INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 30, 2015 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Center for Addictive Diseases - Main Line Affiliates 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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711.93(a) LICENSURE Complete Client Record
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual, which includes follow-up information in six of eleven client records reviewed.
The findings include:
Eleven client records requiring a complete client record on an individual were reviewed on September 30, 2015. The facility did not provide a complete client record for client #s 6, 7, 8, 9, and 10.
Client #6 was admitted into treatment on December 3, 2014 and was discharged on April 28, 2015. The facility failed to include documentation of any follow-up information in the client chart as of the date of the inspection.
Client #7 was admitted into treatment on March 19, 2015 and was discharged on July 13, 2015. The facility failed to include documentation of any follow-up information in the client chart as of the date of the inspection.
Client #8 was admitted into treatment on August 25, 2014 and was discharged on May 27, 2015. The facility failed to include documentation of any follow-up information in the client chart as of the date of the inspection.
Client #9 was admitted into treatment on September 25, 2014 and was discharged on January 6, 2015. The facility failed to include documentation of any follow-up information in the client chart as of the date of the inspection.
Client #10 was admitted into treatment on December 6, 2014 and was discharged on April 1, 2015. The facility failed to include documentation of any follow-up information in the client chart as of the date of the inspection.
Client #11 was admitted into treatment on May 15, 2014 and was discharged on April 3, 2015. The facility failed to include documentation of any follow-up information in the client chart as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical supervisor will review in staff meeting the standard and policy requiring that outreach attempt be completed within 7 days post discharge as well as the aftercare policy. The Discharge Summary form has been amended to reflect multiple discharge status options as well as an area for documenting the 7 day follow up. Compliance with this standard will be ensured by the clinical supervisor via monthly chart audits and reinforced quarterly at the staff meeting. This goal will be achieved by 11-15-2015. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) 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 ensure that an informed and voluntary consent to release information was obtained in one of eleven client records reviewed.
The findings included:
Eleven client records requiring complete informed and voluntary consent to release information forms were reviewed on September 30, 2015. The facility failed to ensure that an informed and voluntary consent to release information form was obtained prior to the disclosure of information in client record #6.
Client #6 was admitted into treatment on December 3, 2014 and was discharged on April 28, 2015. A 'family' session was held on 12/09/14 and the client brought a personal friend, as well as a second 'family' session was held on 01/13/15 and the client brought a "family friend" and a "best friend." However, as of the date of the inspection, there were no consent to release information forms signed by the client, prior to the disclosure of information, for the three individuals that attended the sessions with the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will review in staff meeting confidentiality requirements including: DDAP standards, project policy, and federal and state laws. This includes requiring that project obtain an informed and voluntary consent from the client for disclosure for each family member or friend who will participate in counseling sessions. Compliance with this standard will be ensured via review of relevant policy at quarterly staff meetings and via monthly chart audits to be reconciled with attendance sheets from family sessions. This goal will be completed by 11-15-2015. |