INITIAL COMMENTS
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This report is a result of an on-site inspection to this newly licensed facility following the admittance of its first client. The inspection was conducted on August 12, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of this on-site inspection, Jade Wellness Center, 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 and a plan of correction is due on September 13, 2010.
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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 a review of project policies, Health Insurance Portability and Accountability Act (HIPAA) documents and an interview with the facility director, the facility failed to document a confidentiality policy and procedure that was in compliance with federal and state drug and alcohol confidentiality laws and regulations, as required.
The findings include:
On August 12, 2010, a review was conducted of project policies and HIPAA documentation. Per regulation, 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 confidentiality of client identity and records. The facility failed to provide a project policy and procedure and HIPAA information that was in compliance with 28 Pa Code 709.28, 4 Pa Code 255.5 and 42 CFR Part II. The HIPAA documentation did not include a disclaimer indicating that releases of information permitted by HIPAA regulations, which are prohibited by federal and state confidentiality laws for substance abuse treatment, continue to be prohibited and will require the client's written consent before releasing information. This is in violation of federal and state substance abuse treatment laws and regulations.
On August 12, 2010, the facility director was interviewed and confirmed the HIPAA information and the federal and state confidentiality laws and regulations were not correctly documented by the facility.
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Plan of Correction
The HIPAA Right to Privacy notification has been revised by the Executive Director to include the following statement "Releases of information permitted by HIPAA regulations which are prohibited by the Federal and State Confidentiality Laws for Substance Abuse Treatment continue to be prohibited and will require the client's written consent."
A revised procedure will be developed by the Executive Director to reflect this change and the method for monitoring future compliance.
All old Notifications have been discarded.
The Executive Director will ensure future compliance through regularly scheduled chart monitors. |
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 a review of client records and an interview with the facility director, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in six of six clients records, as required.
The findings included:
Seven client records were reviewed on August 12, 2010. Six client records were reviewed for informed and voluntary consents from the client. Per regulation, the project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record; this consent shall be in writing. Six client records required an informed and voluntary consent from the client. The facility failed to document a qualified service organization agreement (QSOA) or consent for the release of client information to a medical lab that performs blood tests in client records # 1, 2, 3, 4, 5 and 6. The facility failed to obtain an informed and voluntary consent for the disclosure of client information to the funding entity in client records # 1, 2, 3, 4 and 5.
The facility failed to obtain a consent to release client information to a mental health provider in client record # 4.
Client # 1 was admitted to the program on May 18, 2010. On May 18, 2010, the funding entity was contacted for authorization of services without an informed and voluntary consent from the client. An authorization to obtain a blood sample and perform testing was sent to the lab without an informed and voluntary consent from the client.
Client # 2 was admitted to the program on June 4, 2010. On June 4, 2010, the funding entity was contacted for authorization of services without an informed and voluntary consent from the client. An authorization to obtain a blood sample and perform testing was sent to the lab without an informed and voluntary consent from the client.
Client # 3 was admitted to the program on June 4, 2010. On June 4, 2010, the funding entity was contacted for authorization of services without an informed and voluntary consent from the client. An authorization to obtain a blood sample and perform testing was sent to the lab without an informed and voluntary consent from the client.
Client # 4 was admitted to the program on May 24, 2010. On May 24, 2010, the funding entity was contacted for authorization of services without an informed and voluntary consent from the client. An authorization to obtain a blood sample and perform testing was sent to the lab without an informed and voluntary consent from the client. Also, on July 6, 2010, a mental health provider was contacted by phone without written consent from the client.
Client # 5 was admitted to the program on June 3, 2010. On June 3, 2010, the funding entity was contacted for authorization of services without an informed and voluntary consent from the client. An authorization to obtain a blood sample and perform testing was sent to the lab without an informed and voluntary consent from the client.
Client # 6 was admitted to the program on May 24, 2010. An authorization to obtain a blood sample and perform testing was sent to the lab without an informed and voluntary consent from the client.
