INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 13 to September 15,2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on October 10, 2006.
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
One counselor file reviewed did not have the documentation on file to verify that he had 25 hours of training for the past year. Acceptable forms of documentation include a sign in sheet signed by the participants and the trainer, transcripts or training certificates.
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Plan of Correction
All trainings will regularly documented. Program Director will monitor to ensure compliance. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Documentation demonstrating that the fire alarm/smoke detector was being set off during each fire drill was not presented. The facility is in a multi-purpose agency, if the facility does not feel it can pull the alarms without disturbing the other tenants, the director would need to provide documentation that the director of the facility has approved a means of alerting the staff of a fire alarm. In addition, the facility would need to send in a letter to the division explaining the process and showing board approval.
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Plan of Correction
The project will seek departmental approval for an alternative procedure. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
The project failed to present documentation demonstrating that the annual report was made available to the general public within six months of the year's end..
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Plan of Correction
Notice will be given via newspaper. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
No financial statement of income and expenses was documented in the annual report.
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Plan of Correction
A financial statement of income and expenses will be made available. |
709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
The project failed to present documentation demonstrating that the governing body had approved the goals and objectives at least annually.
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Plan of Correction
Will be documentated in Board of Directors Meeting Minutes. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
The agency policy on client confidentiality was incomplete and in some areas was inaccurate. The language in the policy and procedure did not distinguish between HIPAA and 42 CFR Part 2, Subparts A through E. The policy and procedure gives the impression that the project does not recognize the distinctions between the various laws and regulations. The requirements of this regulation stipulate that written procedures comply with 4 Pa. Code subsection 255.5. The procedures as presented at the inspection address only subpart (b) of subsection 255.5. The patient confidentiality notice form incorrectly states that revocations must be put in writing by the client. Clients may revoke consents to release information verbally and staff must then document the revocation in the client record. This notice also incorrectly states that client information can be released without consent to obtain legal or financial services or to another medical facility. The same form also states that Discovery House need not agree to any restrictions on disclosures of information requested by the client. All releases of information must be voluntary unless otherwise excepted by the applicable section of 42 CFR. The section of the confidentiality procedure entitled "Prohibition on Redisclosure" on page 191 of the manual is blank.
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Plan of Correction
Policy will be amended to reflect distinctions between 42 CFR Part 2 and HIPAA regulations. Forms will be changed to comply with cited regulations. |
709.28(a)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(2) Staff access to client records.
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Observations
The Discovery House policy on staff access to client records lacked sufficient detail. The policy should identify by name or position who may access files. The method of access should be outlined. Since the project has an electronic system for keeping client identifying information, a detailed policy and procedure which addresses all of the requirements of the Licensing Alert of May, 2005 relating to Electronic Clinical records must be developed.
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Plan of Correction
Policy will be amended to include language regarding access restriction. An attachment will be available that details by position. |
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
One agency form presented did not comply with the intent of this regulation. The form entitled "Patient Agreement to Pay for Treatment If Third Party Coverage is denied" contains language which indicates information will be released, but the form does not specify what specific information will be sent to third party sources. This constitutes a general consent to release information which does not comply with the requirements of the law.
Releases to family members, without appropriate consent, were noted in client records # 11 and 13.
Consents to release information forms from previous treatment episodes used rather than obtaining new consents at the most recent intake. Consents to release information must be executed at each intake.
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Plan of Correction
From will be changed to comply with regulation. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Medical histories in client records reviewed did not consistently address the family medical history . A family medical history must be collected for each client.
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Plan of Correction
Responsible Medical Staff has been trained in proper procedure for completing the form. Program Director will conduct audits of documentation to ensure that form is completed thoroughly and address as needed. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Personal histories should collect as much personal information about a client as possible since they form the basis from which the psychosocial evaluation and subsequent treatment plans are formulated. Histories did not consistently contain pertinent details in files reviewed.
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Plan of Correction
There will be regular trainings on psychosocial evaluation. Clinical Supervisor will monitor for compliance. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Consents to treatment are not being updated in the files of clients who have been discharged and who then returned to treatment within short periods of time. Consents to treatment must be done at each intake.
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Plan of Correction
Records will be audited prior to admission to ensure compliance. Program Director and Clinical Supervisor will monitor to ensure compliance. |
709.93(a)(7) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(7) Client-related correspondence.
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Observations
Client related correspondence did not provide sufficient detail in client records reviewed to make determinations about the appropriateness of information disclosed about the client to other individuals and agencies. A detailed record of information released must be kept on file. This may include notes, copies of letters, FAXES, e-mails, telephone logs, etc.
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Plan of Correction
Inservice training has been held to ensure compliance. Clinical Supervisor will monitor to ensure compliance. |