INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 23-25, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Catholic Charities Counseling and Adoption Services, 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 document an informed and voluntary consent from the client for disclosure of information that indicated the specific information to be disclosed and the purpose of disclosure in four of six client records. One of six client records disclosed information which exceeded 255.5. One of six client records included information in a client record that violated another client's confidentiality.
The findings included:
Six client records were reviewed on April 24, 2013. Six client records were required to demonstrate compliance with the confidentiality regulations. The facility failed to do so in client records #1, 2, 4, and 6.
Client record #1 - The client was admitted to treatment on 5-8-2012 and discharged on 2-1-2013. A release of information for the funding source was signed on 5-8-2012 and did not include the purpose for the release of information. A release of information for the probation office was signed on 5-8-2012 and did not include the purpose for the release of information. A release of information for the attorney was signed on 5-8-2012 and did not include the specific information to be disclosed or the purpose for the release of information.
Client record #2 -The client was admitted to treatment on 1-4-2013 and discharged on 2-28-2013. Per a letter to the probation office dated 2-28-2013, the facility disclosed the clients discharge summary which included information in excess of the limitations on the release of information at 4 Pa. Code subsection 255.5(b).
Client record #4 - The client was admitted to treatment on 10-24-2012. A release of information for the funding source was signed on 10-24-2012 and did not include the specific information to be disclosed.
Client record #6 - The client was admitted to treatment on 1-16-2013 and discharged on 3-5-2013. A release of information for the probation office was signed on 3-5-2013 and did not include the specific information to be disclosed or the purpose for the release of information. The client record also contained a copy of a follow-up letter dated 3-7-2013 for another client.
The findings were reviewed with the project director and were not disputed.
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Plan of Correction
By June 1st, 2013 the Facility Director will ensure that our Release of Information forms will no longer contain a section allowing other organizations to release information to us. Instead we will focus on correctly filling out the information needed for us to release information to other providers in compliance with BDAP regulations and PA law. Workers will be re-trained in confidentiality rules and on proper usage of our new forms. |
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, the facility failed to document a treatment plan update in two of two client records.
The findings include:
Six client records were reviewed on April 24, 2013. Two client records were required to include documentation of a treatment plan update. Per the facility policy, treatment plan updates are required to be completed within 60 days of the comprehensive treatment plan. The facility failed to document a treatment plan update in client records #1, and 4.
Client record #1 - The client was admitted to treatment on 5-8-2012 and discharged on 2-1-2013. The comprehensive treatment plan was completed on 6-5-2012. A treatment plan update was due by 8-5-2012 but was not completed until 9-11-2012. A treatment plan update was due by 10-5-2012, and was not documented. A treatment plan update was due by 12-5-2012 and was not completed until 12-27-2012.
Client record #4 - The client was admitted to treatment on 10-24-2012. The comprehensive treatment plan was completed on 12-3-2012. A treatment plan update was due by 2-3-2013 and was not documented. A treatment plan update was due by 4-3-2013, but was not completed until 4-19-2013.
The findings were reviewed with the project director and were not disputed.
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Plan of Correction
By May 31, 2013 the Facility Director will meet with the worker in question to review the expectations of treatment plan reviews and will set up a detailed schedule of monthly meetings to ensure proper compliance with the treatment plan update policies. |