INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 28, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cen Clear Child Services, 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 and a plan of correction is due on September 18, 2009.
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Plan of Correction
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709.22(e)(3) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
Based on a review of the annual report during the annual onsite licensing inspection of August 28, 2009, the facility failed to document an annual report which included a statement disclosing the names of officers, directors and principal shareholders.
The findings included:
The 2007-08 annual report was documented as required but a statement disclosing the names of officers, directors and principal shareholders was not included in the documentation as required.
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Plan of Correction
Asistant to the Executive Director is responsible to compile the CCS annual board report that is due end of Sept 09. The assistant is responsible to add a section to the annual board report to include the names of the members and stakeholders.This will be reviewed with the Facility Director. |
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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of client records during the onsite licensing inspection of August 27, 2009, the facility failed to adhere to the limits placed on disclosure of client identifying information specified at 4 Pa. Code subsection 255.5(b) in each client record.
The findings included:
During the onsite licensing inspection two client records were available for review. Each of the records was required to adhere to the limits placed on disclosure of client identifying information specified at 4 Pa. Code subsection 255.5(b). Two of two client records (# 1 & 3) documented consents to release client related information which did not identify the specific information to be released to family members. Each record also contained consents to release information which were confusing ( hence not an informed consent) because the purpose section stated specific pieces of information which could be released rather than identifying why the information specified on the specific information section of the form needed to be released. Items listed under the purpose section of the form included: assessments, histories, treatment plans, relevant consultations with other service providers and significant client contacts. These items were listed on consents to release information to government entities (SCA's and Adult probation) and would exceed the limitations imposed at 4 Pa. Code subsection 255.5(b).
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Plan of Correction
Release of information form has been revised to address state requirements. Developed a new release of information form to include specific information, purpose of release to whom to disclose. The Facility Director is responsible to train staff on the completion and accuracy of the forms. Review of completeness will be the responsibility of Facility Director.. Paperwork will be part of the FD's QA review as part of supervision. We are waiting on agency approval of the revised form. This make take a few weeks. |
709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
Based on the review of client records during the onsite licensing inspection of August 27, 2009, the facility failed to document a clear purpose for the release of information agreed to by the client in each client record reviewed.
The findings included:
During the onsite licensing inspection, two client records were available for review. Each client record was required to clearly identify the purpose for each component of the client record which documented client identifying information . Two of two client records reviewed ( # 1 & 3) contained consents to release information which were confusing ( hence not an informed consent) because the purpose section stated specific pieces of information which could be released rather than identifying why the information specified on the specific information section of the form needed to be released. Items listed under the purpose section of the form included: assessments, histories, treatment plans, relevant consultations with other service providers and significant client contacts.
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Plan of Correction
As stated in previous plan of correction, the Release of Information Form has been revised to reflect the recommmendations of the reviewer. Completeness adn accuracy will be monitored by the Facility Director in supervisions and QA chart reviews. In addition, the FD will be meeting with all counselors reviewing the current active clients and make adjustments accordingly. All forms will be updated once the agency approves final version of form which will take a few weeks. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of agency policy, client records and an interview with the Project Director during the onsite licensing inspection of August 27, 2009, the facility failed to document a preliminary treatment plan by the second session with each client in accordance with agency policy.
The findings included:
At the time of the onsite inspection, only two client records were available for review. Each client record was required to have documentation of a preliminary treatment plan. Based on an interview with the Project Director, a review of client records and written agency policy, one of two client records, (#3), failed to document a preliminary treatment plan by the second session as required by agency policy. A preliminary treatment plan should be based upon information derived from the initial interview.
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Plan of Correction
Facility Director will meet with specific counselor and review policy and procedures of opening a client. Counselor has updated the chart and completed the preliminary plan. This policy will be monitored closely by Facility Director in regular supervisions. If unable to complete plan in the first two visits, progress note will document reason for delay. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on the review of client records during the onsite licensing inspection of August 28, 2009, the facility failed to document complete records of service in each client record reviewed.
The findings included:
During the onsite licensing inspection, only two client records were available for review. Each client record was required to document an accurate, complete record of service. One of two records, (#1), failed to document two individual counseling sessions which were addressed in progress notes, the sessions conducted on 8/17/09 and 8/19/09.
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Plan of Correction
This has been addressed with the Facility Director and revisions to the record of service have been updated to reflect the appropriate appointments and client signed off. This deficiency will be checked during supervision with the counselors and Facility Director. Chart reviews will occur bi weekly to address all deficiency or discrepancies in the chart by Dept assistant. |