INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 23, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Holcomb Associates, 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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709.28(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 document informed and voluntary consent to release forms that complied with Pa Code 255.5.
The findings include:
4 Pa. Code 255.5 states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed
Nine client records were reviewed on March 23, 2016. The facility failed to document an informed and voluntary consent to release form in client record, # 1 and 7.
Client # 1 was admitted to the facility on September 4, 2015, and was still an active client at the time of review. On September 10, 2016, client 1 signed a consent to release to a funder which did not comply with limitations imposed at 255.5. The consent to release allowed for the disclosure of client # 1's biopsychosocial.
Client # 7 was admitted to the facility on September 24, 2015, and was still an active client at the time of review. On September 24, 2015, the facility completed an assessment to a governmental agency that exceeded 255.5. The assessment summary disclosed client # 7's drug of choice and frequency of use.
The findings were reviewed with the facility staff during licensing inspection.
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Plan of Correction
The Kennett Square D&A project will have a training specific to confidentiality and 255.5 procedures. Consent forms will be revised and all clinical support staff and clinicians will be trained on how to complete the form as well as limitations on what can be released. While the consent for client #1 was completed to release a biopsychosocial to a case manager (not to a funder), the staff will be reminded a biopsychosocial can not be released to a funder. Further, the training will clearly address our inability to disclose drug of choice and frequency of use. Following this training, clincial supervisor will conduct chart reviews to monitor ongoing compliance and clinical supports coordinator will conduct monthly checks to monitor this indicator as a quality improvement measure. |
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 client records, the facility failed to document a complete client record which included a discharge summary in one out of two records required.
The findings include:
Three discharge client records were reviewed on March 23, 2016. The facility failed to document a complete client record which included a discharge summary in client record # 3.
Client # 3 was admitted to the facility on October 15, 2015 and discharged on March 1, 2016. As of the time of inspection, the facility failed to document a complete client record which included a discharge summary for client # 3.
The findings were reviewed with the facility staff during licensing inspection.
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Plan of Correction
Holcomb Kennett Square will review policy to discharge all clients within 7 days of completion. Staff will be reminded to complete discharge summary,send out discharge/aftercare plan, and call client within 7 days of discharge for aftercare followup. Clinical supervisor will monitor timely completion of discharge summaries via chart reviews, individual supervision, and team meetings/collaboration. |