INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 22nd and July 24th, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Persad Center, Inc. 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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in one of seven client records.
The findings include:
Ten client records were reviewed on July 22 & 24, 2014. The informed and voluntary consents were reviewed in seven client records and all were required to include an informed and voluntary consent from the client prior to the disclosure of information. Client record #3 did not include documentation of an informed and voluntary consent from the client prior to a family session.
Client #3 was admitted to drug and alcohol treatment on June 13, 2014. A session with the client's husband was conducted on July 10, 2014. There was no documentation that the client had signed an informed and voluntary consent prior to the family session that took place on July 10, 2014.
The findings were discussed with the clinical supervisor and facility director, who confirmed that consent was not obtained prior to the family session on July 10, 2014.
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Plan of Correction
On August 4, 2014 Group Supervision Meeting, the Clinical Supervisor will review the citations Persad's Drug & Alcohol Program recieved as a result of the July 22 & 24, 2014 state monitoring visit.
In this meeting, Clinical Supervisor will also review the Confidentiality regulations, especially 709.28(c) and discuss how this applies to faimily therapy.
The Clinical Director will update the procedures manual to include the need to obtain a signed informed consent to release information form prior to conducting family therapy sessions, by August 31, 2014.
The Clinical Supervisor will ensure that all clinical staff are informed of the new procedure by September 15, 2014. This will be completed in individual Clinical Supervisory meetings.
All therapists doing family therapy will ensure that their client signs an informed consent to release information form prior to conducting family therapy beginning September 16, 2014.
The Clinical Supervisor will review this procedure in the Group Supervision on October 1, 2014.
In Clinical Supervisor will conduct a targeted chart review in December 2014 and May 2015 to ensure consistency and compliance with the confidentiality regulations.
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709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan that included the proposed type of support service in six of seven client records.
The findings include:
Ten client records were reviewed on July 22 & 24, 2014. The individual treatment and rehabilitation plans were reviewed in seven client records. The individualized treatment and rehabilitation plans documented in client records # 1, 2, 3,4 5 and 7 did not include the proposed type of support services.
Client #1 was admitted on March 26, 2014 and the individual treatment and rehabilitation plan was developed with the client on March 26, 2014 and did not include the proposed type of support services.
Client #2 was admitted on November 19, 2013 and the individual treatment and rehabilitation plan was developed with the client on November 19, 2013 and did not include the proposed type of support services.
Client #3 was admitted on June 13, 2014 and the individual treatment and rehabilitation plan was developed with the client on June 13, 2014 and did not include the proposed type of support services.
Client #4 was admitted on June 12, 2014 and the individual treatment and rehabilitation plan was developed with the client on June 12, 2014 and did not include the proposed type of support services.
Client #5 was admitted on June 23, 2014 and the individual treatment and rehabilitation plan was developed with the client on June 23, 2014 and did not include the proposed type of support services.
Client #7 was admitted on April 3, 2014 and the individual treatment and rehabilitation plan was developed with the client on April 3, 2014 and did not include the proposed type of support services.
The findings were discussed with both the clinical supervisor and facility director.
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Plan of Correction
The Clinical Director and the Admissions Coordinator will review regulation 709.92(a)(3)and the citation received during the state monitoring visit on July 22 & 24, 2014, by August 5, 2014.
The Clinical Director will ensure that the procedures for intake and admission clearly reflect the standard of including support services on the comprehensive treatment plan by September 15, 2014
The Clinical Supervisor and the Admissions Coordinator will ensure that all comprehensive treatment plans include individualized and relevent support services.
All Comprehensive Treatment Plans will include support services by September 15, 2014.
The Clinical Supervisor will conduct a targeted chart audit in December 2014 and April 2015 to ensure compliance with this regulation. |