INITIAL COMMENTS
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This report is a result of complaint investigation conducted on August 23, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the allegations made against Bucks County Counseling were partially substantiated and 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(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on review of the facility policy and procedures the facility failed to have records stored according to the facility policy.
The findings include:
The facility's policy and procedures were reviewed on August 23, 2012. According to the facility's policy and procedures, "The project shall secure client records within secure storage containers. All active and closed client records are contained in a locked file cabinet marked confidential in a locked office with the project's facility." A request was made for the retrieval of 2011 closed records. The facility director indicated that these records were no longer at the facility as this documentation was now being stored at his home. After further review it was determined that the records were still at the facility and had not been taken to his home to be stored. The director was interviewed and it was determined that closed records from 2010 were being stored at his home. This is in violation with the facility policy. During the investigation the proper storage of closed records was discussed with the facility director.
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Plan of Correction
Project Director has removed 2010 files that had been stored in a locked filing cabinet in Director's home and moved them in locked file cabinet in office as of 8/24/12. No records were at any time contained outside of a locked file cabinet except during the transport processes.
Project Director will investigate suitable off-site storage of closed files, and modify policy manual to reflect availability of off-site storage, if that option is chosen. If that option is not chosen, files will remain in locked file cabinet in closet in office and policy manual will remain the same. To be complete by 10/15/12
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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 the review of client records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in four of five client records reviewed. The facility exceeded 4 Pa. Code, Subsection 255.5(a)(6) in one of five records reviewed.
The findings included:
Six client records were reviewed August 23, 2012. Five records were reviewed regarding release of information documentation. The facility failed to ensure that an informed and voluntary consent to release information was obtained in four client records reviewed, # 2, 3, 4, and 5. The facility exceeded 4 Pa. Code, Subsection 255.5(a)(6) in client record # 4.
A review of client record # 2 revealed information was released to a funding source in October, November and December of 2011. The client did not sign a release prior to releasing information for the funding entity.
A review of client record # 3 revealed a family session took place on July 9, 2011. The client's mother and father attended the family session. The facility failed to obtain a consent to release for the client's mother and father for attending the family session. The record included a consent to release information for the client's mother, however, it was specifically for whether or not the client was in treatment.
A review of client record # 4 included a consent to release for the client's employer allowing for the release of the date of the assessment and treatment recommendations. The facility exceeded 4 Pa. Code, Subsection 255.5(a)(6) by allowing information to be released to the employer that was not limited to whether the client has or is receiving treatment with the project. The record also revealed information was released to a funding source on July 28, 2011. The client did not sign a release prior to releasing information for the funding entity. Further review of the record revealed that information was received from an employee assistance program on April 20, 2012 and April 24, 2012. The client did not sign a consent to release for the agency prior to the exchange of information.
A review of client record # 5 revealed information was requested from a doctor's office without having the client's prior consent. On July 16, 2012 a letter was written to a doctor's office that had been signed by the facility director. The letter requested that the doctor write a prescription for certification of 30 sessions of Intensive Outpatient (IOP) substance dependence treatment starting on July 16, 2012. The letter was faxed to the doctor's office on July 19, 2012. The record also included returned correspondence from the doctor's office that certified the client's substance abuse treatment. During the on-site review, a consent to release form signed by the client for the facility to contact the doctor was not included in client record # 4. An interview with the facility director on August 23, 2012, at 11:55 AM, confirmed that a consent to release information form had not been signed by the client.
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Plan of Correction
Add item to file checklist for intake process that includes item "funding source release signed?". Project Director to train counselors on file checklist, and monitor all intakes for compliance.
Create default release to family members stating as information to be released "Presence in treatment, nature of emergency, family issues may be discussed during family session".
Training for counselors and director to take place on confidentiality, specifically 42 CFR, 4 Pa Code 255.5 and facility policies. Training will be documented in trainee file.
Project Director responsible.
All to be completed by 9/30/12, Project Director responsible.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment and the counselor's conclusions and impressions in three of three client records. In two additional client records, the facility failed to document a psychosocial evaluation.
The findings include:
Six client records were reviewed on August 23, 2012. A psychosocial evaluation was reviewed in five records. The facility failed to document a psychosocial evaluation that included assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment and the counselor's conclusions and impressions in patient records # 1, 2, and 3. The facility failed to document a psychosocial evaluation in patient records # 4 and 5.
Client # 1 was admitted on August 8, 2011 and discharged September 9, 2011. The psychosocial assessment lacked an evaluation by the counselor of the client's assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment and the counselor's conclusions and impressions.
Client # 2 was admitted on September 20, 2011 and discharged on December 1, 2011. The psychosocial assessment lacked an evaluation by the counselor of the client's assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment and the counselor's conclusions and impressions.
Client # 3 was admitted on June 6, 2011 and discharged on October 30, 2011. The psychosocial assessment lacked an evaluation by the counselor of the client's assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment and the counselor's conclusions and impressions.
Client # 4 was admitted on December 9, 2011. The facility failed to document a psychosocial evaluation in this client record as of the date of the inspection.
Client # 5 was admitted on July 18, 2012. The facility failed to document a psychosocial evaluation in this client record as of the date of the inspection.
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Plan of Correction
Project Director will train all staff on contents and purpose of section 709.91. Certification of training will be placed in employee file.
Project director will amend the psychosocial evaluation document by adding sections titled "CONCLUSIONS : CLIENT'S APPEARANCE, BEHAVIOR AND REACTIONS DURING INTAKE" and " CONCLUSIONS: ATTITUDE TOWARD AND ABILITY TO PARTICIPATE IN THE Tx PROCESS".
Project Director will add item "Completed Psychosocial Eval?" to the file checklist. Project Director will monitor compliance on all new intakes.
To be completed by 10/15/12
Project Director is responsible |
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
Based on a review of client records, the facility failed to document a treatment plan update in one of one client record.
The findings include:
Six client records were reviewed on August 23, 2011. One client record required a treatment plan update. Per the regulation, treatment plan updates are required to be updated at least every 60 days. The facility failed to document a treatment plan update in client record # 4.
Client # 4 was admitted December 9, 2011. The comprehensive treatment plan was completed on December 9, 2011. Treatment plan updates were due by February 9, 2012, April 9, 2012, June 9, 2012, and August 9, 2012. The facility failed to document treatment plan updates in this patient record.
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Plan of Correction
Project Director will train all staff on the project Policy manual as it relates to section 709.92, subchapter C, General Standards for Free-standing treatment activities.
Project Director will train all staff on contents and purpose of section 709.92.
Certification of training will be placed in employee file.
Project director will add item to file checklist "Tx plan updates marked in calendar?". Office software will alert Project Director and Counselors when Treatment plan updates are due for each client. Project Director will monitor for compliance.
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709.93(a)(8) LICENSURE Client records
709.93. 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document case consultations in one of one client records as required.
The findings include:
Six client records were reviewed August 23, 2012. One record required two case consultations at the time of the inspection.
Client # 4 was admitted December 9, 2011. During the on-site investigation, the client's record was reviewed. There were no case consultation in client # 4's record.
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Plan of Correction
Create new file checklist that includes item "enter case consult date in calendar". Train staff to enter task with automatic reminder into Microsoft Outlook before intake is considered complete. Project Director to monitor all intakes for compliance.
To be completed by 9/30/12
Project director responsible.
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