INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 15, 2015 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, Resources for Human Development Inc. Morris House 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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to ensure that a completed informed and voluntary consent to release information was obtained in two of ten client records reviewed.
The findings included:
Ten client records requiring complete informed and voluntary consent to release information forms were reviewed on June 15, 2015. The facility failed to ensure that an informed and voluntary consent to release information form was obtained in client record, #5. Additionally, the facility failed to ensure that all of the required elements of the consent to release information forms were completed in client records, #5 and 8.
Client #5 was admitted into treatment on June 13, 2014 and was discharged on September 18, 2014. A letter to a government agency dated 6/17/2014 was documented in client #5 ' s record. There was no client signed/dated consent to release information form documented in the client record prior to the disclosure of the information. Additionally, there was an consent to release information form signed and dated by the client on 6/13/2014 documented in the record; however, the consent did not indicate the name of the person, agency, of organization to whom the disclosure was to be made to, the specific information to be disclosed, and the purpose of the disclosure.
Client #8 was admitted into treatment on August 6, 2014 and was discharged on January 2, 2015. There was a consent to release information form signed and dated by the client on 8/6/2014 documented in the record; however, the consent did not indicate the name of the person, agency, of organization to whom the disclosure was to be made to, the specific information to be disclosed, and the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will develop a training specifically related to confidentiality and consents, that will be reviewed with all staff during a staff development session before 9/1/15. All new hires will receive this training during their orientation period. The training will address the process by which informed and voluntary consents to release information are obtained from the client, as well as documented in the client record. Additionally, the Program Supervisor will review client records every two weeks to ensure continued compliance with this regulation, beginning 9/1/15. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan in three of ten client records reviewed.
The findings include:
Ten client records requiring documentation of an individual treatment and rehabilitation plan were reviewed on June 15, 2015. The facility failed to document an individual treatment and rehabilitation plan in client records, #3, 6, and 7.
Client #3 was admitted into treatment on April 29, 2015 and was still an active client as of the date of the on-site inspection. There was no individual treatment and rehabilitation plan documented in the client record at the time of the inspection.
Client #6 was admitted into treatment on November 7, 2014 and was discharged on January 8, 2015. There was no individual treatment and rehabilitation plan documented in the client record at the time of the inspection.
Client #7 was admitted into treatment on December 17, 2014 and was discharged on March 3, 2015. There was no individual treatment and rehabilitation plan documented in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The initial and comprehensive individual treatment plans for Client #3 were documented in the client record on 6/17/15, with the subsequent treatment plan update entered on 6/22/15.
On 6/24/15, the Program Director reviewed with clinical staff the requirements for the submission of an individual treatment and recovery plan, as well as the procedures for documentation in client records. Client records will be reviewed by the Program Director every two weeks to ensure compliance with this regulation, beginning 8/1/15.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 30 days in three of ten client records reviewed.
The findings include:
Ten client records were reviewed on June 15, 2015. Six of the records required the treatment and rehabilitation plans to be updated at least every 30 days. The facility failed to document updated treatment and rehabilitation plans in client records, #1, 2, and 9.
Client #1 was admitted into treatment on October 2, 2014 and was still an active client as of the date of the on-site inspection. The comprehensive treatment plan was dated 10/25/14 and an update to the treatment plan was completed on 01/24/2014. There have been no other treatment and rehabilitation plan updates documented in the client record at the time of the inspection.
Client #2 was admitted into treatment on March 2, 2015 and was still an active client as of the date of the on-site inspection. The comprehensive treatment plan was dated 03/14/2014 and there have been no treatment and rehabilitation plan updates documented in the client record at the time of the inspection.
Client #9 was admitted into treatment on August 14, 2014 and was discharged on November 13, 2014. The comprehensive treatment plan was dated 09/03/2014 and there have been no treatment and rehabilitation plan updates documented in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/24/15, the Program Director reviewed with clinical staff the requirements for the review and update of an individual treatment and recovery plan for every client, to be submitted at least every 30 days, as well as the procedures for documentation in client records. Client records will be reviewed by the Program Director every two weeks to ensure compliance with this regulation, beginning 8/1/15.
