INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 25, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Holcomb Associates, Inc. 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:
|
Plan of Correction
|
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
|
Observations
Based on a review of administrative documentation, the project failed to make the annual report available to the public.
The findings include:
Based on a review of administrative documentation, the project failed to provide verification that an annual report has been made available to the public.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Effective Date 5/15/15
Project Director obtain copy of notice which announced Annual Report was available. Project Director to obtain copy within 30 days. Moving forward, Chief Compliance Officer will complete the Project's Annual Report and make available to public via submitting post to newspaper or announcing via Holcomb website. Project Director will ensure that proof of publication of the announcement of the Annual Report will be obtained via securing copy of the announcement. Facility Director has set up "tickler system" so that Facility Director receives a reminder each year to prompt the procedure of posting and obtaining copy of the announcement. This new tickler system will prevent the deficiency from recurring.
|
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:
|
Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent which documented the purpose of the disclosure and the name of the person, agency, or organization to whom the disclosure was made, in four of five client records reviewed. Additionally, the facility failed to document the dated signature of the client and the date, even, or condition on which the consent will expire in three of five client records.
The findings include:
Client #1 was admitted into treatment on 9/12/14 and was still active at the time of the licensing inspection. The consent to release information for a behavioral health agency, which was dated 1/28/15, failed to specify the information disclosed and the purpose of the release. Additionally, the consent to release information for a school, which was dated for 9/12/14, failed to document the name of the school. This client record also contained a consent to release information form dated 9/12/14, for the probation officer. The facility failed to obtain the dated signature of the client, and instead documented the dated signature of the client's guardian.
Client #2 was admitted into treatment on 7/31/14 and was still active at the time of the licensing inspection. The consent to release information for a social service agency, which was dated 8/28/14, failed to specify the information disclosed and the purpose of the release. Additionally, the client record contained two consent to release information forms that were signed by the client and dated 10/15/14. These consent forms failed to document the name of the person, agency, or organization to whom disclosure is made; specific information disclosed; the purpose of the release; and the date, event or condition upon which the consent will expire.
Client #3 was admitted into treatment on 7/24/14 and discharged on 12/11/14. The consent to release information for the PCP, which was dated 7/24/14, failed to document the name of the PCP, only including the notation "none at this time". The consent form also failed to specify the date, event or condition upon which the consent will expire.
Client #4 was admitted into treatment on 8/29/14 and discharged on 10/8/14. The consent to release information for the probation officer, which is dated 8/29/14, failed to specify the name of the probation officer and the agency.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Staff will be trained on consents, with focus on specific identification of content on the release of information, especially what information is being released. This training will be completed by 5/30/15.
The Clinical Coordinator, with the individual therapist, will be responsible for verifying the completion of all areas of the forms.
Regarding the Client-Specific problems:
Client #1 will have all her consents re-done, by the therapist, post-training. The Clinical Coordinator will review, and ensure compliance.
Client #2 will have all her consents re-done, by the therapist, post-training. The Clinical Coordinator will review, and ensure compliance.
The charts for Clients #3 and #4 will be used as training tools by the Clinical Coordinator. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
|
Observations
Based on a review of client records, the facility failed to consistently ensure that the client was offered a copy of the consent to release information form upon signing in two of five records reviewed.
The findings included:
Five client records requiring releases of information were reviewed on March 25, 2015. The facility failed to provide verification that the client was offered a copy of the consent in client records #1 and 2.
Client #1 was admitted into treatment on 9/12/14 and was still an active client at the time of the licensing inspection. A release of information form for a behavioral health agency was signed by the client on 1/28/15. There was no documentation the client was offered a copy of the consent form.
Client #2 was admitted into treatment on 7/31/14 and was still active at the time of the licensing inspection. A release of information form for a social service agency was signed by the client on 8/28/14. There was no documentation the client was offered a copy of the consent form.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Staff will be trained with focus on necessity for copies of consents to be offered, and provided to clients.
Therapist will secondarily verify that a client was offered, and provided a copy. The Clinical Coordinator will provide this training by 5/30/15, and monitor this process on an ongoing basis.
The Clinical Coordinator, with the individual therapist, will be responsible for verifying the completion of all areas of the forms.
Regarding the Client-Specific problems:
Client #1 will have all her consents re-done, by the therapist, post-training. The Clinical Coordinator will review, and ensure compliance. This process will become part of regular staff supervision for all OP staff.
Client #2 will have all her consents re-done, by the therapist, post-training. The Clinical Coordinator will review, and ensure compliance.
|
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
|
Observations
Based on a review of client records, the facility failed to document a signed and dated consent to treatment for outpatient drug and alcohol services in one of five client records reviewed.
The findings include:
Five client records requiring documentation of consent to treatment were reviewed on March 25, 2015. A consent to treatment was not documented during the intake process in client record #1.
Client #1 was admitted on 9/12/14 and was still active at the time of the licensing inspection. The only consent to treatment form documented in the client's record was not signed and dated by the client. The consent to treatment was signed by the client's guardian and dated 9/12/14.
|
Plan of Correction
Applicable laws associated with consent of clients between the ages of 14 and 18 will be reviewed thru training by the Clinical Coordinator.
Consents are always, and will continue to be, completed as indicated thru state law and licensure.
Client #1 came to Holcomb with his legal guardian, and was allowed to sign the consents for treatment. We believed this to be legal and appropriate. But, as this client is still with us, we will have him sign his own consents. The Clinical Coordinator will be responsible for this, and it will be completed by 5-15-15.
|
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
|
Observations
Based on a review of client records, the facility failed to ensure treatment plans for medical assistance recipients were consistently signed by a physician in one of five client records reviewed.
Client #2 was admitted into treatment on 7/31/14 and was still active at the time of the licensing inspection. Medical assistance is the funding source for client #2's treatment. The client's treatment plan updates dated 12/18/14 and 2/26/15 were not signed by a physician.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Holcomb Behavioral Health Systems has hired a new psychiatrist for our program, who will serve as clinical Team Leader, and will be integral in developing as well as signing off on, Treatment Plans.
The Clinical Coordinator will continue to work with the psychiatrist, and verify that all plans are signed and dated by appropriate staff as required by state law and licensure.
This process began 5-1-15, and will be ongoing. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of four personnel records reviewed.
The findings include:
Four personnel records of counselors requiring the documentation of the completion of 25 clock hours of annual training were reviewed on March 25, 2015. The facility failed to document the completion of 25 clock hours of annual training for employee #4.
Employee #4 was hired on 5/4/12 as a counselor. The facility's training year is from January through December. The training year for January 2014 to December 2014 was reviewed. Employee #4 only completed 16 clock hours of annual training for the January 2014 to December 2014 training year.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Coordinator will support Staff Therapists in completing the necessary training requirements that were identified in their Professional Development Plan.
Staff will be provided with multiple training opportunities throughout the year, both in our Field office, and Agency Main office. The Clinical Coordinator will follow up to verify individual attendance, and these hours will be monitored for compliance with applicable regulations. |