INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 5, 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, Casa De Consejeria y Salud Integral, 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 obtain an informed and voluntary consent to release information form prior to the disclosure of information in two of seven patient records reviewed.Patient #1 was admitted on April 12, 2018 and was still active at the time of the inspection. There were two consent forms to the funding source and the urinalysis lab, both signed by the client on April 12, 2018 and expired April 12, 2019. There was evidence of billing and urinalysis submissions from the date of expiration through the date of inspection.Patient # 2 was admitted on February 19, 2018 and was still active at the time of the inspection. There were two consent forms to the funding source and the urinalysis lab, both signed by the client on February 19, 2018 and expired February 19, 2019. There was evidence of billing and urinalysis submissions from the date of expiration through the date of inspection.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The quality assurance specialist has already amended the time frame on releases to state the the release will be valid one year from the date or admission or when the participant has completed treatment. To prevent this from occurring, the clinical supervisor will hold an in service training to discuss changes, essential information and forms which will facilitate compliance to general guidelines of client confidentiality framed by 4 Pa Code 255.5 regulations and 42 CFR Part 2. The nature of the release and the circumstances by which the information may be released, the specific content and limited nature of the information to be released, to whom, the purpose of the disclosure, the method of releasing the information as well as the timeframes for the release, signature of client and witness, date of signatures and whether client received a copy will be discussed in addition to other privacy practices outlined in CASA's confidentiality policy and procedures. This will be completed by 7/31/19.
Clinical staff shall continue to attend recommended Department of Health training and provide documentation in areas such as confidentiality and client recordkeeping. This will be monitored by HR on an annual basis.
The quality assurance specialist will also conduct quarterly audits to specifically check the accuracy of releases and the clinical supervisor will also ensure to address confidentiality and the changes to the forms during individual supervisions and as part of client case consultations. This will be implemented immediately. |
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 provide treatment plan updates within the regulatory timeframe in three of seven client records reviewed.Client #4 was admitted on August 16, 2018 and was discharged May 23, 2019. A treatment plan update was completed on March 8, 2019 and the next update was due no later than May 8, 2019. However, the update was not completed prior to the client's discharge.Client #5 was admitted on September 21, 2018 and was discharged February 28, 2019. A treatment plan update was completed on December 14, 2018 and the next update was due no later than February 14, 2019. However, the update was not completed prior to the client's discharge.Client #7 was admitted on November 27, 2018 and was discharged May 3, 2019. A treatment plan update was completed on December 20, 2018 and the next update was due no later than February 20, 2018. However, the update was not completed prior to the client's discharge.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will review each treatment plan to ensure that updates are being conducted no later than every 60 days. The clinical supervisor will hold an inservice training to reiterate deadlines of treatment planning per our state and internal standards and policies and procedures. The clinical supervisor will focus on guidelines for completing plans when clients need to be discharged to ensure the appropriate documentation is completed timely. This issue will also be addressed in one-on-one supervisions with each counselor.
Quality assurance will conduct monthly case load audits to identify correct deadlines for treatment plan updates and making sure they are being followed appropriately. Facility director will also make sure during her monthly supervision meetings with quality assurance and clinical supervisors that the in service training is conducted, that the clinical supervisors are addressing it during one-on-one supervisions with the counselors, and that quality assurance is conducting the appropriate audits. This will be implemented immediately and in service will be conducted no later than 7/31/19. |