INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 9-10, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northern Tier Counseling, 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(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.
|
Observations
Based on a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in one of ten records reviewed.
The findings included:
Ten client records requiring releases of information were reviewed on July 9-10, 2014. The facility failed to comply with the restrictions imposed at 4 Pa. Code 255.5 (b) in client record #8.
Client #8 was admitted to treatment on 10/15/2013 and was discharged on 02/14/2014. A release of information to a government agency was signed on 02/06/2014 and allowed for the disclosure of the client's initial drug and alcohol evaluation, which exceeded the limitations imposed at 255.5(b).
The Project Director and Facility Director were informed and confirmed the findings.
|
Plan of Correction
Northern Tier Counseling
Plan of Correction
Confidentiality
709.28 (a) (1)
Observation #0271
A written policy outlining 709.28, 4Pa. Code subsection 255.5, 71 P.s. 1690.108 Act 63 can be found in the NTC Policy Manuel. The NTC Release of Information has been revised effective 8/1/14. The revised Release of Information form has been reviewed and approved by Northern Tier Counseling's Compliance Committee also on 8/06/14. All Drug and Alcohol therapists and Administrative Staff have received training as to the appropriate use of the form and all required information needed for a release of information to be considered "complete" on 8/6/2014. All newly hired staff after 8/1/14 will receive in-service in the area of confidentiality specifically 255.5 and within this in-service there would be specific discussion and training as to the correct way to complete all aspects of the Release of Information. Continued in service on regulation 255.5 will be provided during the employee's training plan review and renewal in January 2015. All correspondence leaving the agency will be standardized to ensure that the information that is being released is in accordance to regulation 255.5. All Correspondence will be co-signed by the Program Director.
|
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
|
Observations
Based on a review of client records, the facility failed to consistently ensure that the client was offered a copy of the consent to release information form upon signing in four of ten records reviewed.
The findings included:
Ten client records requiring releases of information were reviewed on July 9-10, 2014. The facility failed to provide verification that the client was offered a copy of the consent in client record #'s 1, 2, 3, and 4.
Client #1 was admitted to treatment on 02/04/2014 and was still an active client at time of the inspection. A release of information form to a government agency was signed by the client on 02/27/2014. There was no documentation the client was offered a copy of the consent form.
Client #2 was admitted to treatment on 11/21/2013 and was still an active client at time of the inspection. Release of information forms to a government agency, signed on 11/21/2013, and a release of information form to a doctor's office were signed by the client on 11/21/2013. There was no documentation the client was offered a copy of the consent form.
Client #3 was admitted to treatment on 04/03/2014 and was still an active client at time of the inspection. Two release of information forms to two different government agencies were signed by the client on 04/16/2014. There was no documentation the client was offered a copy of the consent form.
Client #4 was admitted to treatment on 03/21/2013 and was still an active client at time of the inspection. A release of information form to an insurance company was signed by the client on 03/21/2013. There was no documentation the client was offered a copy of the consent form.
The Project Director and the Facility Director confirmed the findings.
|
Plan of Correction
Plan of Correction
709.28(d)
Confidentiality
Observation #0289
A written policy outlining 709.28, 4Pa. Code subsection 255.5, 71 P.s. 1690.108 Act 63 can be found in the NTC Policy Manuel. The NTC Release of Information has been revised effective 8/1/14. The revised Release of Information form has been reviewed and approved by Northern Tier Counseling's Compliance Committee also on 8/06/14. All Drug and Alcohol therapists and Administrative Staff have received training as to the appropriate use of the form and all required information needed for a release of information to be considered "complete" on 8/6/2014. All newly hired staff after 8/1/14 will receive in-service in the area of confidentiality specifically 255.5 and within this in-service there would be specific discussion and training as to the correct way to complete all aspects of the Release of Information. Continued in service on regulation 255.5 will be provided during the employee's training plan review and renewal in January 2015. All Releases of Information will be reviewed by the Program Director following intake into the Program and then at random times throughout the course of treatment during the Therapist's monthly supervision, and then once again at the point of discharge to ensure compliance with 709.28(d).
|
709.93(a) 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:
|
Observations
Based on a review of client records, the facility failed to document a complete client record on an individual, which includes information relative to the client's involvement with the project in four of ten client records reviewed.
The findings include:
Ten client records requiring a complete client record on an individual were reviewed on July 9-10, 2014. The facility did not provide a complete client record, to include record of services and follow up information for client #s 6, 7, 8, and 10.
The facility indicated that when a client is referred to another treatment facility follow up is to be conducted within 7 days of the date of discharge and all other discharged clients require a 60 day follow up contact.
Client #6 was admitted to treatment on 06/28/2012 and was discharged on 10/31/2013. A follow up was to be completed no later than 12/31/2013; however there was no follow up documented as of the date of the inspection.
Client #7 was admitted to treatment on 09/11/2013 and was discharged on 10/15/2013. The facility failed to include documentation of the client's Record of Service.
Client #8 was admitted to treatment on 10/15/2013 and was discharged on 02/14/2014. A follow up was to be completed no later than 02/21/2014; however there was no follow up documented as of the date of the inspection.
Client #10 was admitted to treatment on 01/24/2014 and was discharged on 06/12/2014. A follow up was to be completed no later than 08/12/2014; however there was no follow up documented as of the date of the inspection. Additionally, the facility failed to include documentation of the client's Record of Service.
The Project Director and the Facility Director confirmed the findings.
|
Plan of Correction
Plan of Correction
709.93(a)
Client Records
Observation #1889
The Northern Tier Counseling Policy as it relates to 709.93 Follow Up Information has been revised effective 8/1/2014. The revised policy now reads:
Only clients that have been successfully discharged from the treatment facility will receive a phone call no later than 30 days from the date of discharge. The follow up phone call will be made by either the treatment therapist or the Clinical Director. During the phone call the following will be asked of the client: 1. Have you had success at maintaining your sobriety?
2. Have you followed your after care plan?
3. Have you utilized the supports you identified as being helpful when you developed your after care plan?
4. Do you need any assistance with referrals for AA/NA or other community supports?
5. Are you in need of additional therapeutic intervention at this time?
This correspondence will be kept in the correspondence section of the chart.
Clients referred to higher levels of care, i.e., Intensive Outpatient or Inpatient Rehabilitation Programs will be contacted within 14 days of the transfer to the higher level of care.
Discharge Summary will be complete per Northern Tier Counseling Discharge Summary Policy within Clients Records Section 709.93.
This policy states that the Discharge Summary will be completed within one week (7) days from the date of last session with the Therapist. Follow ups will be conducted at day 14 for referrals to higher levels of care and on or before 30 days post discharge for successful discharges from the program. |