INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 21-22, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northeast Family Health Care, LLC 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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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
Based on observation and discussion with administrative staff, the facility failed to maintain the confidentiality of client-oriented information.
The findings include:
On May 22, 2013 it was observed by this writer, a patient escorted into the physician's office by prison guards for an intake session. It was further observed by this writer, the door remained open during the history and physical exam with both prison guards at the doorway. The patient was then escorted to the clinical director's office for the intake interview. Again, the counseling door remained open with the guards remaining at the doorway.
This writer was inspecting the dosing area when the patient came to the window to be dosed. The guard also came into the dosing cubicle with the patient. This actions prevented the patient from having her confidentiality maintained during her contacts with facility staff.
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Plan of Correction
The facility is modifying one office to include a door with a window. This office will be used for all counseling of inmates, and all physical exams of inmates as well as any medical visits. In addition, the nursing staff will bring the patient's dose to the patient in this room. The prison staff will be able to supervise the patient but will not be able to hear any discussion. This will be completed by July 1, 2013, and the Facility Director will ensure that this procedure is followed. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to provide counseling services as stated on the treatment plan in four of five client records.
The findings include:
Nine client records were reviewed May 21-22, 2013. Counseling services were reviewed for provision according to the treatment plan in five client records.
Client # 2 was admitted January 23, 2013. The comprehensive treatment included type and frequency that was pre-printed to be provided on a weekly basis. The last documented counseling session was dated more then a month prior to the inspection, April 9, 2013. There was no documentation of why the services were not being provided.
Client # 4 was admitted April 5, 2013. The treatment plan stated the client was to attend a weekly individual session and a weekly group session. The last documented session was dated April 17, 2013. There was no documentation of why the services were not being provided.
Client # 6 was admitted November 13, 2012. The comprehensive treatment included type and frequency that was pre-printed to be provided on a weekly basis. The client received two hours of counseling services in January 2013, less then two and one half hours of counseling services in February 2013 and less than two hours of counseling services in March.
Client # 7 was admitted November 7, 2012. The comprehensive treatment included type and frequency that was pre-printed to be provided on a weekly basis. The client had no documented counseling services in April 2013 and none in May 2013 at the time of the inspection.
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Plan of Correction
The counselors have been instructed in the use of dose holds as well as on documentation and counseling frequency expectations. This took place in individual supervision during the week of June 3 through June 7, 2013. This included the expectation that rescheduled, cancelled and no-show counseling appointments be documented in the case record. Counselors were also instructed in the use of treatment contracts for counseling attendance.
The Facility Director will randomly review 20% of each counselor's caseload each month for six months to ensure compliance with counseling service expectations. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 the review of client records, the facility failed to ensure follow up for two of three clients reviewed.
The findings include:
Nine client records were reviewed May 21-22, 2013. Three client records required documentation of a follow up attempt.
Client # 7 was admitted November 7, 2012 and discharged March 28, 2013 as a transfer to another facility. There was no documentation the facility attempted to make a follow up contact. There was a signed consent by the client for the receiving facility.
Client # 8 was admitted October 3, 2012 and discharged February 1, 2013. The client was involuntarily discharged February 1, 2013. There was no documentation at the time of the inspection of any follow up attempt. There was documentation through a signed consent to release information indicating the client may have been transferred, but this was never clarified within the record reviewed. A Follow-up attempt was to have been made within a week of the referral completion.
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Plan of Correction
The counselors have been instructed in the policy on follow-up expectations. This took place in individual supervision during the week of June 3 through June 7, 2013. The use of the standard follow up form was reviewed. Counselors were instructed that follow ups must be completed for all discharged patients beginning June 1, 2013.
The Facility Director will randomly review 20% of each counselor's caseload each month for six months to ensure compliance with follow up expectations.
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