INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 11, 2009 through March 12, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Open Door Counseling at Mazzoni 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 April 5, 2009.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records on March 10, 2009 the facility failed to make sure that all staff are trained for 4 hours of TB/STD training in the required amount of time in one of five records reviewed, #3. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
Findings:
Employee # 3 was hired February 6, 2005 and was required to have TB/STD training by February 6, 2006. This was not documented in personnel record reviewed.
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Plan of Correction
Employee #3 is registered for TB/STD training at PCCYFS on 5/26/09. Employee will submit verification of attendance to HR, and a copy of certification will be kept in employee's personnel file. This will complete this training requirment for employee #3.
On an ongoing basis, all new employees hired will complete this training requirment within one year of hire. Director and HR will monito on an ongoingn basis. |
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 the review of client records, the facility failed to obtained informed and voluntary consents in five of six client records.
The findings include:
Six client records were reviewed on March 12, 2009. Consent to release forms were required in five records.
Client record #1 contained a consent to release form for their insurance company that exceeded 255.5 by requesting:
HIV/AIDS related information
Drug/Alcohol information
Psychiatric records
Also, client record #1 contained documentation that the client's significant other participated in a session and the facility did not have a consent to release form for that particular person.
Client record #2 consent to release form for their insurance company that exceeded 255.5 by requesting:
HIV/AIDS related information
Drug/Alcohol information
Psychiatric records
"Other?"
Also, documentation in the client's record indicated the client's ex-wife was called on 12/4/08; there was no consent to release documented in client's file for this person.
Client record #4 had a meeting with partner with no consent to release documented in clients file for this person.
Client record #5 consent to release form for Health Federation and CBH exceeded 255.5 by requesting:
HIV/AIDS related information
Drug/Alcohol information
Psychiatric records
Also, a consent to release form for Belmont Hospital did not documented the purpose for the release dated 6/19/08.
"I understand that my records may contain information regarding my mental health, substance use or dependency, or sexuality and gender expression, and also may contain confidential HIV/AIDS-related information." This text of the standardized information consent to release form contains language that makes the release form a general consent to release form that is prohibited by Federal regulations.
"This information has been disclosed to you from records whose confidentiality is protected by State and Federal Law. State regulations limit your right to make further disclosure of this information without prior written consent of the person to whom it pertains (55 PA Code 5100.34 (d))". This disclosure is incomplete and incorrect, it failed to inform the client that information released can not be predisposed without client written consent.
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Plan of Correction
First, the Consent to Release Information form will be amended to include 42 CFR Part 2 Subsection C 2.32 statement.
Second, the following statement will be removed from the form: "I understand that my records may contain information regarding my mental health, substance use or dependency, or sexuality and gender expression, and also may contain confidential HIV/AIDS-related information." This text of the standardized information consent to release form contains language that makes the release form a general consent to release form that is prohibited by Federal regulations."
Third, at a team meeting on 3/20/09, Program Director will review procedure for obtaining approriate consent with staff, and advise not to check HIV/AIDS related information, Drug and Alcohol information, Psychiatric records, or "other", for purposes of insurance. In addition, Program Director will review with staff the proper procedure for obtaining consent whenever information is disclosed to a third-party, including in-person. Staff will be responsible for compliance on an on-going basis. Program Director will monitor on an on-going basis by performing quarterly chart reviews. |
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 client records, the facility failed to complete psychosocial evaluations in five of six client records.
Findings:
Six client records were reviewed on March 11, 2009. Psychosocial evaluations were required in five client records. The psychosocial evaluations contained client responses and client stated comments rather than a clinical assessment of the client that included assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, clients attitude toward treatment and the counselor's impression of the client in client records #1, 2, 3, 4 and 5.
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Plan of Correction
Program Director will amend Psychosocial Evaluation form to include space to comment on assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, clients attitude toward treatment and the counselor's impression of the client in client. These areas are currently included on the existing form, but space will be provided for additional feedback. In addition, Program Director will train current staff to complete the evaluation in an approriate manner during a meeting on 3/20/09. Staff will be responsible for compliance. PD will monitor on an ongoing basis by doing quarterly chart reviews. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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:
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Observations
Based on the review of client records, the facility failed to document treatment plans in five of six client records.
Findings:
Six client records were reviewed on March 11, 2009. Treatment plans were required in five client records. The facility did not document treatment plans in client records #1, 2 and 4. During the review of the facility's policy and procedure manual on March 11, 2009 all treatment plans are to be developed within 30 days following admission. Client #1 was admitted on 2/4/09; the treatment plan had no been completed as of March 11, 2009. Client #2 was admitted on 9/23/08; the treatment plan had not been completed as of March 11, 2009. Client #4 was admitted on 10/29/08; the treatment plan had not been completed as of March 11, 2009. Also, client records #3 and 5 were completed late. Client #3 was admitted on 10/21/08 and his treatment plan was completed on 11/28/08, Client #5 was admitted on 6/19/08 and his treatment plan was completed on 8/13/08.
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Plan of Correction
Policy and procedure manual was amended on 3/11/09 to reflect that Initial Treatment Plans will be completed before the start of the 5th session. Program Direcotr will advise staff of this change during a meeting on 3/20/09. Staff will also be advised of the standard dates of compliance for Treatment Plan updates, and how to make notations in the client record that will thoroughly explain any reason in which a plan is late (for example, client emergency or temporary treatment disruption, etc). Staff will be responsible for maintaining compliance, and Program Director will monitor on an ongoing basis by quarterly chart reviews. |
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.
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Observations
Based on a review of client records, the facility failed to document complete treatment plan updates in three of six client records.
Findings:
Six client records were reviewed on March 11, 2009. Treatment plans updates were required in three client records. Treatment plan update did not include the client's progress in relationship to the stated goals of the treatment plan, but rather included generalized comments that were not specific to the client's progress in treatment in record #2, 3 and 5.
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Plan of Correction
As previously stated, during meeting with staff on 3/20/09, Program Director will review process of completing Treatment Plans in a timely fashion, and will also include a review of the necessary data to include which will adequately reflect the progress a client has made on their specific treatment goals. Staff will be responsible for compliance and Program Director will monitor for compliance on an ongoing basis by reviewing charts each quarter. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records on March 12, 2009, the facility failed to document follow-up information in two of six client records.
Findings:
Six client records were reviewed. Follow-up information was required in two client records. Follow-up information was not documented in records #5 and 6. Client #5 was admitted on 6/19/08 and discharged on 11/24/08. In accordance with the facility's policy, all follow-ups are to be completed 7 days after clients discharge date. Client #6 was admitted on 10/2/08 and discharged on 2/6/09.
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Plan of Correction
The review of records occured on 3/11/09, not 3/12/09 as stated in Observation report.
During a meeting on 3/20/09, Program Director will review Follow-up policy with staff and discuss ways to remain compliant with this standard. Staff will be responsible for ongoing compliance. Director will monitor for compliance on an ongoing basis by quarterly chart reviews. |