Client #1 completed the program and was discharged on 6/15/15.
Updated treatment plans for Client #2 were documented in the client record on 6/17/15
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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 a review of client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in three of ten records reviewed.
The findings included:
Ten client records requiring the documentation of the provision of services in accordance with those specified in the treatment plan were reviewed on June 15, 2015. The facility failed to provide counseling services as stated in the treatment and rehabilitation plan in client records, #1, 2, and 3.
Client #1 was admitted into treatment on October 2, 2014 and was still an active client at the time of the inspection. An individual treatment and rehabilitation plan was developed with the client on 10/25/2014 and the plan stated that the client would be provided individual sessions 1 time per week. There were no individual sessions documented in the client's record of service and there were no individual session progress notes documented in the record at the time of the inspection.
Client #2 was admitted into treatment on March 2, 2015 and was still an active client at the time of the inspection. An individual treatment and rehabilitation plan was developed with the client on 03/14/2015 and the plan stated that the client would be provided individual sessions 1 time per week. There were no individual sessions documented in the client's record of service and there were no individual session progress notes documented in the record at the time of the inspection.
Client #3 was admitted into treatment on April 29, 2015 and was still an active client at the time of the inspection. A preliminary individual treatment and rehabilitation plan was developed with the client on 04/30/2015 and the plan stated that the client would be provided individual sessions 1 time per week. There were no individual sessions documented in the client's record of service and there were no individual session progress notes documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/24/15 the Program Director met with the clinical staff to review the requirement of the documentation of the provision of services in accordance with the treatment plan, and how to ensure that treatment plans reflect a reasonable and attainable number of individual sessions between the counselor and the client per week.
Client #1 completed the program and was discharged on 6/15/15
Documentation of Individual Sessions were documented in the record for client #2 on 6/24/15.
Documentation of Individual Sessions were documented in the record for Client #3 on 6/17/15.
Additionally, beginning 8/1/15 the Program Director will be reviewing client charts every two weeks to ensure that the documentation reflecting the provision of services in accordance with the treatment plan are in the client record, in compliance with this regulation.
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709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual, which includes case consultation notes, discharge summaries, and follow-up information in four of ten client records reviewed.
The findings include:
Ten client records requiring a complete client record on an individual were reviewed on June 15, 2015. The facility did not provide a complete client record, to include case consultation notes, discharge summaries, and follow-up information for clients, #6, 7, 8, and 9.
Client #6 was admitted into treatment on November 7, 2014 and was discharged on January 8, 2015. The facility failed to include documentation of the discharge summary and follow-up information in the client record at the time of the inspection.
Client #7 was admitted into treatment on December 17, 2014 and was discharged on March 3, 2015. The facility failed to include documentation of the discharge summary and follow-up information in the client record at the time of the inspection.
Client #8 was admitted into treatment on August 6, 2014 and was discharged on January 2, 2015. The facility failed to include documentation of the discharge summary and case consultation notes in the client record at the time of the inspection.
Client #9 was admitted into treatment on August 14, 2014 and was discharged on November 13, 2014. The facility failed to include documentation of the discharge summary in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director met with the clinical staff on 6/24/15 to review the requirements necessary to document a complete client record on an individual. The Program Director met with the Program Supervisor on 7/7/15 to review the requirements necessary to document a complete client record. The Program Supervisor will meet with the clinical staff and Program Supervisor before 8/1/15 to designate responsibilities for the documentation of case consultation notes, discharge summaries, and follow-up information for clients to ensure they are reflected in the client records. Additionally, beginning 8/1/15, the Program Director will conduct reviews of client records every two weeks in order to ensure compliance with the regulation.
Discharge summaries for Client #6, Client #7, Client #8, and Client #9 will be completed by the counselors and recorded in the client records by 8/1/15.
The Program Director will ensure that Case Consultations occur every 90 days and are documented and submitted into the client records.
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