On August 12, 2010, the facility director was interviewed and confirmed that informed and voluntary consents were not obtained from clients # 1, 2, 3, 4, 5 and 6. The facility director reported that this issue has already been addressed with staff and they will ensure that written consents are obtained from clients prior to releasing any information.
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Plan of Correction
Individual consets have been created for labratory, pharmacy, PCP and all other entities related to the client's care to ensure that the client's care is coordinated and Confidentiality is maintained. Each client will sign the consent and the consent will include an expiration date. A copy of that consent will be in the client's chart. The consents were revised by the Exectuive Director.
All staff have been trained to utilize the new consent forms
The Executive Director will ensure ongoing compliance with the requirement for individual consents will be monitored by regularly scheduled chart monitors. |
709.28(c)(6) 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:
(6) Expiration date of the consent.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document an informed and voluntary consent from the client that included the expiration date of the consent in four of six client records, as required.
The findings include:
Seven client records were reviewed on August 12, 2010. Six client records contained informed and voluntary consents from the client. Six client records were required to document an expiration date on the informed and voluntary consent. Per regulation, 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 an expiration date of the consent. The facility failed to document an informed and voluntary consent that included an expiration date in client records # 1, 2, 3 and 5.
Client # 1 was admitted to the program on May 18, 2010. Client record # 1 included consents to release information to the client's physician. The consents were signed by the client on May 18, 2010 and did not include an expiration date.
Client # 2 was admitted to the program on June 4, 2010. Client record # 2 included consents to release information to the client's physician and mental health provider. The consents were signed by the client on June 4, 2010 and did not include an expiration date.
Client # 3 was admitted to the program on June 4, 2010. Client record # 3 included consents to release information to the client's physician. The consents were signed by the client on June 4, 2010 and did not include an expiration date.
Client # 5 was admitted to the program on June 3, 2010. Client record # 5 included consents to release information to the client's physician and a relative. The consents were signed by the client on June 3, 2010 and did not include an expiration date.
The facility director was interviewed on August 12, 2010 at approximately 2:00 PM. The facility director reviewed the informed and voluntary consents and confirmed there was no documentation of an expiration date.
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Plan of Correction
New consents have been developed for all entitities involved with the client's treatment and include an expiration date. The new forms were created by the Executive Director.
All staff have been trained regarding the utilization of the new consent forms.
The Executive Director will ensure compliance through regularly scheduled chart monitors. |
709.91(b)(2)(i) 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:
(i) Project policies.
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Observations
Based on a review of project policies, the client orientation handbook, Health Insurance Portability and Accountability Act (HIPAA) documents and an interview with the facility director, the facility misinformed clients of their right to confidentiality per federal and state drug and alcohol regulations, as required.
The findings include:
On August 12, 2010, a review was conducted of client orientation information, project policies and HIPAA documents. Per regulation, intake procedures shall include documentation of client orientation to the project which shall include project policies. The facility failed to provide project policy and HIPAA information that was in compliance with 28 Pa Code 709.28, 4 Pa Code 255.5 and 42 CFR Part II. The HIPAA information provided to the client did not include a disclaimer indicating that releases of information permitted by HIPAA regulations, which are prohibited by Federal and State confidentiality laws for substance abuse treatment, will require the client's written consent. This violates the clients right to confidentiality per federal and state drug and alcohol laws and regulations. Clients admitted to the program were not correctly informed of their confidentiality rights during the intake process.
On August 12, 2010, the facility director was interviewed and confirmed that clients did not receive accurate information regarding HIPAA and the federal and state confidentiality laws and regulations.
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Plan of Correction
The Client Handbook will be revised by 10/31/2010 and that revision will include the necessary corrections regarding confidentiality and the exceptions to Confidentiality Laws.
