INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 6, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Schuylkill Health System Center for Counseling Services 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 and a plan of correction is due on June 3, 2009.
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Plan of Correction
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on review of client census lists, the self report staffing form completed by the facility director on May 5, 2009, and interviews with the facility director and the clinical supervisor on 5/5/2009 at 8:30 AM, the facility failed to maintain caseloads at the required limit of 35:1.
The findings include:
Two of two counselors had documented client to counselor caseloads exceeding the maximum allowable 35:1 caseload size. Employee # 10 had a caseload of 45:1; employee # 8 had a caseload of 59:1. This is a repeat citation from 2008.
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Plan of Correction
1. Two new clinical Staff have been hired (4/23/2009)and(5/16/2009). A three month probationary period and competency review is completed prior to assignment of a full caseload. At time of caseload assignment we will prioritize and when necessary transfer cases from other counselors to new staff to balance individual patient/staff ratios.
Time Frame: Ongoing to 9/30/2009
Responsiblity: Facility Director and Clinical Supervisors
2.Utilization Review will be conducted on active cases by creating a 30 day no contact list identifing assigned therapist and patients not seen in thirty days for face to face contact. This list will be reviewed in individual and or group supervision and inentify cases in need of follow up or closure and help insure appropiate processing of patients.Review will occur weekly with each counselor
Responsiblity: Facility Director and Clinical Supervisors
Timeframe: Ongoing 6/15/2009.
3. Patient Staff ratios will be calculated monthly using the Staffing Requirements Facility Summary Report (pg.5)in order to assess ratios on each counselor and adjust as determined necessary.Summary will be completed on the first day of the new calander month for the previous calander month and be adjusted as needed.
Responsible Staff: Clinical Supervisors and Facility Director.
Timeframe: Monthly beginning June 2009.
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711.91(b)(3)(iii) LICENSURE Personal History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records during the onsite licensing inspection of May 7, 2009, the facility failed to document comprehensive personal histories on each client.
The findings include:
Eight client records were reviewed during the annual onsite licensing inspection. Each client record was required to include documentation of a complete personal history.
Client records #1, 2, 3, 4, 5, 6 and 7 did not include documentation of complete family histories as evidenced by the absence of family interrelationships in the family of origin, as well as the current family constellation.
Employment histories failed to document full employment histories and addressed only the most recently held jobs in client records # 1, 2, 3, 7 and 8.
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Plan of Correction
1. Clinical Staff In-Service on Intake Assessment focusing on expansion of information collected in all areas of assessment with focus on accurate completion of required information as well as more comprehensive value added recording of responses. The areas of family history and employment will be included in the presentation.
Responsible Person: Clinical Supervisors/Program Director
Timeframe: 6/30/2009
2. Clinical supervisors will review all intake assessments completed and include an evaluative review of the family and employment histories. Feedback to clinical staff will occur in weekly individual supervision.
Responsible Person: Clinical Supervisors
Timeframe: 7/1/09 ongoing
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711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records on May 7, 2009, the facility failed to document treatment plan updates which addressed the stated goals of the treatment plan and/or did not document needed modifications to the existing treatment plans based on the progress made.
The findings include:
Eight records were in the sample. Seven client records were required to have treatment plan updates documented.
Based on a review of client records # 1, 3, 5, 6, 8 on May 7, 2009, progress on the documented short term treatment goals was not addressed in the treatment plan updates in these client records.
Each client record reviewed had a support services plan documented at the time of intake. This method of documentation of support services for the treatment plan is utilized by the agency rather than including the support services on the comprehensive treatment plan document . No update to this plan was documented in eight of eight client records reviewed, specifically client records # 1, 2, 3, 4, 5, 6, 7, 8.
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Plan of Correction
This Plan of Correction has a scope beyond the observation recorded but includes steps that are designed to correct the area of concern while improving the overall process:
A. New Admissions: All new patient records are reviewed by the clinical supervisor at the time of admission. The review process will be expanded to include the following steps:
1.Establish Reason for referral
2.Review problem list and develop clinical strategies to be considered on treatment plan.
3.Establish areas to be included on the master treatment plan
4. Establish an interval of clinical contact given the clinical severity and need for intervention
5.Affirm level of care decision and group assignment
6. Assign case to primary counselor.
This information will be given to the assigned counselor to be utilized in the development of the master treatment plan.
The assigned counselor is responsible for the development of the master treatment plan and for scheduling the appointment.
The master treatment plan is to be completed at the first session with the assigned therapist and this session is to occur within ten working days of case assignment.
Initial plan will then be reviewed by the clinical supervisor for appropiateness and conformance to requirements.
The review will include but not be limited to the following:
1.Appropiate problem and goal statements
2.Appropiate objectives and methods and timeframes.
3. Clinical interval for contact.
4. Signatires.
This supervisor review is the point of compliance monitoring.
Treatment Plan Update:
1. Occur every 60 days.
2. A computerized list will be generated listing all patients scheduled for review.
3. The list will include the following: Assigned therapist
Patient name
Assigned therapist
date previous plan developed
Date update due
4.Updates will occur in individual supervision where plans can be drafted with new and clinically appropiate goals and progress on previous plan reviewed.Assigned therapist will then process plan with patient.
A check list will be added to the treatment plan update form identifing services currently being utilized by the patient relative to ongoing support. These check boxes will utilize the catagories on the Support Service plan.
