INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 2, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lehigh Valley Hospital - Schuylkill - Counseling 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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711.43(d)(2) LICENSURE Informed/voluntary Consent
711.43. Client records.
(d) Confidentiality.
(2) 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 a written informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven applicable client records reviewed.
Client #8 was admitted for intake, evaluation, and referral services only on August 5, 2021. There was documentation of disclosures to a treatment provider on August 11, 2021; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1.Review Confidentiality Policy with clinical staff to insure valid consent is in the record before any referral to outside services occurs.
2. random assessment chart review (5 charts/monthly)to monitor compliance.
Responsible person: Program Director
Compliance by 6/30/22 with ongoing monthly chart review. |
711.43(d)(2)(iv) LICENSURE Client's signature
711.43. Client records.
(d) Confidentiality.
(2) 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:
(iv) The dated signature of client or guardian.
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in one of seven applicable client records reviewed.
Client #12 was admitted for intake, evaluation, and referral services only on July 9, 2021. There were release of information forms to a treatment provider and a funding source that were signed and dated by the witness on July 9, 2021; however, the dated signature of the client was not documented on either form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Confidentiality Policy Review with clinical staff to insure understanding of all elements of a valid consent.
2. random chart audit (3 charts per counselor/monthly) to monitor compliance.
Responsible Person: program Director
Compliance by: June 30,2022 with ongoing monthly review. |
711.92(c)(2) LICENSURE Type & Frequency of TX
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment on the individual treatment and rehabilitation plan in seven of seven applicable client records reviewed.
Client #1 was admitted on October 22, 2021 and was active at the time of inspection.
Client #2 was admitted on August 31, 2021 and was active at the time of inspection.
Client #3 was admitted on September 17, 2021 and was active at the time of inspection.
Client #4 was admitted on September 20, 2021 and was discharged on January 17, 2022.
Client #5 was admitted on July 21, 2021 and was discharged on December 30, 2021.
Client #6 was admitted on July 20, 2021 and was discharged on February 14, 2022.
Client #7 was admitted on July 16, 2021 and was discharged on March 29, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1.Review with clinical staff including the type and frequency of services in the "methods" section of the treatment plan.
2.Ongoing review by clinical supervisor when clinical documents are submitted for review and approval with feedback in clinical supervision.
3. Monthly chart audit (3 charts/counselor) to monitor compliance.
Responsible person: Program Director
Compliance by: 6/30/22 with ongoing monitoring (monthly) |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in three of seven applicable client records reviewed.
Client #1 was admitted to the outpatient level of care on October 22, 2021 and was still active at the time of inspection. The comprehensive treatment plan was completed on December 21, 2021, and the first update was due no later than February 21, 2022; however, the update was completed on March 7, 2022. Additionally, the next update was due no later than May 7, 2022; however, the update was completed on May 18, 2022.
Client #2 was admitted to the outpatient level of care on August 31, 2021 and was still active at the time of inspection. The comprehensive treatment plan was completed on March 24, 2022, and the first update was due no later than May 24, 2022; however, the update was not completed at the time of inspection.
Client #3 was admitted to the outpatient level of care on September 17, 2021 and was still active at the time of inspection. The comprehensive treatment plan was completed on December 16, 2021, and the first update was due no later than February 16, 2022; however, the update was completed on May 18, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Report tracking treatment plan dates on all patients will be utilized as a monitoring report for compliance.
2. The report includes patient name, date treatment plan is developed, most recent treatment plan update date, Clinical staff responsible and date when next treatment plan is to be developed.
3. report will be discussed in clinical supervision and weekly clinical team meeting.
Rationale for any non-compliance with update (patient non-compliance) documented in progress note
5. Chart audit 9 3 charts/counselor) monthly to monitor compliance
Responsible Person: Program Director
Compliance by 6/30/22 with ongoing monitoring monthly. |
711.93(c)(3) LICENSURE Copy-Client Consent
711.93. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client in one of seven applicable client records reviewed.
Client #2 was admitted to the outpatient level of care on August 31, 2021 and was still active at the time of inspection. A release of information form to a funding source was signed and dated by the client on August 31, 2021; however, there was no documentation that a copy of the form was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Confidentiality Policy review with clinical staff to insure compliance with offering patient a copy of the form and recording response on the form.
2. Random chart audit (3 charts/counselor) monthly to monitor compliance.
Responsible Person: Program Director
Compliance by: 6/30/22 with monthly monitoring. |