INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 28 - 30, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cornell Abraxas I 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 a written informed and voluntary consent from the client for the disclosure of information contained in the client record in six of seven client records. In addition, the facility exceeded the limitations imposed at 4 Pa. Code 255.5 when releasing information to a funding entity in two of seven client records.
The findings include:
Fourteen client records were reviewed on January 28 - 30, 2014. Seven client records were reviewed for informed and voluntary written consents from the client. 42 CFR Part 2, Subpart C, subsection 2.31 (a)(8), requires a statement that the consent is subject to revocation at any time except to the extent that the program or person which is to make the disclosure has already acted in reliance on it. The consent can be revoked by the client verbally or in writing. The facility's consent to release information to the funding entity included the following statement: "I also understand that I may revoke this consent in writing at any time". This is in violation of federal confidentiality regulations. The facility failed to obtain an informed and voluntary consent to release information from the client in client records # 1, 9, 10, 11, 13 and 14. The facility exceeded the limitations imposed at 4 Pa. Code 255.5 when releasing information to a funding entity in client records # 7 and 8.
Client # 7 was admitted into treatment on June 13, 2013. A form titled "Critical Incident Report" was faxed the to funding entity on January 14, 2014. The form indicated the client was involved in a physical intervention and had to be physically restrained by staff. The information released to the funding entity exceeded the limitations imposed at 4 Pa. Code 255.5.
Client # 8 was admitted into treatment on June 6, 2013. A form titled "Critical Incident Report" was faxed to the funding entity on October 13, 2013. The form indicated the client was involved in a physical intervention and had to be physically restrained by staff. The information released to the funding entity exceeded the limitations imposed at 4 Pa. Code 255.5.
The Quality and Compliance Specialist was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The Quality & Compliance Specialist revised the consent to release information form on January 30, 2014, which now reads, "I also understand that I may revoke this consent at any time." All clients have signed the revised consent to release information form, and the new forms were placed in each client's chart.
By March 31, 2014, the Clinical Director, Program Manager, and Quality & Compliance Specialist will train the Managed Care Counselors and Treatment Supervisors to write appropriate "Critical Incident Reports", to include the nature of the information we are legally permitted to disclose to funding sources.
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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to inform the client, in writing, of the reasons for the involuntarily termination of the client's treatment at the project in one of one client records.
The findings include:
Fourteen client records were reviewed on January 28 - 30, 2014. One record pertained to a client that was involuntarily terminated from treatment. The facility failed to inform the client, in writing,of the reasons for the involuntary termination of the client's treatment at the project in client record # 6.
Client # 6 was admitted into treatment on November 21, 2012 and involuntarily terminated from treatment on April 19, 2013. Client record # 6 included an involuntary termination letter dated April 19, 2013. This letter did not include the reasons for the involuntary termination of the client's treatment at the project.
The Quality and Compliance Specialist was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The Community Services Supervisor edited the letter provided to clients when involuntarily terminated from treatment. The letter now includes the reasons for a client's termination from treatment. The Quality & Compliance Specialist will audit charts of clients who are involuntarily terminated and verify the required written correspondence is completed. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document a physical examination that included a physician's signature in seven of seven client records.
The findings included:
Fourteen client records were reviewed on January 28 - 30, 2014. Seven client records were reviewed for documentation of a physical examination. The facility failed to document a physical examination that included a physician's signature in client records # 1, 9, 10, 11,12, 13 and 14.
Client # 1 was admitted into treatment on June 13, 2013. A physical examination was completed on June 18, 2013. The physical exam for client # 1 was only signed by a physician's assistant and did not include a physician's signature.
Client # 9 was admitted into treatment on October 29, 2013. A physical examination was completed on November 5, 2013. The physical exam for client # 9 was only signed by a physician's assistant and did not include a physician's signature.
Client # 10 was admitted into treatment on November 7, 2013. A physical examination was completed on November 12, 2013. The physical exam for client # 10 was only signed by a physician's assistant and did not include a physician's signature.
