INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the February 28, 2012 licensure renewal inspection. The follow-up inspection was conducted on November 5, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Clinical Outcomes Group Incorporated 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 records, the facility failed to ensure that a valid consent to release information form was utilized in nine of nine client records.
Based on the review of client records, the facility failed to ensure that an informed and voluntary consent to release information was obtained. In addition the facility exceeded 4 Pa. Code, Subsection 255.5(b).
The findings included:
Five client records requiring consents to release information were reviewed on November 5, 2012. One out of five client records failed to include a consent to release information prior to the release of information, specifically client #1. One out of five client record had a consent to release of information that exceeded the limits of 4 PA Code 255.5, specifically client #2.
Client record #1 contained a consent to release information form dated July 2, 2012, however, documentation in the client record revealed information was released to a funding source on June 29, 2012.
Client record #2 contained a consent to release information form dated October 3, 2012, allowing for the release of medical records, attendance, discharge summary, and client participation to a funding source. 4 PA Code 255.5 only allows for the release of the following items to a funding source:
(1) Whether the client is or is not in treatment.
(2) Client ' s prognosis.
(3) The nature of the project.
(4) A brief description of the client ' s progress.
(5) A short statement as to whether the client has relapsed into drug or
alcohol abuse and the frequency of such relapse.
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Plan of Correction
Effective 11/06/12, administrative staff and clinical staff will obtain written permission from all new clients and existing clients prior to checking eligibility of benefits. Staff will have clients sign a valid release of information prior to disclosing information. Effective 11/06/12, all staff will no longer obtain verbal permission from clients to disclose or obtain information.
Clinical Supervisor will monitor the charts to ensure compliance. She will meet with all staff to review policy. Facility will be in full compliance with the above POC by 11/06/12. The charts will be monitored on a monthly basis for the next three months to ensure compliance.
Effective 11/06/12, all releases to funding sources will only include the following: 1. Whether a client is or is not in treatment; 2. Client's prognosis; 3. The nature of the project; 4. A brief description of the client's progress; 5. A shorth statement as to whether the client has relapsed in drug or alcohol abuse. Clinical Supervisor will meet with the staff members to discuss the release of information to be used with our funding sources. She will review confidentiality if necessary to answer any questions during bi-monthly treatment team meetings. Clinical Supervisor will review charts on a monthly basid for next three months to ensure compliance. Facility will be in full compliance beginning 11/06/12. |
709.93(a)(7) 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:
(7) Client-related correspondence.
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Observations
Based on review of clinet records the facility failed to maintain a complete client record showing all correspondences relating the the clients treatment.
The findings include:
Five client records requiring documentation of client correspondence were reviewed on November 5, 2012. Two out of five records reviewed did not have complete documentation of the client related correspondence.
Client record #2 included a fax cover sheet indicating 14 pages were sent to a funding source, however, only six were included in the record.
Client record #3 included a fax cover sheet indicating that nine pages were sent, however, only five were included in the record.
The facility director confirmed the findings and indicated that staff filed the information in the client record and did not make a complete copy of the fax for the client related correspondence.
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Plan of Correction
Clinical Supervisor will meet with all staff to include both administrative and clinical to explain the following: all faxed correspondence will be copied completely and attached to the fax cove sheet and confirmation sheet. These items in then be placed in the correspondence section of the chart. The original forms can then be filed in the appropriate place within the clinical chart. The procedure will begin 11/06/12. The clinical supervisor will monitor the charts on a monthly basis to ensure compliance. Facility will be in compliance effective 11/06/12. Clinical supervisor will meet with staff on bi-monthly basis to review comliance as well. |