The Project Director will revise that document, train staff on the new document and ensure that distribution to all clients takes place. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, and an interview with the project/facility director, the facility failed to document psychosocial evaluations that included a clinical assessment of the client in six of six client records, as required by regulation.
The findings include:
Seven client records were reviewed on August 12, 2010. Six client records required the completion of psychosocial evaluations, per regulation. Six client records did not include a clinical assessment of the client; and only included client historical information. The facility failed to document a psychosocial evaluation that included a clinical assessment in client records # 1, 2, 3, 4, 5 and 6.
Client # 1 was admitted to the program on May 18, 2010. The psychosocial evaluation was completed on May 18, 2010. The psychosocial evaluation did not include a clinical assessment of the client; and only included client historical information.
Client # 2 was admitted to the program on June 4, 2010. The psychosocial evaluation was completed on June 4, 2010. The psychosocial evaluation did not include a clinical assessment of the client; and only included client historical information.
Client # 3 was admitted to the program on June 4, 2010. The psychosocial evaluation was completed on June 11, 2010. The psychosocial evaluation did not include a clinical assessment of the client; and only included client historical information.
Client # 4 was admitted to the program on May 24, 2010. The psychosocial evaluation was completed on May 24, 2010. The psychosocial evaluation did not include a clinical assessment of the client; and only included client historical information.
Client # 5 was admitted to the program on June 3, 2010. The psychosocial evaluation was completed on June 11, 2010. The psychosocial evaluation did not include a clinical assessment of the client; and only included client historical information.
Client # 6 was admitted to the program on May 24, 2010. The psychosocial evaluation was completed on May 24, 2010. The psychosocial evaluation did not include a clinical assessment of the client; and only included client historical information.
The facility director was interviewed on August 12, 2010 at approximately 2:00 PM. The facility director confirmed the psychosocial evaluations did not include a clinical assessment of the client.
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Plan of Correction
The Psycho Social Evaluation has been revised and now exists as two tools: a Needs Assessment and a Psycho Social Evaluation. That revision has been completed by the Executive Director. New staff have been trained and adherence will be monitored by the Executive Director by way of regularly scheduled chart monitors.
The Executive Director ensures that the deficiency has been corrected. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 and an interview with the facility director, the facility failed to document that an individual treatment and rehabilitation plan was developed with the client in six of six client records, as required.
The findings included:
Seven client records were reviewed on August 12, 2010. Six client records were reviewed for the development of an individual treatment and rehabilitation plan with the client. Per regulation, an individual treatment and rehabilitation plan shall be developed with a client. Per facility policy, a treatment plan will be developed with a client within 14 days of admission to the program. The facility failed to document that an individual treatment and rehabilitation plan was developed with the client in client records # 1, 2, 3, 4, 5 and 6.
Client # 1 was admitted to the program on May 18, 2010. The treatment plan was completed by the counselor on May 18, 2010. The treatment plan was not signed by the client; nor was there a progress note indicating the client had participated in the development of the treatment plan. The client had participated in several counseling sessions since the admit date and would have been available to participate in the development of the treatment plan.
Client # 2 was admitted to the program on June 4, 2010. The individual treatment and rehabilitation plan was due to be completed no later that June 18, 2010. There was no documentation of a treatment plan in client record # 2.
Client # 3 was admitted to the program on June 4, 2010. The individual treatment and rehabilitation plan was due to be completed no later that June 18, 2010. There was no documentation of a treatment plan in client record # 3.
Client # 4 was admitted to the program on May 24, 2010. The individual treatment and rehabilitation plan was due to be completed no later that June 7, 2010. There was no documentation of a treatment plan in client record # 4.
Client # 5 was admitted to the program on June 3, 2010. The individual treatment and rehabilitation plan was due to be completed no later that June 17, 2010. There was no documentation of a treatment plan in client record # 5.
Client # 6 was admitted to the program on May 24, 2010. The individual treatment and rehabilitation plan was due to be completed no later that June 7, 2010. There was no documentation of a treatment plan in client record # 6.
