INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 14, 2017 through February 15, 2017 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, Family Service Association of Bucks County 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 (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.
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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 client records # 1, 2, 3, 4, 5, 6, and 7. Additionally, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in client record # 5.
Client #1 was admitted on 08/19/2013 and was an active client at time of inspection. A consent to release form was signed and dated on 05/04/2016 to the funding source which allowed for the release of evaluations and assessments.
Client #2 was admitted on 08/29/2016 and was an active client at time of inspection. A consent to release form was signed and dated on 08/29/2016 to the funding source which allowed for the release of evaluations and assessments.
Client #3 was admitted on 11/11/2016 and was an active client at time of inspection. A consent to release form was signed and dated on 11/11/2016 to the funding source which allowed for the release of evaluations and assessments.
Client #4 was admitted on 04/25/2016 and was discharged on 06/16/2016. A consent to release form was signed and dated on 04/25/2016 to the funding source which allowed for the release of evaluations and assessments.
Client #5 was admitted on 05/10/2016 and was discharged on 02/06/2017. A consent to release form was signed and dated on 05/10/2016 to the funding source which allowed for the release of evaluations and assessments. Additionally, the record contained documentation of a facsimile to a government agency for which there was no consent, and released psychiatric evaluation, progress notes, client history, psychosocial assessment, and treatment plans.
Client #6 was admitted on 10/14/2015 and was discharged on 05/03/2016. The record contained a consent to release information form to the funding source, signed and dated on 10/14/2015, which allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5, including " all of the above. "
Client #7 was admitted on 06/22/2016 and was discharged on 10/27/2016. A consent to release form was signed and dated on 06/22/2016 to the funding source which allowed for the release of evaluations and assessments.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address the issue found in the records of Clients #1, 2, 3, 4, 5, 6 and 7 the Funder Release of Information form has been revised to limit the information to be released to the five categories allowed in accordance with PA Code 255.5(b). The option of "all of the above," as noted in record 6, had been removed previously. This updated release form went into effect on 2/15/17 and staff gathering the initial consents were trained on the use of this new form. Full compliance on the use of the revised release is expected by 3/10/17 and will be overseen by the Clinical Director and Clinical Supervisors. Clients 1, 2 and 3 are still active and will be asked to sign an updated Funder Release of Information form. Acquiring signatures on the updated Funder Release of Information forms is expected to be completed by 3/17/17. The Clinical Supervisors who oversee the treating therapists are responsible for implementing this corrective action. Clients 4, 5, 6 and 7 have been discharged so no further action is possible.
It was indicated that Record # 5, "contained documentation of a facsimile to a government agency for which there was no consent, and released psychiatric evaluation, progress notes, client history, biopsychosocial assessment, and treatment plans." The document referred to "Authorization to Disclose Information to The Social Security Administration (SSA)" was electronically signed by the requesting client. For client record #5, the information released exceeded 255.5. As noted above, the ROI was updated as of 2/15/17 and staff were trained on its use. Full compliance on the use of the revised release in the electronic health record is effective 3/10/17 and was overseen by the Clinical Director and Clinical Supervisors. Clinical Director discussed the updated release with the Senior Records Specialist on 3/2/17 to prevent inappropriate disclosure in the future Because this client was discharged, the ROI for record #5 cannot be updated.
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709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on a review of the facility's data collection system, the facility failed to ensure that the system utilized provided accurate client admission and discharge dates within the specified time period of December 2016 to February 2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This is the first time Family Service has collected client admission and discharge data strictly via the use of the electronic health record system and there were noted flaws in this process. The process is being reviewed by the Clinical Director and EHR Systems Administrator to develop a consistent process for entering data, and training staff on this process. The process is expected to be developed by 3/17/17. The Systems Administrator will train staff by 3/24/17. Full compliance is expected by 4/1/17. Clinical Director and Systems Administrator will run reports to check the accuracy of the process developed and make any changes or additions by 5/1/17 which will allow some time for data entry. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to provide documentation that clients were informed of the project's hours of operation and fee schedule as part of the orientation process in client record #'s 2, 3, 4, 5, 6, and 7.
Client #2 was admitted on 08/29/2016 and was an active client at time of inspection.
Client #3 was admitted on 11/11/2016 and was an active client at time of inspection.
