INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 25-26, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Family ACTS, Inc - Ford City 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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contain in the client record, which included: name of the person, agency or organization to whom disclosure was made, specific information disclosed, purpose of the disclosure, dated signature of client, dated signature of witness and an expiration date of the consent in 4 of 12 client records.
The findings include:
Fourteen client records were reviewed on June 25-26, 2013. The consents to release information were reviewed in twelve client records. Client records # 2, 3 , 10 and 12 did not contain consents which included the required components.
Client #2 was admitted on March 18, 2013. A family session occurred with the client's mother on March 25, 2013 and there was no consent to release information signed by the client. Other releases, signed March 20, 2013 , did not include the specific information to be disclosed and the purpose of the disclosure.
Client #3 was admitted on August 6, 2012. Two releases, signed August 6, 2012, did not include the specific information to be disclosed and the name of the person, agency or organization to whom the disclosure was made.
Client #10 was admitted on April 2, 2013. Family sessions occurred on April 16, 22, and 29, May 6, 13, 20, 29 and June 3, 2013. There was no consent to release information signed by the client.
Client #12 was admitted on August 23, 2012. A release signed on August 23, 2012 did not include the name of a person, agency or organization to whom the disclosure was made.
An interview with the project/facility director took place on June 26, 2013 at which time the aforementioned information was confirmed.
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Plan of Correction
Facility/Project Director will ensure that informed voluntary consents to releases are obtained for disclosure of information contained in the client record, which includes: name of person, agency or organization to whom disclosure is made, specific information disclosed, purpose of disclosure, dated signature of client, dated signature of witness and an expiration date. All staff will be retrained during 07/3/13 and 07/10/13 staff meetings. Facility/Project Director will perform monthly chart reviews to ensure ongoing compliance after 07/10/13 staff meeting. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to provide an individual treatment and rehabilitation plan which included proposed type of support service in 8 of 11 client records.
The findings include:
Fourteen client records were reviewed on June 25-26, 2013. The individual treatment and rehabilitation plans were reviewed in eleven client records and all required the documentation of proposed type of support service. The facility did not document proposed type of support services in client records # 1, 2, 3, 4 , 5, 6, 9 and 10.
Client # 1 was admitted on August 15, 2012. The individual treatment and rehabilitation plan was completed on September 13, 2012. There was no documentation of support services in the treatment plan.
Client # 2 was admitted on March 18, 2013. The individual treatment and rehabilitation plan was completed on April 1, 2013. There was no documentation of support services in the treatment plan.
Client # 3 was admitted on August 6 , 2009. The individual treatment and rehabilitation plan was completed on September 11, 2012. There was no documentation of support services in the treatment plan.
Client # 4 was admitted on April 4, 2013. The individual treatment and rehabilitation plan was completed on April 23, 2013. There was no documentation of support services in the treatment plan.
Client # 5 was admitted on December 18, 2012. The individual treatment and rehabilitation plan was completed on February 13, 2013. There was no documentation of support services in the treatment plan.
Client # 6 was admitted on April 8, 2013. The individual treatment and rehabilitation plan was completed on April 24, 2013. There was no documentation of support services in the treatment plan.
Client # 9 was admitted on September 26, 2012. The individual treatment and rehabilitation plan was completed on October 4, 2012. There was no documentation of support services in the treatment plan.
Client # 10 was admitted on April 2, 2013. The individual treatment and rehabilitation plan was completed on April 22, 2013. There was no documentation of support services in the treatment plan.
An interview with the project/facility director took place on June 26, 2013, at which time the aforementioned information was confirmed.
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Plan of Correction
Facility/Project Director will ensure that all individual treatment and rehabilitation plans include support services, effective 07/10/2013. The addition of support services will be entered into the individual treatment plan during development of each individual treatment plan. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a complete discharge summary that included the patient's reason for treatment, services offered, response to treatment and client's status upon discharge in four of six patient records.
The findings include:
Six discharged client records were reviewed on June 25-26, 2013. Four of the six client records did not have discharge summaries that included all required components, # 9, 11, 13 and 14.
Client # 9 was admitted on September 26, 2012 and discharged on February 14, 2013. The discharge summary that was completed on February 14, 2013 failed to document the services offered , response to treatment and client status.
Client #11 was admitted on February 14, 2013 and discharged on May 8, 2013. The discharge summary that was completed on May 8, 2013 failed to document the reasons for treatment, services offered and response to treatment.
Client #13 was admitted on May 29, 2012 and discharged on March 13, 2013. The discharge summary that was completed on March 13, 2013 failed to document the reasons for treatment.
Client # 14 was admitted on July 2, 2012 and discharged on February 24, 2013. The discharge summary that was completed on February 24, 2013 failed to document the services offered , response to treatment and client status.
The aforementioned information was reviewed with the project/facility director on June 26, 2013 and it was not disputed.
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Plan of Correction
Facility/Project Director will ensure that all discharge summaries include: patient's reason for treatment, services offered, response to treatment and client's status upon discharge. All staff will be retrained on the completion of discharge summaries during 07/03/2013 and 07/10/2013 staff meetings. |