INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 25-27, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Tadiso 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(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 a review of client record, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in eighteen of twenty six client records.
The findings included:
Forty one client records were reviewed on October 25-27, 2011. Twenty six records were reviewed for compliance with obtaining an informed and voluntary consent. The facility failed to obtain an informed and voluntary consent for the disclosure of client information in client records # 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29 and 30. The consent to release information forms signed by the clients for the information to be released to the third party payer exceeded the limitations on the release of information imposed at 4 Pa. Code subsection 255.5 (b). The releases documented that "other" information could be released in addition to what is permitted under 4 Pa. Code subsection 255.5 (b), but failed to define what "other" information was.
The facility director was interviewed on October 27, 2011 and confirmed the findings.
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Plan of Correction
The Chief Administrative Officer will ensure that fiscal personnel receive the mandated confidentiality trainingand/or updated instructions. All authorization forms will be monitored BY THE FISCAL SUPERVISOR to comply with regulations. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of specific information contained in the client record in eighteen of twenty six clients records.
The findings included:
Forty one client records were reviewed on October 25-27, 2011. Twenty six records were reviewed for compliance with obtaining an informed and voluntary consent for the release of specific information in the client record. The facility failed to obtain an informed and voluntary consent for the disclosure of specific client information in client records # 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29 and 30. The client records included documentation that information was sent to the Department of Public Welfare in order to verify the client's eligibility status. There was no documentation in the client records listed, that a consent to release the information had been obtained from the client prior to the release of the information.
The facility director was interviewed on October 27, 2011 and confirmed the findings.
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Plan of Correction
The Chief Administrative Officer will ensure that fiscal personnel receive the mandatory confidentiality training and or updated instructions. Consent forms will be monitored BY THE FISCAL SUPERVISOR to verify adherence to regulations. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to provide counseling to a client on a regular and scheduled basis including individual counseling, at least twice weekly in five of the five client records.
The findings include:
Forty one client records were reviewed on October 25-27, 2011. Five client records were reviewed as partial hospitalization records. Five client records were required to include documentation of individual counseling at least twice weekly. Client records # 8, 9, 10, 11 and 12 did not include documentation of individual counseling at least twice weekly.
Client # 8 was admitted on August 30, 2011. There was one individual counseling session documented for the weeks of September 12, 19, and 26, 2011. There were no individual counseling sessions documented for the weeks of September 5, October 3, 10 and 17, 2011.
Client # 9 was admitted on September 20, 2011. There was one individual counseling session documented for the week of October 10, 2011. There were no individual counseling sessions documented for the weeks of September 20, October 3, and 17, 2011.
Client # 10 was admitted on August 9, 2011. There was one individual counseling session documented for the weeks of August 15, 29, September 5, 12, and 19, October 3, 10, and 17, 2011. There were no individual counseling sessions documented for the weeks of August 22 and September 26, 2011.
Client # 11 was admitted on August 1, 2011 and discharged on October 21, 2011. There was one individual counseling session documented for the weeks of August 15, 22, 29, September 5, 19 and October 3, 2011. There were no individual counseling sessions documented for the weeks of August 1, 8, September 12, 26 and October 10, 2011.
Client # 12 was admitted on August 1, 2011 and discharged on September 12, 2011. There was one individual counseling session documented for the weeks of August 15 and 22, 2011. There were no individual counseling sessions documented for the weeks of August 8, 29 and September 5, 2011.
The facility director was interviewed on October 26, 2011 and confirmed the findings.
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Plan of Correction
Chief Administrative Officer will direct the Partial Hospitalization counselor to formulate a schedule that allows for individual counseling of the program participants as mandated. Adherence to this schedule of services will be monitored by Administration to verify that sessions are documented upon occurrence. |
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.
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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 three personnel records reviewed.
The findings included:
Twelve personnel records were reviewed on October 25-27, 2011. Three personnel record were reviewed as counselor personnel records. Three personnel records were required to include documentation of the completion of 25 clock hours of annual training. The facility training year is from July 1 through June 30. The training year for July 1, 2010 to June 30, 2011 was reviewed. The facility failed to document 25 clock hours of annual training in personnel record # 8.
Employee # 8 was hired on July 16, 2009. Employee # 8 had only 18 documented clock hours of annual training for the July 1, 2010 to June 30, 2011 training year.
The project director was interviewed on October 25, 2011 and confirmed the findings.
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Plan of Correction
Chief Administrative Officer will ensure adherence to individual training plans of counselors to ensure that adequate training hours are obtained. Monitoirng of training hours will be conducted quarterly to offset any mishaps and allow for changes and additional training if needed. |