INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 6-8, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Libertae Family House Libertae, 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)(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 shall 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 and an interview with the clinical supervisor, the facility failed to stay within the limits imposed by 4 Pa. Code 255.5 in relation to the release of information forms in three of five client records.
The findings include:
Five client records were reviewed on June 7- 8, 2011. Per regulation, 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 specific information disclosed. The facility allowed for the release of specific client information that exceeded the limits imposed by 4 Pa. Code 255.5 in client records # 3, 4, and 5.
The project has pre-typed consent forms that are being utilized for probation and parole and funding agencies. These forms stated , "This information may include my forwarding address and telephone number after discharge from Liberate, Inc. I further understand that this information is necessary to coordinate further services with the above funding source." This information exceeded 255.5.
Client #3 was admitted to treatment 12-27-10. A release of information to the funding source was signed and allowed for the disclosure of information (forwarding address and telephone number) which exceeded 255.5.
Client # 4 was admitted to treatment 7-15-10. A release of information for the funding source was signed and allowed for the disclosure of information (forwarding address and phone number), which exceeded 255.5.
Client # 5 was admitted to treatment 10-25-2010. A release of information for probation and parole was signed and allowed for the disclosure of information (forwarding address and phone number), which exceeded 255.5. Also, a release for the funding source was signed and allowed for the disclosure of information (forwarding address and phone number), which exceeded 255.5.
In the discussion with the director and the clinical supervisors, it was confirmed that the release of information forms included information that exceeded 4 Pa. Code 255.5.
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Plan of Correction
The Responsible Party: The Clinical Director.
Upon review of the old informed and voluntary consents it was realized that some were not purged with the last paperwork streaming done earlier in the year (January 15, 2011).
The Clinical Director ensured on 6/13/11 with the front office staff that all of the old releases with the statement failing to stay within the limits of 4 PA Code 255.5 were purged from intake and therapist forms. They were indeed replaced with the revised copy that did not have this statement. A copy of the revised release of information and a copy of the 4 PA Code 255.5 were both reviewed in the joint clinical team meeting on 6/14/2011 to serve as a /training reminder of the confidentiality guidelines.
The Clinical Director will monitor that if there are any current clients that have the old informed and voluntary consents filed they will be purged and the new release will be reviewed & signed with the client and then filed in their charts no later than 7/30/11. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on a review of client records, the facility failed to ensure that staff physician signed verbal orders in two of two client record within 24 hours of calling them in as required by this regulation.
The findings included:
On June 7-8, 2011 five client records were reviewed. Two client records required a verbal order to be signed off by the prescribing physician within 24 hours of calling the order in for the client. In client records # 3 and 4, the physician failed to affix his/her signature within 24 hours of calling in an order. Specific findings are addressed below:
Client # 3 had a note on their medication record written by the resident manager stating the client was to stop Trazodone. The resident manager did not date their signature. The last dose the client took of this medication was on 4/14/2011. There was a doctor's order signed on 4/29/2011 to stop the medication. There is no way to determine if the medication was signed off within 24 hours due to the resident manager not signing the order. Also, it appears to look as if the dose was stopped on 4/14/2011 as this was the last time it was documented that the client took the medication. The note the doctor wrote was not dated until 4/29/2011 which is 15 days after the last dose.
Client # 4 was prescribed Seroquel 50 mg. Take one tab by mouth in the evening at 9:30 p.m. There was a note written on the medication record by the resident manager that stated the medication was discharged by the doctor. The discharge order was not dated by the resident manager. The last dose the client took was on 10/30/2010. There was no verbal order signed by the doctor in the client record.
Client # 4 was prescribed Seroquel 150 mg. Take one tab by mouth at 5:30 p.m. There was a note written on the medication record by the resident manager that stated the medication was discharged by the doctor. The discharge order was not dated by the resident manager. The last dose the client took was on 9/9/2010. There was no verbal order signed by the doctor in the client record.
Client # 4 was prescribed Seroquel 100 mg. Take one tab by mouth in the evening at 9:30 p.m. There was a note written on the medication record by the resident manager that stated the medication was discharged by the doctor. The discharge order was not dated by the resident manager. The last dose the client took was on 10/30/2010. There was no verbal order signed by the doctor in the client record.
This is a repeat citation from the June 22- 24, 2010 licensing inspection.
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Plan of Correction
The Responsible Party: Operations Manager and Residential Manager
The Operations Manager reviewed the Medication Protocols on 6/21/11 with Resident Manager.
A training and review with all managers and treatment technicians will take place at the department meeting on 7/18/2011 to ensure the protocol is understood and practiced within the realms of compliance.
To ensure compliance with the 24 hour psychiatrist verbal order sign off protocol; The Operations Manager and Resident Manager will review medication log weekly for accuracy.
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709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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
Based on the review of client records, the facility failed to document the type and frequency of services in the individual treatment and rehabilitation plan in two of five client records.
The findings include:
Five client records were reviewed on June 7- 8, 2011. The type and frequency of services were required in the individual treatment and rehabilitation plan in five client records. The facility did not document the type and frequency of services in the individual treatment and rehabilitation plan in client records # 4 and 5.
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Plan of Correction
The Responsible Party: Clinical Director
The Clinical Director reviewed and trained the therapists in the clinical team meeting on 6/14/11 that on all Comprehensive treatment plans(Individual treatment and rehabilitation plan) "Type and Frequency of Services" for Individual and Group Therapy groups need to be reflected in the demographic portion. Other psychoeducational or specialized groups can be aligned with the client's specific action steps.
The Clinical Director will monitor client charts in regular chart reviews as well as in individual bi monthly clinical supervisions when Comprehensive Treatment plans (Individual treatment and rehabilitation plan) are reviewed and signed. This will take place to ensure that Type and Frequency of services are reflected. |