INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 4, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, A Better Today, Inc. Satellite Hazleton 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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709.28 (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
Based on the review of 13 client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 2 records. Additionally, 1 record had consent to release information forms that were missing the purpose of the disclosure.
Client #3 was admitted to the outpatient level of care on 09/25/2017 and was still active at the time of the inspection. There was documentation that a treatment update letter was faxed to a government agency on 09/26/2017; however, there was no proper consent to release information form signed by the client prior to disclosure.
Client #4 was admitted to the outpatient level of care on 05/08/2017 and was discharged on 10/03/2017. There was documentation that a treatment update letter was faxed to the probation officer on 10/03/17; however, there was no proper consent to release information form signed by the client prior to disclosure.
Client #12 was assessed in the intake, evaluation, and referral level of care on 05/15/2017. There was a release of information form to another treatment provider and a release of information form to the court system, both signed/dated by client on 5/15/17 and both forms did not have the purpose of the disclosure included.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Disclosure of Records: The office staff were educated on confidentiality and the importance of completing a release for any third party disclosure.
Monthly training will include how to properly complete a release of information.
Weekly Quality Insurance will be performed to insure completion of required documentation and releases are completed.
Clinical Director is responsible for this implementation and continued education. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of 7 outpatient client records, there was no documentation that the clients received counseling services according to their individual comprehensive treatment plan in 5 charts reviewed.
Client #2 was admitted on 03/22/2017 and was still active at the time of the inspection. The comprehensive treatment plan, dated 03/22/17, indicated 3 group sessions per week (or 12 groups per month). The chart's record of service and progress notes indicated that the client had received no group sessions for the months of October 2017 and November 2017.
Client #3 was admitted on 09/25/2017 and was still active at the time of the inspection. The comprehensive treatment plan, dated 09/25/17, indicated 3 group sessions per week (or 12 groups per month). The chart's record of service and progress notes indicated that the client had received a total of 6 group sessions during the month of October 2017 and a total of 7 group sessions during the month of November 2017.
Client #4 was admitted on 05/08/2017 and was discharged on 10/03/2017. The comprehensive treatment plan, dated 05/08/17, indicated 1 group sessions per week. The chart's record of service and progress notes indicated that the client did not receive any group sessions during the months of July 2017, August 2017, and September 2017.
Client #5 was admitted on 04/06/2017 and was discharged on 08/17/2017. The comprehensive treatment plan, dated 04/06/17, indicated 3 group sessions per week (or 12 groups per month). The chart's record of service and progress notes indicated that the client had received a total of 9 group sessions during June 2017, 7 group sessions during July 2017, and 0 group sessions during the month of August 2017.
Client #6 was admitted on 05/10/2017 and was discharged on 10/04/2017. The comprehensive treatment plan, dated 05/10/17, indicated 1 individual session per week. The chart's record of service and progress notes indicated that the client did not receive an individual session for the weeks of 7/24-7/30, 7/31-8/06, 8/7-8/13, and 9/25-10/01.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Documentation of client rescheduling or No Show will be documented on the Record of Service. An updated Record of Service has been implemented to include client missed appointments. This has been distributed and implemented in the charts.
Weekly census will include updating the Record of Service for missed appointments.
Clinical Director is responsible for the implementation and continued education. |
709.93(a) 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:
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Observations
Based on a review of 7 client records, the facility failed to provide a complete client record in 1 of 1 applicable client records.
Client #6 was admitted on 05/10/2017 and was discharged on 10/04/2017. The client record did not contain documentation of any follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director trained the staff on follow-up procedures on clients discharge and will be implemented into the monthly training.
The client's counselor called to follow up with the client's progress on 12/12/2017.
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