INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 8, 2016 through September 9, 2016 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, John F. Kennedy Behavioral Health Center 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
Based on a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record #'s 5 and 11. Additionally, client record #'s 6 and 7 had disclosures made without proper consent to release forms. Also, client #1 had a consent form that was missing the specific information to be released.
4 Pa. Code states that information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of the code, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following:
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Client #1 was admitted on July 22, 2015 and was discharged on August 27, 2016. There was a consent to release form to an outside agency, dated August 12, 2016, that failed to specify the specific information to be released.
Client #5 was admitted on May 6, 2002 and was an active client as of the date of the inspection. There were consent to release forms to two funding sources, both dated February 22, 2016, which allowed for the release of the discharge documentation, doctor notes, medication order sheets, psychiatric evaluation/CBE/CBR, therapist notes, and treatment plans. One of the funding source consent forms was not signed/dated by a witness and the other funding source consent form included intake documentation to be released.
Client #6 was admitted on June 4, 2015 and was an active client as of the date of the inspection. There were consent to release forms to two funding sources and both expired in June 4, 2016. There were no current consent forms in the record at the time of inspection and the client record indicated that the client's funding source had been billed multiple times since June 4, 2016.
Client #7 was admitted on May 2, 2016 and was an active client as of the date of the inspection. The consent to release form to a funding agency was dated May 26, 2016, which was several weeks after the client was considered admitted to treatment. The client record indicated that the client's funding source was billed between 05/02/2016 and 05/26/2016.
Client #11 was admitted on February 7, 2014 and was an active client as of the date of the inspection. Consent to release forms to two separate funding sources, one dated January 28, 2016 and the other dated May 25, 2016, allowed for the release of the discharge documentation, doctor's notes, intake documentation, medication order sheets, psychiatric evaluation/CBE/CBR, therapist's notes, and treatment plans.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
the release of information form has been revised in order to comply with 4 PA.code 255.5. The clinical supervisor will provide 1 staff training on the completion and utilization of the revised form. With regard to the deficient records reviewed during the inspection, each of these clients remains active since the inspection and will sign the revised consent to release form. We will also check this release in all other active records that were not reviewed during inspection to ensure full compliance. The clinical supervisor will monitor staff completion of this form on a weekly basis to ensure compliance.
The clinical supervisor will provide 1 staff training to reinforce a fundamental component of drug/alcohol treatment, that client information cannot be released without client's written consent. The clinical supervisor will monitor all completed forms on a weekly basis to ensure compliance.
The clinical supervisor will provide 1 staff training to clarify the requirement to fully complete all areas of information on the consent to release forms including the specific information to be released. The clinical supervisor will monitor all completed consent to release forms on a weekly basis to ensure compliance. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of client records, the facility failed to document an annual evaluation of the patient in patient record # ' s 8 and 10.
Patient #8 was admitted on 03/23/2012 and the most recent annual evaluation was due no later than 03/23/2016.
Patient #10 was admitted on 11/01/2011 and the most recent annual evaluation was due no later than 11/01/2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will provide 1 staff training regarding the timely completion of Annual evaluations. Staff will utilize the case management form to accurately track due dates for the annual evaluation. The clinical supervisor will maintain a current copy of case management logs of all staff. Case management logs will be reviewed by the clinical supervisor in weekly supervision to ensure timely completion of this document. |
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
Based on a review of patient records, patient record #'s 1, 2, 3, 4, 5, 6, 8, 11, 13, and 16 had treatment plan updates that were either completed after the regulatory timeframe or completely missing from the client record.
Client #1 was admitted on July 22, 2015 and discharged on August 27, 2016. The comprehensive treatment and rehabilitation plan was completed on 08/19/2015 and a treatment plan update was due no later than 10/19/2015; however, the update was not completed until 11/11/15. Additionally, a treatment plan update was due no later than 05/09/2016, but was not completed until 05/25/2016.
Client #2 was admitted on November 6, 2006 and was discharged on September 1, 2016. A treatment plan update was due to be completed no later than 09/01/2015; however, it was not completed until 10/22/2015. Additionally, the next treatment plan update was due no later than 12/22/2015; however, the update was not completed until 02/26/2016.
Client #3 was admitted on October 15, 2015 and was discharged on September 7, 2016. The comprehensive treatment and rehabilitation plan was completed on 10/23/2015. An update was due to be completed no later than 12/23/2015; however, it was not completed until 01/26/2016. The next update was due no later than 03/26/2016; however, there were no additional treatment and rehabilitation plan updates documented in the client chart as of the date of the inspection.
Client #4 was admitted on April 24, 2001 and was an active client at the time of inspection. A treatment plan update was completed on 08/15/2015 and the next update was due no later than 10/15/2015; however, it was not completed until 11/19/2015. Additionally, another treatment plan update was due to be completed no later than 04/17/2016; however, the update was not documented until 05/18/2016.
Client #5 was admitted on May 6, 2002 and was an active client at the time of inspection. A treatment plan update was completed on 08/05/2015. The next update was due no later than 10/05/2015; however, it was not completed until 12/18/2015. Additionally, another treatment plan update was due no later than 04/22/2016; however, the update was not completed until 05/18/2016.
Client #6 was admitted on June 4, 2015 and was an active client at the time of inspection. A treatment plan update was completed on 11/06/2015. The next update was due no later than 01/06/2016; however, it was not completed until 01/25/2016. Additionally, another treatment plan update was due no later than 05/10/2016; however, the update was not completed until 07/09/2016.
Client #8 was admitted on March 23, 2012 and was discharged on November 2, 2015. A treatment plan update was due no later than 09/14/2015; however, it was not completed until 09/22/2015.
Client #11 was admitted on February 7, 2014 and was an active client at the time of inspection. A treatment plan update was due no later than 10/22/2015; however, the update was not completed until 12/11/2015. Additionally, another treatment plan update was due no later than 04/24/2016; however, the update was not completed until 05/17/2016.
Client #13 was admitted on March 16, 2016 and was an active client at the time of inspection. The comprehensive treatment and rehabilitation plan was completed on 04/06/2016. The treatment plan update was due no later than 06/06/2016; however, the update was not completed until 09/01/2016.
Client #16 was admitted on June 9, 2015 and was an active client at the time of inspection. A treatment plan update was due no later than 11/16/2015; however, the update was not completed until 01/09/2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will provide 1 staff training on the timely completion of treatment plan updates. The clinical supervisor will maintain a current copy of each staff's case management log in order to track treatment plan due dates. The clinical supervisor will review the case management log with staff in weekly supervision to ensure timely completion of this document. |