INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 13-14, 2016, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Persad Center 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:
|
Plan of Correction
|
709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
|
Observations
Client #4 was admitted for treatment on 06/03/2015, and was an active client at the time of the onsite inspection. The consent to release information to the funding source for Client #'4's treatment did not include the name of the funding source.These findings were reviewed with the facility staff during the inspection process.
|
Plan of Correction
Clinical Supervisor reviewed the deficiency report with billing staff. The omission of the insurance company's name was a clerical error. Clinical Supervisor reviewed the policy regarding obtaining consent and the requirement for naming the insurer on the consent form.
The Billing Department prepared a new consent to release information form for Client #4 naming the correct funding source. Client will be asked to sign the updated release at regularly scheduled appointment ? October 25, 2016.
On October 3, 2016 at the monthly team meeting the Clinical Director instructed clinical staff to include in their 60 day treatment update, and all future 60 day reviews, a review of the billing section of the file to ensure that the insurer has been named on the consent to bill form and the appropriate signatures have been obtained.
|
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.
|
Observations
The facility failed to update the individualized treatment plan every 60 days for Clients #3, 4 and 6.Client #3 was admitted for treatment on 10/29/2015, and was an active client at the time of the onsite inspection. Client #3's individualized treatment plan was completed on 10/31/2015, and the treatment plan updates were completed on 12/31/2015, 05/17/2016 and 07/29/2016. Treatment plan updates 05/17/2016, and 07/29/2016, were both completed more than 60 days after the updates immediately prior to each of them. Client #4 was admitted for treatment on 06/03/2015, and was an active client at the time of the onsite inspection. Client #4 had treatment plan updates completed on 01/14/2016, 04/14/2016 and 07/28/2016. Treatment plan updates 04/14/2016, and 07/28/2016, were both completed more than 60 days after the updates immediately prior to each of them. Client #6 was admitted for treatment on 09/30/2014, and was discharged on 05/05/2016, but the client's last treatment plan update was completed on 10/16/2015.These findings were reviewed with the facility staff as part of the inspection process.
|
Plan of Correction
On October 3, 2016 the Clinical Director reviewed the deficiency report with Clinical team at monthly meeting. The Clinical Director reviewed the stated policy which indicates that treatment plans must be updated at least every 60 days and reflect the current condition and goals of the client. Clinicians will bring files to weekly supervisory meetings so that each file is monitored monthly by the Clinical Director or the Clinical Supervisor for completion. |