Observations
Based on the review of client records, and a discussion with the facility director the facility failed to ensure that an informed and voluntary consent to release information was obtained in eight of eight client records reviewed or that a Qualifying Organization Service Agreement (QSOA) was in place with the Lab conducting the Urinalysis Drug Screening.
The findings included:
Eight client records requiring voluntary consent to release information forms were reviewed on May 1, 2014. The facility failed to ensure that an informed and voluntary consent to release information was obtained in client record #'s 1, 2, 3, 4, 5, 6, 7, and 8.
Client #1 was admitted to treatment on March 18, 2014 and was still an active client at time of the inspection. There was a disclosure of information to the urinalysis lab on 04/26/2014. There was no signed release of information prior to the disclosure nor did the facility have a QSOA in place.
Client #2 was admitted to treatment on November 11, 2013 and was still an active client at time of the inspection. There were disclosures of information to the urinalysis lab on 02/10/14, 02/28/14, 03/20/14, 03/21/14, 04/05/14, 04/10/14, 04/19/14, and 04/26/14. There was no signed release of information prior to the disclosures nor did the facility have a QSOA in place.
Client #3 was admitted to treatment on February 10, 2014 and was still an active client at time of the inspection. There was a disclosure of information to the urinalysis lab on 04/26/14. There was no signed release of information prior to the disclosure nor did the facility have a QSOA in place.
Client #4 was admitted to treatment on January 14, 2014 and was still an active client at time of the inspection. There were disclosures of information to the urinalysis lab on 02/28/14, 03/14/14, 03/19/14, 03/20/14, 03/21/14, 04/10/14, and 04/26/14. There was no signed release of information prior to the disclosures nor did the facility have a QSOA in place.
Client #5 was admitted to treatment on July 15, 2013 and was discharged on October 7, 2013. There were disclosures of information to the urinalysis lab on 07/29/13, 08/16/13, 08/27/13, 08/31/13, 09/26/13, and 10/01/13. There was no signed release of information prior to the disclosures nor did the facility have a QSOA in place.
Client #6 was admitted to treatment on July 17, 2013 and was discharged on October 17, 2013. There were disclosures of information to the urinalysis lab on 07/29/13, 08/16/13, 08/27/13, 08/31/13, and 09/22/13. There was no signed release of information prior to the disclosures nor did the facility have a QSOA in place.
Client #7 was admitted to treatment on July 02, 2013 and was discharged on July 23, 2013. There were disclosures of information to the urinalysis lab on 07/08/13 and 07/14/13. There was no signed release of information prior to the disclosures nor did the facility have a QSOA in place.
Client #8 was admitted to treatment on September 17, 2013 and was discharged on December 16, 2013. There were disclosures of information to the urinalysis lab on 09/26/13, 10/01/13, 10/31/13, and 12/11/13. There was no signed release of information prior to the disclosures nor did the facility have a QSOA in place.
The Facility Director confirmed the findings.
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Plan of Correction
The Program Director ensured that a release for urinalysis was signed by all residents on May 2, 2014. The Administrative Assistant and Clinical staff were also directed to ensure that a release for urinalysis was signed by each client upon admission to the program. The consent is included in the admission packet. This was completed on May 6, 2014. |
Observations
Based on a review of client records, the facility failed to document a preliminary treatment and rehabilitation plan in eight of eight client records reviewed.
The findings include:
Eight client records requiring documentation of a preliminary treatment and rehabilitation plan were reviewed on May 01, 2014. The facility failed to document preliminary treatment and rehabilitation plans in client records #1, 2, 3, 4, 5, 6, 7, and 8.
Client #1 was admitted on March 18, 2014 and was still an active client as of the date of the on-site inspection. There was no preliminary treatment and rehabilitation plan documented in the client record as of the date of the inspection.
Client #2 was admitted on November 11, 2014 and was still an active client as of the date of the on-site inspection. There was no preliminary treatment and rehabilitation plan documented in the client record as of the date of the inspection.
Client #3 was admitted on February 10, 2014 and was still an active client as of the date of the on-site inspection. There was no preliminary treatment and rehabilitation plan documented in the client record as of the date of the inspection.
Client #4 was admitted on January 14, 2014 and was still an active client as of the date of the on-site inspection. There was no preliminary treatment and rehabilitation plan documented in the client record as of the date of the inspection.
Client #5 was admitted on July 15, 2013 and was discharged on October 7, 2013. There was no preliminary treatment and rehabilitation plan documented in the client record as of the date of the inspection.
Client #6 was admitted on July 17, 2013 and was discharged on October 17, 2013. There was no preliminary treatment and rehabilitation plan documented in the client record as of the date of the inspection.
Client #7 was admitted on July 02, 2013 and was discharged on July 23, 2013. There was no preliminary treatment and rehabilitation plan documented in the client record as of the date of the inspection.
Client #8 was admitted on September 17, 2013 and was discharged on December 16, 2013. There was no preliminary treatment and rehabilitation plan documented in the client record as of the date of the inspection.
The Facility Director confirmed the findings.
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Plan of Correction
The Program Director conducted a 1 1/2 hour training for counselor's on 5/5/2014 relating to Initial, Comprehensive and Updated treatment plans. Regulations and Gaudenzia Policy and Procedures were reviewed along with treatment plans to ensure understanding. From 5/5/2014 forward all treatment plans are required to conform to the Gaudenzia Policy and Procedures. The Program Director will sign all treatment plans as required and will further review all treatment plans on a rotating basis to insure conformity. The completion date is: June 1, 2014. |