INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 21-22, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Chester County Intermediate Unit-Changes, was found to be not 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 conducted on December 21-22, 2016, the facility failed to obtain a valid consent to release information form in the following client records.
Client #2 was admitted on 9/14/16 and was still an active client at the time of the inspection. A successful facsimile transmission to a funding source, dated 12/16/16, containing a pre-authorization request for medication, and that identified the client as being enrolled "in a Drug and Alcohol treatment program" was found in the record, however there was no consent to release information to the funding source.
Client #9 was admitted on 10/6/15 and was discharged on 9/6/16. An authorization from a funding source dated 10/15/15 and a second authorization from the same funding source dated 1/3/16 was found in the record, however there was no consent to release information to the funding source.
Client #15 was admitted on 9/8/15 and was discharged on 6/8/16. A letter from a funding source dated 11/3/15 regarding denial of authorization for treatment was found in the record, however there was no consent to release information to the funding source.
This information was reviewed with the facility staff during the licensing process.
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Plan of Correction
A staff meeting was held on 12/27/16 to review confidentiality and consent regulations, specifically reviewed issues surrounding funding sources and insurance providers. The Clinical Supervisor will ensure that consents to release information to funding sources and insurers will be obtained and that all students who receive medication management by IU psychiatrist will have a signed release for funding source completed upon intake or at the time of initial prescription.
Corrective action was completed 1/3/17 for all active students and will releases will be obtained at intake for all new admissions.
Client #2: A release of information was obtained for funding source on 1/3/17 as this was clients next day in program after audit .
No authorization was obtained for Client 9 or
15 as they were discharged prior to the audit. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records conducted on December 21-22, 2016, the facility failed to comply with the regulation in the following client records.
Client #4 was admitted on 8/29/16 and was an active client at the time of the licensing inspection. A comprehensive treatment plan was documented on 11/3/16; a treatment plan update was due by 12/3/16 but was not completed until 12/5/16.
Client #5 was admitted on 11/9/15 and was an active client at the time of the licensing inspection. A treatment plan update was documented on 11/18/16; a subsequent update was due by 12/18/16 but was not documented at the time of the inspection.
Client #9 was admitted on 10/6/15 and was discharged from this level of care on 6/23/16. A treatment plan update was documented on 5/20/16; a subsequent update was due by 6/20/16 but was not documented until 6/23/16.
Client #11 was admitted on 2/16/16 and was discharged 7/26/16. A treatment plan update was documented on 6/1/16; a subsequent update was due by 7/1/16 but was not documented at the time of the inspection.
This information was discussed with facility staff during the licensing process.
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Plan of Correction
A staff meeting was held 12/27/16 to review regulation regarding treatment plans.
Treatment plans will be updated and signed by therapist with in 30 days of prior plan regardless of access to client. When clients are unexpectedly absent from program, are medically hospitalized, or detained, the clinician will clearly document the reason for lack of client signature. For Plans due on weekends, clinician will ensure that the plan be completed with therapist signature on Friday's instead of the next program day.
Treatment plan dates will be reviewed at weekly staff meeting to ensure compliance. Dates will be tracked by Clinical Supervisor |