On August 12, 2010, the facility director was interviewed at approximately 2:00 PM. The facility director confirmed there was no documentation that the treatment plan had been developed with client # 1. The facility director also confirmed there was no documentation of an individual treatment and rehabilitation plan in client records # 2, 3, 4 and 5.
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Plan of Correction
The treatment planning process has been revised to include a Preliminary Treatment Plan, a Comprehensive Treatment Plan and timely Updates with clearly defined time frames for completion. That process has been completed by the Executive Director. New staff have been trained and Executive Director will ensure compliance through regularly scheduled chart monitors. |
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.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document a discharge summary that included information relative to the client's involvement with the project in three of four client records, as required.
The findings include:
Seven client records were reviewed on August 12, 2010. Four client records were closed and required the completion of a discharge summary. Per regulation, there shall be a complete client record on an individual which includes information relative to the client' s involvement with the project and this shall include a discharge summary. The facility did not document the completion of a discharge summary that included information relative to the client's involvement with the project in client records # 4, 5 and 6.
Client # 4 was admitted to the program on May 24, 2010 and discharged on July 16, 2010. The discharge summary was completed on July 16, 2010 and did not include information relative to the client's involvement with the project. The discharge summary did not include reasons for the client's treatment or the client's response to treatment.
Client # 5 was admitted to the program on June 3, 2010 and discharged on August 10, 2010. The discharge summary was completed on August 10, 2010 and did not include information relative to the client's involvement with the project. The discharge summary did not include reasons for the client's treatment or the client's response to treatment.
Client # 6 was admitted to the program on May 24, 2010 and discharged on July 30, 2010. The discharge summary was completed on July 30, 2010 and did not include information relative to the client's involvement with the project. The discharge summary did not include reasons for the client's treatment or the client's response to treatment.
The facility director was interviewed on August 12, 2010 at approximately 2:00 PM. The facility director confirmed the discharge summaries did not include the reasons for the client's treatment or the client's response to treatment.
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Plan of Correction
The Discharge Summary has been revised with clearly established time frames. New staff have been trained and the Executive Director will monitor adherence through regularly scheduled chart monitors.
The new Discharge Summary was revised by the Executive Director. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to document follow up in three of three client records, as required.
The findings include:
Seven client records were reviewed on August 12, 2010. Four client records were closed. Three client records required the completion of a follow up. A follow up was not due in one of the closed client records. Per the agency policy, follow up is required within 7 days of discharge. The facility did not document follow up in client records # 4, 6 and 7.
Client # 4 was admitted on May 24, 2010 and discharged on July 16, 2010. Follow up was required to be completed no later than July 23, 2010. There was no documentation of a follow up in client record # 4.
Client # 6 was admitted on May 24, 2010 and discharged on July 30, 2010. Follow up was required to be completed no later than August 6, 2010. There was no documentation of a follow up in client record # 6.
Client # 7 was admitted on May 13, 2010 and discharged on July 7, 2010. Follow up was required to be completed no later than July 14, 2010. There was no documentation of a follow up in client record # 7.
The facility director was interviewed on August 12, 2010 at approximately 2:00 PM. The facility director confirmed that no follow ups had been conducted with clients # 4, 6 and 7.
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Plan of Correction
A protocol for follow up has been devloped including forms to evidence completion of that protocol. That protocol will include a discharge meeting with the client (when possible) at which time the client will sign the aftercare plan. The client will also sign a consent to allow a follow up telephone call to the client and to the referral source (when applicable). In the case of an unplanned discharge, when possible, a meeting will take place with the client who sign the Unplanned Discharge form and the consent for follow up. All of the necessary documents will be offered to the client and copies will be maintained in the clients' discharged chart. This process will developed by the Executive Director. All staff have been trained in the utilization of the new process. The Executive Director will ensure compliance through regularly scheduled chart monitors. |