INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on January 19 - 20, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, JF Kennedy Community MH/MR Center 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 February 23, 2011.
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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 upon a review of the facility ' s consent to release information form titled
Release of Information (Revised August 2010), the facility failed to comply with state law 71 P.S federal regulation 42CFR Part 2, Subpart B, and 42CFR Part 2, Subpart C,
In addition, based on the review of client records and an interview with the facility director, the facility failed to document informed and voluntary consent from the client for the disclosure of information contained in twelve of thirteen client records.
The findings include:
On January 18 through January 21, 2011 while reviewing client records, it was observed that the facility was using a consent to release information form titled Release of Information (Revised August 2010), the facility failed to comply with state law 71 P.S federal regulation 42CFR Part 2, Subpart B, and 42CFR Part 2, Subpart C, form did not comply for the following reasons:
The form allowed for the parent of a child to grant permission to release information. This is in violation of state law 71 P.S and federal regulation 42CFR Part 2, Subpart B, Regulation 42CFR Part 2, Subpart B, states:
Minor patients. (a) Definition of minor. As used in these regulations the term minor means a person who has not attained the age of majority specified in the applicable State law, or if no age of majority is specified in the applicable State law, the age of eighteen years. (b) State law not requiring parental consent to treatment. If a minor patient acting alone has the legal capacity under the applicable State law to apply for and obtain alcohol or drug abuse treatment, any written consent for disclosure authorized under subpart C of these regulations may be given only by the minor patient. This restriction includes, but is not limited to, any disclosure of patient identifying information to the parent or guardian of a minor patient for the purpose of obtaining financial reimbursement. These regulations do not prohibit a program from refusing to provide treatment until the minor patient consents to the disclosure necessary to obtain reimbursement, but refusal to provide treatment may be prohibited under a State or local law requiring the program to furnish the service irrespective of ability to pay.
State Law 71 P.S states:
Notwithstanding any other provisions of law, a minor who suffers from the use of a controlled or harmful substance may give consent to furnishing of medical care or counseling related to diagnosis or treatment. The consent of the parents or legal guardian of the minor shall not be necessary to authorize medical care of counseling related to such diagnosis or treatment. The consent of the minor shall be valid and binding as if the minor had achieved his majority. Such consent shall not be voidable nor subject to later disaffirmance because of minority. Any physician or any agency or organization operating a drug abuse program, who provides counseling to a minor who uses any controlled or harmful substance may, but shall not be obligated to inform the parents or legal guardian of any such minor as to the treatment given or needed.
The form failed to comply with federal regulation 42CFR Part 2, Subpart C, for the following reason:
The form required that the client sign or initial that they understood that there was a potential for the released information to be redisclosed by the recipient.
42CFR Part 2, Subpart C, states:
Prohibition on redisclosure.Notice to accompany disclosure. Each disclosure made with the patient's written consent must be accompanied by the following written statement: This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.In addition the form includes the statement " I consent to release and disclosure of my confidential Drug & Alcohol related information " thus making it a general consent to release information.
The form also includes the statement " I consent to release and disclosure of my Confidential HIV-related information " . HIV related consents to release information are to be on a separate consent form.
Thirteen client records were reviewed on January 20, 2011 for documentation of informed and voluntary consent. The facility did not document informed and voluntary consent from the client for the release of information in twelve of thirteen records reviewed, specifically, records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12.
In client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12, the release forms disclosing client information to a funding source did not include a statement informing the client of his/her right to verbally revoke the consent to release information. The facility documented that the client must revoke the consent in writing.
In client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12, the release forms disclosing client information to a government agency did not include a statement informing the client of his/her right to verbally revoke the consent to release information. The facility documented that the client must revoke the consent in writing.
In client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12, the release forms disclosing client information to the client ' s primary care physician did not include a statement informing the client of his/her right to verbally revoke the consent to release information. The facility documented that the client must revoke the consent in writing.
In client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12, the release forms disclosing client information to a medical transportation company did not include a statement informing the client of his/her right to verbally revoke the consent to release information. The facility documented that the client must revoke the consent in writing.
An interview with the facility director on January 20, 2011, confirmed the facility did not document informed and voluntary consent for the disclosure of client information.
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Plan of Correction
By March 23, 2011 our release of information form will be revised to read, "For mental health treatment only, print child's name if under 14 years of age".
Effective March 23, 2011 the statement "I understand that there is a potential for the released information to be redisclosed by the recipient" will be deleted from our consent to release form.
By March 23, 2011 the statement, "I consent to release and disclosure of my confidential HIV-related information" will be deleted from our release of information form.
By March 23, 2011 the statement, "I consent to disclosure of my treatment summary,if any, in relation to my drug, alcohol abuse or deprndency to medical personnel, government officials, judges and probation/parole officers and 3rd party payors. This is pursuant to 4 Pa Code subchapter 255.5" will be deleted from our release of information form.
By March 23, 2011 the statement, "I consent to release and disclosure of my confidential drug & alcohol related information" will be deleted from our release of information form.
The Director of Addictive Behavior Programs, the Vice-President of Behavioral Health and the President of JFK are responsible of making the above listed revisions to ensure conpliance with drug/alcohol confidentiality regulations.