Client #4 was admitted on 04/25/2016 and was discharged on 06/16/2016.
Client #5 was admitted on 05/10/2016 and was discharged on 02/06/2017.
Client #6 was admitted on 10/14/2015 and was discharged on 05/03/2016.
Client #7 was admitted on 06/22/2016 and was discharged on 10/27/2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Hours of operation are posted on the front door of the site, visible to anyone entering the building. The fee schedule and other payment information are posted in the lobby, also highly visible. Family Service had two DDAP audits in December 2016 and this was in compliance with regulations for both audits. There was no notification of any regulation changes during the two month time frame between the audits so we had no idea the posting of the documents was out of compliance. Family Service was told at the time of the audit about this unannounced change. To address the hours of operation, the Clinical Director will revise the Welcome Packet given to clients as part of their orientation to include the hours of operation by 3/15/17. The fee schedule was revised on 2/24/17 and is pending approval by the Board of Directors. The Clinical Director Service will make the fee schedule part of the orientation process by 3/24/17. |
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
Based on a review of client records, the facility failed to include in the intake and admission process, a personal history that included sexual information in client record #'s 2, 3, 4, 5, 6, and 7. Additionally, the facility failed to obtain a medical history in client record # 5. The facility also failed to include in the intake and admission process, a drug and alcohol history that included details of route of administration in client record #'s 2, 4, 5, and 7 or frequency of use and last use in client record # 2.
Client #2 was admitted on 08/29/2016 and was an active client at time of inspection.
Client #3 was admitted on 11/11/2016 and was an active client at time of inspection.
Client #4 was admitted on 04/25/2016 and was discharged on 06/16/2016.
Client #5 was admitted on 05/10/2016 and was discharged on 02/06/2017.
Client #6 was admitted on 10/14/2015 and was discharged on 05/03/2016.
Client #7 was admitted on 06/22/2016 and was discharged on 10/27/2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regarding the sexual history, Family Service's position was that this was included in the initial assessment when therapists asked about "cultural and personal factors." Since this is not in compliance, Family Service will add a section which will specifically ask about sexual history to the biopsychosocial assessment. This will be done by 3/24/17.
Regarding not obtaining the medical history in Client record #5, this is unusual as the medical history is done by the nurse or clinician on the client profile and then injects into the assessment form. It appears that this was clinician error. The Clinical Director and Supervisors will evaluate the initial assessment and make a determination of which questions or sections need to be required fields by 3/17/17. The System Administrator will make the electronic health record changes required to the assessment form by 3/31/17. Clinical Supervisors will ensure therapists use the revised assessment form by 4/7/17 so the expectation is to be in full compliance by this date. Because the client whose record is #5 is closed to services, no medical history can be added to her chart as it would not be based on current information from the client.
Clinical Supervisors also reviewed the importance of completing the entire biopsychosocial assessment in the February 24th and 28th trainings focusing on treatment plans, golden thread and documentation with clinicians and will continue to review in ongoing supervision.
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709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records, the facility failed to ensure compliance with 55 PA. Code Part III, relating to medical assistance in client record #'s 5 and 7.
Client #5 was admitted on 05/10/2016 and discharged on 02/06/2017 and was identified as a medical assistance client. The facility failed to document the physician signature on the client's comprehensive treatment plan, dated 05/10/2016.
Client #7 was admitted on 06/22/2016 and discharged on 10/27/2016 and was identified as a medical assistance client. The facility failed to document the physician signature on the client's comprehensive treatment plan, dated 06/22/2016 and treatment plan update, dated 08/17/2016.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Clinicians regularly obtain physician signatures as required by Medical Assistance regulations/ stipulations. Since Family Service transitioned to the electronic health record, there have been occasions when obtaining signatures has been a challenge due to clinician error and/or to issues with the electronic health record. The instances listed appear to be due to clinician error. To correct this issue, Clinical Supervisors started tracking treatment plan due dates with clinicians they supervise in September 2016, after these incidents occurred, and will continue to do so until the electronic health record can meet this need. Clinical Director reviewed D&A regulations in the Treatment Planning trainings held on February 24th and 28th. Clinical Team and System Administrator have been exploring processes in the electronic health record to make the process of obtaining signatures more achievable for the clinicians. It is hoped that a more permanent solution can be established by 4/1/17, this will be based on the findings of the System Administrator. |