Timeframe:7/31/2009
Responsible Person: Clinical Supervisors and Director.
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711.93(c)(1)(i) LICENSURE Confidentiality - Client Identity/Records
711.93. Client records.
(c) Confidentiality.
(1) A written procedure shall be developed by the project director which complies 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:
(i) Confidentiality of client identity and records.
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Observations
Based on interviews with the facility director on May 5 at 10:30 AM and May 7 at 3:30 PM, and documentation noted in client records and the agency manual on May 5-7, 2009, the facility failed to document policies consistent with applicable confidentiality laws.
The findings include:
The notice of privacy practices document, which is given to each client and documented via client sign off , was noted in 8 of 8 client records reviewed, specifically client records # 1, 2, 3, 4, 5, 6, 7, 8. This document incorrectly identifies circumstances when the facility may release client information without the client's specific, signed consent to do so . Examples of these circumstances include releases to medical personnel, related service providers such as home health agencies and laboratories, funding entities, domestic violence reporting . This document also incorrectly informs the client that they may request restrictions on the use of their health information, but the agency is not obligated to honor these requests. This language is not consistent with 4 Pa. Code Subsection 255.5 (b), the enabling legislation at 71 P. S. Subsections 1690.102 through 1690.112 and with the federal regulations at 42 CFR Part 2, Subparts A through E.
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Plan of Correction
The form referenced is the"Notice of Privacy Pratices" uesd in all areas of the instuition. In light of this the following Plan of Correction is offered:
1. An attachment will be added to the form that is department specific.The attachment will detail the additional provisions for confidentiality afforded to patients in treatment for substance abuse that go beyond the Privacy Pratice Notice.
Both federal and state confidentiality
provisions will be addressed and will include the need for a specific release of information authorizing any release of information as well as circumstances under which a release may occur without consent.Responsible Person: Program Director
Timeframe: 6/30/2009
3. In-service to all clinical staff on modification of confidentiality attachment on Privacy Pratice Notice.Person: Program Director
Timeframe: 6/30/2009
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711.93(c)(2)(ii) LICENSURE Specific Info. Disclosed
711.93. Client records.
(c) Confidentiality.
(2) 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:
(ii) The specific information disclosed.
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Observations
Based on interviews with the facility director on May 5, 2009 at 10:30 AM and 5/7/09 at 3:30 PM, and a review of client records, the facility failed to limit disclosures of client identifying information to the parameters outlined at 4 Pa. Code subsection 255.5(b).
The findings include:
The onsite annual licensing inspection was held from May 5 to May 7, 2009. Documentation in the client records demonstrated that a third party payer mandates that facility staff complete a level of care assessment which demands information regarding specifics of the clients' high risk behavior over the previous 12 month period. The specific information requested includes: suicide attempts , homicide attempts , inability to care for self, violent/aggressive behavior, victim of sexual/physical abuse, jail, homelessness, D&A abuse and social isolation. This information exceeds the parameters at 4 Pa Code subsection 255.5(b). Based on an interview with the facility director, it was confirmed that the agency is completing this document for each client funded by that third party payer. In the sample of eight client records information was released from client records # 4 and 8 to this third party payer which exceeded the parameters of 4 Pa. Code Subsection 255.5 (b).
Consents to release information to next of kin and/or significant others in two of eight applicable client records did not specify what specific information would be released in the event of an emergency or on phone messages . The consent to release information forms documented in client records # 5 and 6 did not list the specific information to be disclosed.
Client record # 2 included documentation of a release of information on a Pennsylvania Client Placement Criteria form which included information that exceeded the parameters at 4 Pa . Code 255.5(b). The information released included family conflict issues, medications taken by the client and illicit drugs used, where the information was released to a third party payer entity.
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Plan of Correction
1.Contacted the third party payor representative and informemed him of confidentiality issue related to form (via e-mail 5/20/2009).Faxed him a blank form as per his request(5/21/2009).
Facility has informed payor that we will no longer complete the section of the form that exceeds PA.255.5(5/21/2009)We will indicate on the form that the information requested in that section exceeds PA.255.5
Third party payor representative contacted facility and has agreed to accept forms within appropiate parameters of PA 255.5.(5/21/2009)
Responsible Person: Program Director
Timeframe: Noted Above
2.The program will continue to monitor forms prior to sending to insure the information beyond scope of PA 255.5 is not part of transmission.
Responsible Person:Program Director/System Specialist
Timeframe: 5/26/2009 ongoing.
3. In-service with clinical staff regarding confidentiality modifications in program will occur in June 2009.
Responsible Person: Program Director/Clinical Supervisors.
Timeframe: By 6/30/2009
Emergency Contact Release
1. The Release of Information for Emergency Contact will be made into a template to insure that the scope is consistant for all patients.
The purpose of the release will read:
" contact of the identified person in the event of an emergency related to the patient".
Information will be limited to the following:
1.Nature of emergency
2.Location of patient
3.Patient demographics.
2.In-service with clinical staff regarding confidentiality modifications in program will occur in June 2009.
3. Review with all clinical staff the scope of information to be included in PCPC Level of care determination.
Contact Supervisor if there are any requests to go beyond the scope of information deemed appropiate to release.
In-service June 2009 to inform staff of all confidentiality modifications in the program.
Timeframe; 6/30/2009
Responsible person: Clinical Supervisor and Director. |