evaluative.
Client record # 2- The client was admitted on 9/14/10. The content of the psychosocial evaluation in this record was not constructed to identify the individual treatment needs of the client. The language in the document included rote phrases written in generic language. An example of this is as follows: "..Client needs to appropriately learn positive coping skills in order to gain techniques to aid in recovery...to avoid people places and things..become involved in a sober support network". The document was not specific to the client, was not individualized and was not evaluative.
Client record # 3- The client was admitted on 8/18/10. The content of the psychosocial evaluation in this record was not constructed to identify the individual treatment needs of the client. The language in the document included rote phrases written in generic language. An example of this is as follows: "..Client needs to appropriately learn positive coping skills in order to gain techniques to aid in recovery...to avoid people places and things..become involved in a sober support network". Coping mechanisms were identified from the client's viewpoint and identified coping mechanisms as drug use. The document was not specific to the client, was not individualized and was not evaluative.
The findings were reviewed with the lead counselor who was the ranking staff person for the Drug and Alcohol Treatment activity during the inspection and she did not dispute them.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.92(a) 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:
|
Observations
Based on a review of client records, the facility failed to document an individualized treatment plan in three of three client records reviewed.
The findings include:
On November 16, 2010, three client records were reviewed. Each was required to include documentation of an individualized treatment plan. The content of the treatment plans were similar or identical in the three client records reviewed.
Client record # 1- The client was admitted on 11/4/10. The treatment plan was formulated on 11/5/10. The content of the treatment plan in this record was not constructed to address the individual treatment needs of the client and was not an individualized treatment plan. The language in the document included rote phrases written in generic language.
Client record # 2- The client was admitted on 9/14/10. The treatment plan was formulated on 10/1/10. The content of the treatment plan in this record was not constructed to address the individual treatment needs of the client and was not an individualized treatment plan. The language in the document included rote phrases written in generic language.
Client record # 3- The client was admitted on 8/18/10. The treatment plan was formulated on 9/3/10. The content of the treatment plan in this record was not constructed to address the individual treatment needs of the client and was not an individualized treatment plan. The language in the document included rote phrases written in generic language.
The findings were reviewed with the lead counselor who was the ranking staff person for the Drug and Alcohol treatment activity during the inspection and she did not dispute them.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(3) LICENSURE Client records
709.93. 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:
(3) Record of services provided.
|
Observations
Based on a review of client records and an interview with clinical staff, the facility failed to document a record of services for each client which included a chronological listing (separate from progress notes) of the various specific services provided to the individual client in three of three client records reviewed.
The findings include:
On November 16, 2010, three client records were reviewed. Each was required to include documentation of a record of service.
Client record # 1- The client was admitted on 11/4/10. No record of service was documented in the client record.
Client record # 2- The client was admitted on 9/14/10. No record of service was documented in the client record.
Client record # 3- The client was admitted on 8/18/10. No record of service was documented in the client record.
The lead counselor was interviewed on 11/16/10 at approximately 3:30 P.M. and acknowledged that none of the D&A records contained records of service.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |