INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 5, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, Chartiers Community Mental Health and Retardation Center, Inc. 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
The facility failed to document an informed and voluntary consent from the client for the disclosure of information contained in the client record in three of seven client records reviewed on December 5, 2018.
The client's name and diagnosis was released to the funding entity for authorization of counseling services in the following client records:
Client # 1 was admitted August 9, 2018.
Client # 4 was admitted August 14, 2018 and discharged October 4, 2018.
Client # 5 was admitted April 24, 2018 and discharged September 4, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On December 6, 2018, the Facility Director conducted training, utilizing the regulations and discussion, for existing staff regarding regulations related to disclosure to all funding entities. Also on December 6, 2018, the Facility Director developed and implemented tracking via a spreadsheet so as to ensure that there is complete documentation of informed and voluntary consents prior to any disclosures by reviewing all disclosures prior to occurrence and verifying adherence to relevant regulations regarding disclosure.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to document treatment plan updates at least every sixty days in three of six client records reviewed on December 5, 2018.
Client # 5 was admitted April 24, 2018 and discharged September 4, 2018. The individual treatment plan was completed April 24, 2018. The only treatment plan update was not documented until September 4, 2018.
Client # 6 was admitted August 8, 2018 and discharged October 31, 2018. The individual treatment plan was completed August 8, 2018. The only treatment plan update was not documented until October 31, 2018.
Client # 7 was admitted April 2, 2018 and discharged August 27, 2018. The individual treatment plan was completed April 2, 2018. No treatment plan updates were documented.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plans were not updated by the 60th day of the plan's due date, which is required by regulations. On December 6, 2018, the Facility Director conducted training, utilizing the regulations and a discussion of the time lines and expectations for treatment plan documentation. In addition, an ongoing schedule to ensure that Service Plan Reviews occur every 60 days has been re-implemented by the Facility Director on December 6, 2018.
The Facility Director is responsible to check the schedule on an ongoing basis to review and ensure timely completion of each review via system alerts as well as clinical record. In the event that the client does not show for a scheduled appointment so as to complete a Service Plan review, a Substance Abuse Review of Treatment Progress shall be documented in the electronic record by the primary counselor so as to ensure completion within the sixty (60) day time frame.
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