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715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to follow the specific dose determined by the physician when they refused to dose the patient for failure to comply with counseling attendance.
The findings include:
Thirteen client records were reviewed on January 20, 2011.
One client record contained a mandatory counseling attendance letter that stipulated a patient's dose of methadone would be held if the patient failed to comply with treatment agenda.
The physician's determination of a patient's dose is based on medical assessment. The facility's refusal to dose a patient for behavioral or therapeutic reasons failed to comply with the physician's determination and order for the course of patient treatment.
Client # 9 was admitted to the program on 6/8/10.
On 6/8/10 the client signed a mandatory counseling attendance letter which stated that "Your medication will be placed on an overnight hold on the day of your individual and/or group therapy sessions. Should you arrive late or fail to attend, you will not be medicated until you participate in individual and/or group counseling."
An interview with the facility director on January 20, 2011, confirmed that a behavioral or therapeutic contract was documented in client # 9's chart.
However, the facility director stated that the facility in no way places a hold on client's medication.
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Plan of Correction
The facility does not place over-night holds or, in anyway, withold a patient's daily prescribed dose of medication. The letter found in one of thirteen charts misrepresents the facilty's practice. Nevertheless, all staff were reminded in a staff meeting on February 8, 2011 to maintain compliance with our practice of ensuring that all patients who routinely arrive at the facility for medication are afforded this service. The facility supervisor will maintain responsibilty for ensuring ongoing compliance. |
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 and a review of the facility ' s policy manual, the facility failed to document a psychosocial evaluation in eight of ten client records.
The findings include:
Ten client records were reviewed on January 20, 2011 for psychosocial evaluations. The facility did not document a psychosocial evaluation, as per facility policy, in client records # 1, 2, 3, 4, 5, 8, 10 and 11.
The facility ' s policy titled " Intake and Admission " states:
" A Psychosocial Evaluation will be completed by the therapist within 30 days of intake/admission. The evaluation will provide a composite picture of the client in relationship to his/her psychosocial history to identify possible relationships, conditions and underlying causes leading to the client ' s current situation. Psychosocial evaluations include but not limited to:
- a clear description of the client ' s presenting and underlying problems.
- client needs or problems that can or cannot be resolved through treatment or that might inhibit treatment.
- client assets, strengths or other factors that can contribute to the resolution of identified problems.
- the potential or available client support systems.
- negative factors that might affect treatment.
- the client ' s preferred coping mechanisms.
- conclusions regarding the client ' s appearance, behavior and reactions during the intake process.
- conclusions regarding the client ' s attitude toward and ability to participate in the treatment process. "
The facility did not document a psychosocial evaluation to include the client ' s assets/strengths that can contribute to the resolution of identified problems in client records # 1, 2, 3, 4 and 5.
The facility did not document a psychosocial evaluation to include the client ' s preferred coping mechanisms in client records # 1, 2, 3, 4, 5, 8 and 10.
The facility did not document a psychosocial evaluation to include the client ' s negative factors that might affect treatment in client records # 1, 2, 3, 4 and 5.
Additionally, client #11 was admitted to the program on 4/22/10, but a psychosocial evaluation was not documented at the time of review on 1/20/11.
An interview with the facility director on January 20, 2011, confirmed that the facility did not document a psychosocial evaluation in accordance with facility policy in the identified client records.
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Plan of Correction
By March 7, 2011 the facility director will conduct two staff trainings designed to improve documentation of client assets/strenghts, preferred coping mechanisms, and negative factors affecting treatment. In addition, by March 7, 2011 the facility director will improve our psychosocial evaluation procedure to ensure that all patients receive such evaluation and ensure that the documentation of the evaluation is reviewed and promptly placed in the counseling file by the facility director. The facility director will be responsible for maintaining compliance with this standard. |
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 a case consultation in five of eleven client records.
The findings include:
Eleven client records were reviewed on January 20, 2011 for documentation of case consultations. The facility did not document a case consultation at least every 90 days, as per facility policy in client records # 2, 4, 8, 9 and 11.
The facility ' s policy titled " Client Records " states:
" Case consultation notes will be completed by the therapist at least every 90 days for the initial year of treatment and at least bi-annually thereafter. "
Client #2 was admitted to the program on 5/27/10, but the first case consultation was not documented until 10/18/10.
Client #4 was admitted to the program on 7/14/10, but a case consultation was not documented at the time of review on 1/20/11.
Client #8 was admitted to the program on 8/25/10, but a case consultation was not documented at the time of review on 1/20/11.
Client #9 was admitted to the program on 6/8/10. A case consultation was documented on 9/3/10, but a subsequent case consultation was not documented at the time of review on 1/20/11.
Client #11 was admitted to the program on 4/22/10. A case consultation was documented on 6/10/10, but a subsequent case consultation was not documented until 11/9/10.
An interview with the facility director on January 20, 2011, confirmed that the facility did not document a case consultation in accordance with facility policy in the identified client records.
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Plan of Correction
By February 28, 2011 the facility director will conduct a staff training on the timely completion of case consultations. Staff will be given an easy to use tickler system for notification of case consultation due dates. The facility director will review this system in weekly staff supervision to ensure compliance with this standard. |