INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 17, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on May 15, 2007.
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Plan of Correction
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
The written procedures for the confidentiality of client identity and records contained a document designed by CODAAP titled "Confidentiality Regulations and the Drug and Alcohol Treatment Programs." This document contained incorrect language regarding disclosure to parents of a minor without the client's consent, the wording "with or without the client's consent" to judges and probation/parole. In addition, written procedures stated that "a client may revoke a consent to release information, in writing, to the clinic or project manager". The facility must honor a client's verbal revocation of a consent and the facility must document the verbal revocation in writing.
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Plan of Correction
The Director of Quality Improvement has removed the CODAPP document from the policy and procedure manual. This was replaced with copies of the 255.5 and 42CFR regulations. The Project Director will oversee that the company's confidentiality policy is revised to allow for verbal revocation of consents. The Facility Director will oversee the distribution and review of this revised policy to all staff in staff meeting. |
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
Consent to release information forms indicated that clients must revoke a consent in writing in four of four records reviewed, #1, 2, 3 and 4. A parent signed a consent to release form in record #1.
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Plan of Correction
The Quality Improvement Department is currently overseeing the revision of our consent forms to allow for written or verbal revocation. The Facility Director will oversee that all staff receive the revised consent forms and are educated on how to document verbal revocation.
The Facility Director will oversee that all staff are reminded in staff meeting that the client must sign all consent to release forms, even if the client is a minor. Staff will also be reminded that parent/guardians cannot sign consent forms for minors. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Personal histories failed to address family relations, significant events/problems related to the family history and recreation history in four of four client records reviewed, # 1, 2, 3, and 4. In addition, one word responses from the client were documented without any additional information to clarify these responses.
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Plan of Correction
The Facility Director will oversee that all clinical staff receive training in staff meeting to educate the therapists on gathering more detailed information regarding family relations, significant events/problems related to the family history, and recreation interests in each client's personal history. Therapists will also be reminded to avoid one word answers and to clarify responses from the clients. |
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
Treatment plan updates did not include a review of progress on previously stated goals in three of three records reviewed, #1, 2 and 4.
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Plan of Correction
The Facility Director will oversee that all clinical staff receive training in staff meeting to educate staff on completing a thorough treatment plan update which addresses the client's progress in the past 60 days as it relates to the treatment plan goals identified on the individual treatment plan. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Case consultations failed to address the purpose of the consultation, the summary of the discussion, the disposition or an accurate account of which staff attended the consultation in two of two client records reviewed, # 1 and 2.
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Plan of Correction
The Quality Improvement Department will oversee the revision of the case consultation format to include the purpose of the consultation, a summary of the discussion that was held or a disposition and an accurate account of which staff attended the consultation. The Facility Director will oversee the distribution and review of the revised case consultation note to all clinical staff in staff meeting. Clinical staff will also be educated in completing the note thoroughly. |