INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 9, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Deerfield Dual Diagnosis LP 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 prior to the disclosure of information in two of two client records.
The findings include:
Two client records were reviewed on April 9, 2014. Two client records were required to include an informed and voluntary consent from the client prior to the disclosure of information.
Record #1 - The client was admitted to treatment on March 2, 2014. The consent to release information forms for BC/BS and Erie County D & A were signed on February 26, 2014 and did not include the specific information to be disclosed. The specific information section on the release of information form indicated "Other" but the explanation was blank.
Record #2 - The client was admitted to treatment on March 28, 2014. The consent to release information forms for Erie County Assistance office, CCBH, and Erie County D & A case management were signed and did not include the specific information to be disclosed. The specific information section on the release of information form indicated "Other" but the explanation was blank.
The findings were reviewed with the project director and were not disputed.
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Plan of Correction
The Program has scheduled a mandatory Staff meeting on 5/7/14 to review the correct way of completing consent to release. Program Director will monitor this process in a monthly chart review. |
709.53(a)(3) LICENSURE Records of Service
709.53. 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:
(3) Record of services provided.
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Observations
Based on the review of the client records, the facility failed to document individual counseling sessions on the record of service in two of two client records.
The findings include:
Two client records were reviewed on April 9, 2014. The record of service documentation was required in two client records. The facility did not document the individual counseling sessions on the record of service in client records #1, and #2.
Client record # 1- The client was admitted March 2, 2014, and was discharged on March 24, 2014. The record of service did not include documentation of an individual counseling session provided to the client. Progress notes documented that an individual counseling session occurred on March 3, 6, 11, 16, 17, 20 and 23, 2014, but there is no entry of this service on the record of service.
Client record # 2- The client was admitted March 28, 2014. The record of service did not include documentation of an individual counseling session provided to the client. Progress notes documented that an individual counseling session occurred on March 28, 30, 31, and April 3, 7, 8, 2014, but there is no entry of this service on the record of service.
The findings were reviewed with the project director and were not disputed.
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Plan of Correction
Program Director meet with Clinical staff on 4/15/14 to review the non compliance. The Program Director reviewed the regulation to have all services completed documented on the record of service log. Program Director will monitor this through a monthly chart audit. |