INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 18, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services York Psychiatric 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 April 18, 2008.
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Plan of Correction
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply 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:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the facility's policies and procedures, the facility failed to have a written procedure that complied with 4 Pa. Code Subsection 255.5. The facility's written procedures for the confidentiality of client identity and records contained a document entitled "Confidentiality Regulations and the Drug and Alcohol Treatment Programs". This procedure included the wording that allowed for the release of client information "with or without the client's consent" to judges and probation/parole. Releasing information without the client's written consent is a direct violation of the state law at 71 P. S. Subsection 1690.108(b) and the federal regulations at 42 CFR Part 2, Subpart C, Subsection 2.31.
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Plan of Correction
The Director of Quality Improvement has revised the "Confidentiality Regulations and the Drug and Alcohol Treatment Programs" procedure to state that client information can only be released with the client's consent to judges and probation/parole. |
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 a review of client records, the facility failed to individualize psychosocial evaluations in six of six client records reviewed, #1, 2, 3, 4, 5, and 6. Psychosocial evaluations contained standardized comments and were not individualized based on each client's needs. Comments were standardized relative to the client's assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and attitude towards treatment.
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Plan of Correction
The Facility Director will oversee that staff are re-educated in staff meeting to provide psychosocial evaluations which are individualized to each client. Staff will be reminded to give more clinical insight and to avoid using standardized comments when assessing the client's assets/strengths, support systems, coping mechanisms and other factors that may affect treatment. The Quality Improvement Department will also oversee the revision of our psychosocial evaluation to include additional room for staff to document more detailed clinical impressions. The Quality Improvement Department will also monitor the content of our psychosocial evaluations through ongoing chart audits. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document treatment plan goals stated in terms of measurable criteria in ten of ten client records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
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Plan of Correction
The Facility Director will oversee that all staff are re-educated through staff meeting in regards to utilizing treatment plans goals that are stated in terms of measurable criteria. The Quality Improvement Department will monitor the content of treatment plans through random chart audits. |
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 complete treatment plan update in four of four client records reviewed, #1, 4, 5 and 7. Treatment plan updates did not include an assessment of the client's progress in relationship to the stated goals of the treatment plan.
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Plan of Correction
The Facility Director will oversee that staff are re-educated in staff meeting to thoroughly complete treatment plan updates and to include an assessment of the client's progress in relationship to the goals stated on the comprehensive treatment plan. The Quality Improvement Department will monitor the content of the treatment plan updates through random chart audits. |
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 a review of client records, the facility failed to document case consultations in two of three client records reviewed, #4 and 5.
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Plan of Correction
The Facility Director will oversee that all staff are reminded in staff meeting to thoroughly complete case consultations in a timely manner. The Quality Improvement Department will oversee an internal monitoring system by office administration to ensure the timely completion of case consultations. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in two of three records reviewed, #8 and 10. The facilities policy and procedure stated that all follow-up information should be completed within 60 days from the discharge date. Client record number eight was discharged on 12/27/07. Follow-up information was not documented as of the date of the inspection, though the due date was 2/27/08. Client record number ten was discharged on 12/20/07 and follow-up information was not documented as of the date of the inspection, though the due date was 2/20/08.
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Plan of Correction
The Facility Director will oversee that staff follow company procedure regarding discharge notification and follow-up to ensure that follow-up information is documented in each discharged client record. The Quality Improvement Department will provide ongoing monitoring through random chart audits. |