INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 9 & 10, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Al-Assist Behavioral Health Care Center 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 and a plan of correction is due on October 12, 2009.
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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 four client records on September 10, 2009, the facility failed to document an informed and voluntary consent to include the information being released in three of four records reviewed.Findings: A review of four client records was conducted on September 10, 2009. Three of the four records reviewed, #2, 3, &4, contained consents to release information that did not identify what information was being released.
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Plan of Correction
Plan of Correction:
Standard in Noncompliance
709.28 (c)(2) Confidentiality
In an effort to comply with regulation 709.28, the written findings from the September 10, 2000 were reviewed in detail with the Clinical Coordinators and Counselor III during the clinical staff meeting to again review Standard 709.28 and the agency's Confidentiality policy and procedures supportive of Standard 709.28(c)2)/4 Pa code Subsection 255.5(b), and to reiterate the importance of accurately documenting on the informed and voluntary consent form the specific information to be released/disclosed with the clear understanding that the released/disclosed information must not exceed the limitation set forth in 4 Pa Code Subsection 255.5(b): 1. whether the client is or is not in treatment; 2. The prognosis of the client; 3. The nature of the project; 4. A brief description of the progress of the client; and 5. a short statement as to whether the client has relapsed into drug and alcohol and frequency of such relapse. In addition, medical record clerks and clinical staff were instructed to do away with all old blank consent to release forms that did not indicate in writing what information was to be released in accordance with regulation 709.28, and to only utilize the consent to release forms designated for consumers in the drug and alcohol outpatient program that reference specific guidelines outlined in regulation 709.28. All staff were informed during the meeting that failure to comply with the Confidentiality policy and procedures, Standard 709.28(c) (2), will result in 1. (First violation) a written reprimand 2. (Second violation) suspension without pay, pending termination of employment. Informed and voluntary consent forms will be routinely audited by the Medical Record clerks and randomly audited weekly for compliance by the Client Service Coordinator to ensure compliance. A random audit of each therapist caseload will be conducted periodically by the Clinical Coordinator to ensure that standard 709.28 is being followed properly.
Correction Time: Correction Completed Monitoring On-going
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709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of four client records on September 10, 2009, the facility failed to document a drug and alcohol history that included documentation of prior treatment episodes in two of four records reviewed.. Findings:On September 10, 2009, four client records were reviewed. The facility failed to document a drug an alcohol history that included documentation of all prior treatment episodes in two of four records reviewed, specifically, records #1 and #3.
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Plan of Correction
Plan of Correction:
Standard in Noncompliance
709.91 (b)(3)(ii) Intake and Admission
In an effort to comply with regulation 709.91 (b)(3)(ii) the written findings from the September 10, 2009 were discussed with all clinical staff during the October 09, clinical staff meeting. At which time, the Clinical Coordinator reviewed with the Counselors, the intake and admission process and information required to be collected and documented including but not limited to a complete psychosocial evaluation of the client's composite picture: which includes but certainly not limited to a full history of the client's prior drug and alcohol usage and prior drug and alcohol treatment inclusive of impatient treatment, outpatient treatment, and attempted alternative drug and alcohol management and/or methods. Random audits of each counselor's caseload will be conducted weekly by the Clinical Coordinators to ensure that standard 709.91 (b) (6) (ii) is being followed properly. Counselors found non-compliant of this regulation will receive additional support from the Clinical Coordinator during weekly individual supervision sessions. Targeted audits of the complete intake process will be conducted every 90 days to ensure full compliance of regulation 709.91.
Correction Time: November 13, 2009 Monitoring On-going
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of four client records on September 10, 2009, the facility failed to document psychosocial evaluations that included a description of client assets and strengths, coping mechanisms, negative factors that may affect treatment, and counselor impressions and conclusions in two of fourrecords reviewed. Findings: On September 10, 2009, four client records were reviewed. The facility failed to provide psychosocial evaluations to include to include a description of client preferred coping mechanisms and negative factors that may affect treatment and, the psychosocial assessment in two of four records reviewed,specifically, records #1, 7, & .3. Client records #1 & #3. Record #3 also failed to include counselor impressions and conclusions regarding the client's attitude and ability to participate in the treatment process.
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Plan of Correction
Plan of Correction:
Standard in Noncompliance
709.91 (b)(6) Intake and Admission
In an effort to comply with regulation 709.91 (b)(6) the written findings from the September 10, 2009, were discussed with all clinical staff during the clinical staff meeting. In addition, the Clinical Coordinators are scheduled to facilitate an in-service peer review on Friday, November 20, 2009 to critique along with the counselors, random samples of their existing psychosocial evaluations measuring them against the standards set forth in regulation 709.91 (b) (6), allowing them to receive feedback from their peers and superiors to better understand the intent of regulation 709.91 (b) (6) and to assist them in identifying any clinical documentation weak points he/she may be experiencing in completing the psychosocial evaluation of the client's composite picture: such as: client's problems/needs, support systems, coping mechanisms, assets/strengths, negative factors that may inhibit treatment, attitude towards treatment, ability to participate in treatment and the counselor's impressions of the client and etc. In addition, all new hires prior to successfully completing orientation must demonstrate his/her ability to complete the psychosocial evaluation covering all areas of regulation 709 (b) (6). A random audit of each therapist caseload will be conducted monthly by the Clinical Coordinators to ensure that standard 709.91 (b) (6) is being followed properly. Counselors found non-compliant of this regulation will receive additional support from the Clinical Coordinator during weekly individual supervision. Failure to demonstrate competency in this area after 60 days will result in termination of employment.
Correction Time: November 20, 2009 Monitoring On-going
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