INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 12, 2007 to March 13, 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 April 12, 2007.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
In all personnel files reviewed, feedback is not being consistently documented on completed training. Feedback forms need to be documented for both internal and external training.
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Plan of Correction
Completed 3/15/07. A system has been implemented in which all training feedback forms are kept in a separate binder for better record keeping. In addition, the Personnel Policy & Procedure has been revised to reflect a specific timeframe (within a week from the date of training) in which completed training feedback forms are to be turned in. This will be monitored by the Project Director on a monthly basis. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
The nursing staff did not have individual training plans for the current 2007 training year,
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Plan of Correction
Nursing Individual Training Plans have been completed for year 2007 as of 3/21/07. The Assistant Director of Nursing has been trained on the yearly completion of Training Plans. The Assistant Director of Nursing will monitor every January. |
157.23 (b) LICENSURE Patient records.
157.22 Patient records.
(b) Patient records shall be kept confidential in accordance with applicable Federal drug and alcohol regulations and the confidentiality requirements in 4 Pa. Code 255.4 and 255.5 (relating to UDCS: confidentiality and access to information and projects and coordinating bodies: disclosure of client-oriented information).
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Observations
The Kensington Hospital's "Notice of Privacy Practice" (HIPAA) document does not include a disclaimer that HIPAA does not supersede the Federal and State Drug and Alcohol Confidentiality Laws/Regulations and for all drug and alcohol clients, the most stringent will be adhered to.
Client record number 3 had a consent to release information form directed to CBH. The consent was limited to the information defined in 4 Pa. Code 255.5. However the information that CBH is requesting on the "BHS Substance Abuse Concurrent Review Form Adult" exceeds these limitations. This information includes:
1. Urine results including the type of drug.
2. DSM-IV criteria that includes the client's use history.
3. Aftercare planning and follow up.
4. Presenting new/additional problems
5. Treatment objectives
A facility ' s disclosure to third party payors may not exceed these 5 items. Even if the client requests that additional information be released, the facility remains bound by regulations and must limit the release of information. The facility is violating Pennsylvania Code when it complies with the requests for information by CBH that are in excess of the parameters defined by 4 Pa. Code Subsection 255.5(b). The facility is also invalidating the informed and voluntary consent to release information when it exceeds the limitations included on the signed consent to release information form.
The Department advises Kensington Hospital to respond to these requests with the Pennsylvania Client Placement Criteria (PCPC) Summary form which is widely used by both County and 3rd party insurers in Pennsylvania.
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Plan of Correction
The Notice of Privacy Practice (HIPAA) form is being revised to include disclaimer. Once the revision is complete, staff will be in-serviced on the revision. Revision to be completed by 4/2/07. |