Client # 11 was admitted into treatment on October 30, 2013. A physical examination was completed on November 5, 2013. The physical exam for client # 11 was only signed by a physician's assistant and did not include a physician's signature.
Client # 12 was admitted into treatment on November 20, 2013. A physical examination was completed on November 26, 2013. The physical exam for client # 12 was only signed by a physician's assistant and did not include a physician's signature.
Client # 13 was admitted into treatment on October 2, 2013. A physical examination was completed on October 8, 2013. The physical exam for client # 13 was only signed by a physician's assistant and did not include a physician's signature.
Client # 14 was admitted into treatment on August 7, 2013. A physical examination was completed on August 7, 2013. The physical exam for client # 14 was only signed by a physician's assistant and did not include a physician's signature.
The Quality and Compliance Specialist was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The Nurse Manager spoke with the contracted Physician's office and was informed that the Physician is reviewing and co-signing all of the Physician Assistant's work, but has not been returning copies to the facility. The Nurse Manager requested copies of all these documents to be filed in each client's medical chart.
Moving forward, the Physician Assistant's documentation will be co-signed by the Physician within 10 days and the Office Manager at the Physician's office will send the co-signed documents back to the medical department at Abraxas I.
The Nurse Manager will conduct monthly audits of all the medical charts to ensure the Physician has co-signed all of the Physician Assistant's documentation.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation that included a clinical assessment of the client's assets/strengths, coping mechanisms, negative factors and conclusions regarding the client's attitude toward and ability to participate in the treatment process in five of seven client records.
The finding include:
Fourteen client records were reviewed on January 28 - 30, 2014. Seven client records were reviewed for psychosocial evaluations that included a clinical assessment of the client. The facility failed to document a psychosocial evaluation that included a clinical assessment of the client's assets/strengths, coping mechanisms, negative factors and conclusions regarding the client's attitude toward and ability to participate in the treatment process in client records # 1, 10, 11, 12 and 13.
Client # 1 was admitted into treatment on June 13, 2013. A psychosocial evaluation was completed on June 18, 2013. The psychosocial evaluation for client # 1 did not include a clinical assessment of the client's coping mechanisms, negative factors and conclusions regarding the client's attitude toward and ability to participate in treatment and only included client reported historical information.
Client # 10 was admitted into treatment on November 7, 2013. A psychosocial evaluation was completed on November 7, 2013. The psychosocial evaluation for client # 10 did not include a clinical assessment of the client's coping mechanisms, negative factors and conclusions regarding the client's attitude toward and ability to participate in treatment and only included client reported historical information.
Client # 11 was admitted into treatment on October 30, 2013. A psychosocial evaluation was completed on November 27, 2013. The psychosocial evaluation for client # 11 did not include a clinical assessment of the client's assets/strengths, coping mechanisms, negative factors and conclusions regarding the client's attitude toward and ability to participate in treatment and only included client reported historical information.
Client # 12 was admitted into treatment on November 20, 2013. A psychosocial evaluation was completed on January 8, 2014. The psychosocial evaluation for client # 12 did not include a clinical assessment of the client's coping mechanisms and negative factors and only included client reported historical information.
Client # 13 was admitted into treatment on October 2, 2013. A psychosocial evaluation was completed on October 22, 2013. The psychosocial evaluation for client # 13 did not include a clinical assessment of the client's assets/strengths and coping mechanisms and only included client reported historical information.
The Quality and Compliance Specialist confirmed the findings.
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Plan of Correction
By March 31, 2014, the Clinical Director will provide training on the process for completion of the psychosocial evaluation with the counselors responsible for completing them. The Clinical Director will explain the requirements for the psychosocial evaluation as stated in the regulations, to include the clinical assessment of the client's assets/strengths, coping mechanisms, negative factors and conclusions regarding the client's attitude toward and ability to participate in the treatment process. The psychosocial evaluation (Integrated Summary) form will be revised to include prompts to remind counselors of the required components.
The Clinical Director will monitor with the quality of psychosocial evaluations to verify they include all required components. The Clinical Director will review psychosocial evaluations as they are completed and provide feedback to the counselors when necessary.
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