INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 23, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, The Children's Service Center of Wyoming Valley Inc. 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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709.24 (a) (4) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(4) Written procedures for referral outlining cooperation with other service providers including, but not limited to, provisions for access to emergency services.
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Observations
The facility's administrative records were reviewed on May 21-22, 2019 for the licensing renewal inspection. The facility's policy pertaining to referral procedures did not address the provision of access to emergency services. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
A meeting was held with the Project and Facility Director on 6/19/2019. A thorough review of the organizations Policy and Procedure manual was completed. In review of Licensing Regulation 709.24 (a) (4) it was determined that the current policy was not sufficient in meeting the any possible emergent needs of our patients.
Based on this review, the Project and Facility Director updated Licensing Regulation 709.24 (a) (4) to more accurately reflect the efforts of the organization. On 6/24/2019 this policy was reviewed by the Project and Facility Director, along with the CEO and approved for placement in the organizations Policy and Procedure manual.
During normal business hours the facility will meet the emergent physical health needs of its patients through its integrated care partner, The Wright Center. Any physical health needs that cannot be met by the staff at The Wright Center will be referred to our local emergency department, Commonwealth health, which operates 24-hours emergency care in both Luzerne and Wyoming Counties. Children's Service Center operates a 24-hour crisis department that can meet the needs of any patient experiencing emergent mental health needs. Furthermore, all patients of Children's Service Center are made aware at the time of intake of the 24-hour helpline, as well as, other physical and behavioral health partners.
Effective 6/24/2019, the Policy and Procedure manual of Children's Service Center's Drug and Alcohol Program have been updated to reflect this change. This policy, along with the all others are reviewed annually to ensure they accurately reflect and changes in regulations, or activities.
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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 must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
The facility's administrative records were reviewed on May 21-22, 2019 for the licensing renewal inspection. Based on a review of the project's policy pertaining to the confidentiality of client records, the following deficiencies were identified: -The project failed to develop written policy and procedures that accurately described how drug and alcohol treatment client records are stored at the facility. The written policy indicated that client records are stored in a designated records room that is staffed by employees assigned to this department. The policy also described procedures for obtaining client records from the records room. However, facility staff confirmed that drug and alcohol treatment client records are instead stored in the facility director's office, in a locked filing cabinet designated for client records. -The written policy and procedures don ' t identify the person or position responsible for the maintenance of client records. -Facility staff reported that client billing data is maintained on electronic records. However, the written policy did not address protocols implemented for the security of electronic records. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A meeting was held with the Project and Facility Director on 6/19/2019. A thorough review of the organizations Policy and Procedure manual was completed. In review of Licensing Regulation 709.28 (a), it was determined that the current policy did not accurately reflect the effort that is taken to hold patient records in strict confidence.
Based on this review, the Project and Facility Director updated the policy to ensure full compliance with Licensing Regulation 709.28 (a). On 6/24/2019 this policy was reviewed and approved by the Project Director, Facility Director, and CEO. As a result, this policy was placed in the organizations Policy and Procedure manual.
Beginning 6/24/2019, all client records are stored in a locked filing cabinet that has been designated for client records. This locked filing cabinet is secured in a locked office at each facility location. Access to these client records is limited to the Project Director, Facility Director, and assigned therapist. The maintenance of the records is the responsibility of the assigned clinician, with oversight from the Project or Facility Director.
Currently, all Drug and Alcohol records are completed on paper charts. However, the organization does utilize an electronic billing system that requires the capturing of some client specific data. The information contained on this secure server is limited to only what is needed for billing purposes. This system is heavily monitored by the organization Chief Information Officer and access is limited to only the CIO and the CFO for the purpose of generating billing claims.
Effective 6/24/2019, the Policy and Procedure manual of Children's Service Center's Drug and Alcohol Program have been updated to reflect this change. This policy, along with the all others are reviewed annually to ensure they accurately reflect and changes in regulations, or activities.
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709.28 (a) (2) 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 must include, but not be limited to:
(2) Identification of project staff having access to records, and the methods by which staff gain access.
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Observations
The facility's administrative records were reviewed on May 21-22, 2019 for the licensing renewal inspection. Based on a review of the project's policy regarding the confidentiality of client records, the facility failed to identify all project staff that have access to client records. Additionally, the facility failed to identify the methodology used by staff to gain access to client records. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A meeting was held with the Project and Facility Director on 6/19/2019. A thorough review of the organizations Policy and Procedure manual was completed. In review of Licensing Regulation 709.28 (a) (2), it was determined that the current policy did not accurately reflect the effort that is taken to hold patient records in strict confidence.
In review of the current policy, it was determined that the policy reflected the strict confidentiality of all client records, but was not specific in identifying the staff who have access to the records and the process utilized to gain access. As a result, the Project and Facility Director updated the policy to accurately reflect the entirety of Licensing Regulation 709.28 (a) (2). This policy was reviewed by the Project Director, Facility Director, and CEO on 6/24/2019 and approved for placement in the Organizations Policy and Procedure manual.
All Drug and Alcohol records are stored in locked filing cabinets, behind a locked office door. Access to the records is limited to the Project Director, Facility Director, and assigned clinician. Any clinician needing access to these records must gain approval from either the Project or Facility Director. Access to patient records is limited and only approved for the normal update, or maintenance of records.
