INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 22, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Rehab Management Inc. was found to be not 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.
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Observations
Based on a review of seven client records on March 22, 2017, the facility failed to obtain a valid consent to release in client record, #5.
Client #5 was admitted on 5/11/16 and was discharged on 7/18/16. A consent to release dated 5/11/16 did not have the person or agency to whom information was to be released. Additionally, the facility failed to document a consent to release for the client's funding source.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
709.28 (c) Confidentiality
Site Director will conduct a training on Confidentiality with staff members during weekly staff meeting on April 12, 2017. During this meeting, Site Director will review regulations and policies regarding client confidentiality, 4Pa. Code 255.5. The training will review the need for an insurance company to be selected on the managed care/insurance company consent form to secure the funding source.
Site Director will perform quarterly audits of 10 charts minimum in order to monitor compliance with confidentiality regulations. Site director will perform these audits to ensure that the appropriate measures and documentation of confidentiality is being utilized in all consent forms on Rehab After Work paperwork, specifically stating who the consent form is for.
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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
Seven client records were reviewed on March 22, 2017. The facility failed to update the treatment plan every 60 days in two out of six applicable client records, #4 and 6.
Client #4 was admitted on 12/28/16 and was discharged on 3/7/17. A comprehensive treatment plan was created on 12/28/16; a treatment plan update was due by 2/26/17 but was not documented at the time of the licensing inspection.
Client #6 was admitted on 8/13/16 and was discharged on 12/12/16. A treatment plan update was created on 10/11/16; another treatment plan update was due by 12/10/16 but was not documented at the time of the licensing inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
709.92(b) Treatment and rehabilitation services
Site Director will conduct a training on treatment and rehabilitation services. Treatment plans will be reviewed with staff members during a weekly staff meeting on April 26, 2017. During the meeting, Site Director will review regulations and policies regarding the need for treatment plans be reviewed and updated at least every 60 days even if the client is no longer engaged in services and their case is then closed.
Site Director will perform quarterly audits of 10 charts minimum in order to monitor compliance with treatment and rehabilitation services. Site director will perform these audits to ensure that treatment plans are reviewed and updated at a minimum of every 60 days.
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