INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 12, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services York Psychiatric 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 February 7, 2009.
|
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 the facility ' s policy and procedure manual, the facility failed to document a written policy/procedure that shall comply with 4 Pa. Code 255.5
The findings include:
The facility ' s policy and procedure manual was reviewed on January 5, 2009 and January 6, 2009. The facility ' s policy regarding confidentiality of client identity and records included language allowing the facility to disclose information to the parent or guardian of a minor without the minor ' s consent.
|
Plan of Correction
The Quality Improvement Department will revise the confidentiality policy to comply with all federal and state confidentiality laws. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
|
Observations
Based on a review of client records, the facility failed to document complete aftercare plans in three of four client records.
The findings include:
Seven client records were reviewed on January 12, 2009. Aftercare plans were required in four client records. The facility did not document aftercare goals that were individualized to each client's needs or that were stated in measurable terms in client records #6 and 7. The aftercare plan was missing in client record #5.
|
Plan of Correction
The Quality Improvement Department has revised the Aftercare Plan to include prompts to remind therapists to create individualized goals. The QI Department will also be re-educating clinical staff via staff meeting to develop individualized aftercare plans with personal/measurable goals and action steps for all clients who are successfully discharged. QI will then monitor on-going compliance through random chart reviews and re-educate staff as necessary. |
709.93(a)(10) 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:
(10) Discharge summary.
|
Observations
Based on a review of client records, the facility failed to document a complete discharge summary in three of four client records.
The findings include:
Seven client records were reviewed on January 12, 2009. A discharge summary was required in four client records. The facility did not document a specific reason or event that led to the client's reason for treatment in client records #4 and 6. The reason for treatment was listed as drug and/or alcohol dependency. The facility did not document a discharge summary for client record #5. The discharge summary was missing.
|
Plan of Correction
The Quality Improvement Department will re-educate clinical staff via staff meeting to elaborate on the reason/event that led the client to treatment. The QI Department will monitor ongoing compliance via random chart reviews and will re-educate staff as needed. The Facility Director will oversee that office administration monitors for completion of discharge summaries. Every discharged file will be reviewed prior to being placed in the archives. |