INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 11, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, SPHS Behavioral Health 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) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to obtain an informed and voluntary consent in three of seven client records reviewed on January 11, 2019.
Client record # 2 documented a letter to the client's probation officer. The letter identified the substance abused by the client.
Client record # 6 documented a letter to the client's probation officer. The letter identified the substance abused by the client.
Client record # 9 documented a letter to the client's probation officer. The letter identified the substance abused by the client.
The records also documented a release of information for a funding agency. The release included specific information which exceeded the limits of 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Supervisor will conduct a mandatory staff meeting scheduled to occur on Monday, February 4, 2019 for the purposes of re-educating all staff on Drug and Alcohol Confidentiality and, moreover, for refraining from divulging drug-specific indicators in letters to external providers. All staff will sign the meeting minutes verifying understanding of the expectation, and staff who are absent will be required to review in individual session with the Program Supervisor.
Program Director is scheduled to meet with Administrative Assistance (staff in charge of activating, de-activating, and modifying Electronic Health Record forms) on Wednesday, January 30, 2019. Release of information forms will be modified in the electronic health records to include only the components of code 255.5 which permits the release of the following information with informed client consent and signature:
(1) Whether the client is or is not in treatment.
(2) The prognosis of the client.
(3) The nature of the project.
(4) A brief description of the progress of the client.
(5) A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
All other release forms will be de-activated by 2/4/2019 and the staff will be instructed to discard any paper versions of said forms. The Program Director and Program Supervisors will announce the changes once they have gone into effect at the 2/4/2019 mandatory staff meeting.
As follow-up procedure, the Program Supervisor will conduct random chart reviews for one month to ensure releases are completed correctly. In addition, Program Supervisor will check the releases for clients who are being staffed during that one month time span for individual supervision as an extra layer of checking to make sure releases are being completed accurately. All corrective actions will be in full effect by February 4, 2019. |
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
The facility failed to review and update treatment and rehabilitation plans every 30 days in one of two client records reviewed on January 11, 2019.
Client record # 4 had a treatment plan update due by November 3, 2018. There was no documentation the update was completed as of the time of review.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Program Supervisor created and distributed timeline handouts to all staff to ensure compliance adherence with documentation deadlines. At the very top of the handout, the Plan Of Care/Treatment Plan section outlines the following due dates and update frequencies:
- At admission
- Change in modality (stepping down from group, into group, level of care change, Etc.)
- If the individual has met a goal or if a goal needs updated for any reason
- Mental Health 90/120 days (a plan of care must be done on the due date ? even if a discharge is pending).
- Drug and Alcohol Partial 20/30 days (a plan of care must be done on the due date ? even if a discharge is pending).
- Drug and Alcohol IOP or OP 45/60 days (a plan of care must be done on the due date ? even if a discharge is pending).
The staff meeting was documented and filed and staff signed the minutes verifying receipt of the information.
The management team added a required field in progress notes so that treating clinician must click on a box verifying that an active and valid treatment plan exists in order to submit their service provision documents. Moreover, the Program Supervisor will review client charts randomly and during supervision to ensure clinicians' timely submissions of treatment plan updates. The corrective action date will be in effect as soon as 1/29/19.
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