Effective 6/24/2019, the Policy and Procedure manual of Children's Service Center's Drug and Alcohol Program have been updated to reflect this change. This policy, along with the all others are reviewed annually to ensure they accurately reflect and changes in regulations, or activities.
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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Eight client records were reviewed on May 23, 2019. The facility failed to document a complete preliminary treatment plan, to include treatment goals, for client records # 1, 4, and 6. Client # 1 was admitted into treatment on August 13, 2018 and was still active in treatment. Client # 4 was admitted into treatment on November 8, 2018 and was discharged on January 8, 2019. Client # 6 was admitted into treatment on December 17, 2018 and was discharged on March 27, 2019. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A clinical staff meeting was held on 6/19/2019 and attended by all staff from our 3 facility locations. The Project and Facility Director utilized this meeting to review the recent onsite licensing inspection and discuss all citations. In review of the citation for Licensing Regulation 709.91 (b) (7) it was determined that some staff were not providing enough detail to support an accurate preliminary treatment plan.
Effective 6/19/2019, all staff have received significant training and instruction on the proper development of preliminary treatment plans. In all of the records reviewed, a preliminary treatment plan was completed, but did not contain goals specific to problem statement. All staff were trained on developing preliminary goals that were specific to the patients presenting concerns.
The Project and Facility Director will ensure full compliance to this change during biweekly chart audits and monthly clinical staff meeting. This monitoring process will continue to ensure full compliance.
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709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Eight client records were reviewed on May 23, 2019. The facility failed to specify the type and/or frequency of treatment and rehabilitation services on comprehensive treatment plans completed for client records # 2, 3, 4, 5, 6, and 8. Client # 2 was admitted into treatment on September 6, 2018 and was still active in treatment. The client's comprehensive treatment plan, completed on September 18, 2018, did not specify the type and frequency of treatment and rehabilitation services. Client # 3 was admitted into treatment on October 24, 2018 and was still active in treatment. The client's comprehensive treatment plan, completed on October 29, 2018, did not specify the type of treatment and rehabilitation services. Client # 4 was admitted into treatment on November 8, 2018 and was discharged on January 8, 2019. The client's comprehensive treatment plan, completed on December 4, 2018, did not specify the type of treatment and rehabilitation services. Client # 5 was admitted into treatment on December 27, 2018 and was discharged on March 19, 2019. The client's comprehensive treatment plan, completed on January 10, 2019, did not specify the type of treatment and rehabilitation services. Client # 6 was admitted into treatment on December 17, 2018 and was discharged on March 27, 2019. The client's comprehensive treatment plan, completed on January 3, 2019, did not specify the frequency of treatment and rehabilitation services. Client # 8 was admitted into treatment on March 4, 2019 and was discharged on May 2, 2019. The client's comprehensive treatment plan, completed on March 18, 2019, did not specify the type of treatment and rehabilitation services. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A clinical staff meeting was held with all staff from our 3 facility locations. The Project and Facility Director utilized this meeting to review the recent licensing inspection and discuss all citations. In review of Licensing Regulation 709.29 (a) (2) it was determined that treatment staff must be more specific in outlining the type of treatment and rehabilitation that is being recommended.
In all of the records that were reviewed during our onsite licensing inspection, the staff were noting the frequency of services, but were not specific on the type of service that was being offered. Beginning 6/19/2019 all staff have been educated on Licensing Regulation 709.92 and directed to specify individual, group, or family when making a recommendation for outpatient counseling.
The Facility and/or project Director will continue to monitor the compliance to this change during biweekly chart audits and monthly clinical staff meetings. However, effective 6/19/2019 all treatment staff have been made aware of this change and will accurately reflect Licensing Regulation 709.92 (a) (2) during the development of all comprehensive treatment plans going forward.
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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
Six client records requiring documentation of treatment plan updates were reviewed on May 23, 2019. The facility failed to document a treatment plan update at least every 60 days for client records # 1 and 7. Client # 1 was admitted into treatment on August 13, 2018 and was still active in treatment. The last two treatment plan updates documented in the client's records were completed on February 15, 2019 and May 7, 2019. The last treatment plan update was due to be completed by no later than April 16, 2019. Client # 7 was admitted into treatment on January 25, 2019 and was discharged on April 24, 2019. A comprehensive treatment plan was completed for the client on February 7, 2019. A treatment plan update should have been completed for the client by no later than April 8, 2019, and one was not documented in the client's record. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A clinical staff meeting was held on 6/19/2019 and attended by all staff from our 3 facility locations. The Project and Facility Director utilized this time to review the recent onsite licensing inspection and discuss all citations. All clinical staff were further educated on the importance of adhering to the documentation regulations set forth by the Department of Drug and Alcohol Program, in particular, the requirement to complete a Treatment Plan Review at least once every 60 days.
All clinical staff were provided an opportunity to have their questions answered and acknowledge their compliance with this regulation. The Project and Facility Director will monitor the organizations compliance with the regulation on a continually basis through biweekly chart audits and monthly clinical staff meetings.
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