INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 10, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection,The Children's Service Center of Wyoming Valley 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) (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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records conducted during the onsite inspection, the facility failed to ensure that the signed informed to consent to release information forms listed all of the required information in 5 of 7 records reviewed.
Client #1 was admitted for treatment on 12/15/2015, and was an active client at the time of the onsite inspection. The client had a signed informed consent to release information for an insurance provider dated 12/7/2016, but the release listed, " insurance purposes " as the information to be disclosed. The phrase, " insurance purposes " does not specify the information to be disclosed.
Client #2 was admitted for treatment on 12/14/2016, and was an active client at the time of the onsite inspection. The client had a signed informed consent to release information for a psychotherapist dated 12/14/2016, but the release listed, " collaboration of treatment " as the information to be disclosed. The phrase, " collaboration of treatment " does not specify the information to be disclosed.
Client #2 had a signed informed consent to release information for an insurance provider dated 12/14/2016, but the release listed, " insurance purposes " as the information to be disclosed. The phrase, " insurance purposes " does not specify the information to be disclosed.
Client #3 was admitted for treatment on 12/14/2016, and was discharged on 6/23/2017. The client had a signed informed consent to release information for a psychotherapist dated 4/17/2017, but the release listed, " collaboration of treatment " as the information to be disclosed. The phrase, " collaboration of treatment " does not specify the information to be disclosed.
Client #4 was admitted for treatment on 11/15/2016, and was discharged on 3/17/2017. The client had a signed informed consent to release information for an insurance provider dated 11/15/2016, but the release listed, " insurance purposes " as the information to be disclosed. The phrase, " insurance purposes " does not specify the information to be disclosed.
Client #5 was admitted for treatment on 9/27/2016, and was discharged on 11/14/2017. The client had a signed informed consent to release information for an insurance provider dated 9/27/2016, but the release listed, " insurance purposes " as the information to be disclosed. The phrase, " insurance purposes " does not specify the information to be disclosed.
These findings were reviewed with the facility as part of the inspection process.
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Plan of Correction
Client #1 did not follow up with session and was discharged. No further communication with the insurance company was necessary. Client #2 will have a new release signed indicating specific information disclosed to the insurance company when she comes in for her session 8/28. The faulty release will be shredded. Client #3,4,5 were discharged cases. No further communication with the insurance company was necessary. An in service was provided on 7/26/17 and a follow up in service provided 8/8/17 to the Therapists by the Facility Director with emphasis on disclosure of information to insurance companies and to document the specific information that is being released. The Facility Director will review active cases for updated insurance releases and new cases during the monthly Quality Review audit. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records conducted during the onsite inspection, the facility failed to document that it informed clients in writing of the reason the clients were being involuntarily discharged in 1 of 1 applicable records reviewed.
Client #4 was admitted for treatment on 11/15/2016, and was involuntarily discharged on 3/17/2017.
These findings were reviewed with the facility as part of the inspection process.
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Plan of Correction
An involuntary discharge letter has been developed to indicate why the client is being discharged from the Program. An in service was provided on 7/26/17 and a follow up in service will be provided 8/8/17 to the Therapists by the Facility Director with focus on the process if a client is involuntary discharged from service. The Facility Director will review all involuntary discharges. |
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 a review of client records conducted during the onsite inspection, the Facility failed to document treatment plan updates at least once every 60 days in 2 of 5 applicable records reviewed.
Client #6 was admitted for treatment on 11/18/2016. The client ' s individualized treatment plan was dated 12/12/2016, and the client ' s treatment plan was due to be updated on 2/12/2017, but there was no documented treatment plan update at the time of the client ' s discharge on 2/27/17.
Client #7 was admitted for treatment on 2/27/2017. The client ' s individualized treatment plan was dated 3/29/2017, and the client ' s treatment plan was due to be updated on 5/29/2017, but there was no documented treatment plan update at the time of the client ' s discharge on 6/19/2017.
These findings were reviewed with the facility as part of the inspection process.
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Plan of Correction
An in service was provided on 7/26/17 and a follow up in service will be provided 8/8/17 to the Therapists by the Facility Director with focus on treatment plan updates. A Quality Assurance review of random records will be reviewed monthly for timeliness of treatment plans by the Facility Director. |