INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 14, 2010 through July 15, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Interim House West 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 August 17, 2010.
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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 the review of client records, the facility failed to document consent to release forms that included all required documentation in four of six client records reviewed.
The findings include:
Six client records were reviewed on July 15, 2010. Consent to release information forms were required in six client records reviewed.
Client record #1 had three consent to release information forms that were not completed. The consent to release information forms dated 5/10/10 did not include documentation of what was being released and whether or not the client was offered a copy. Another consent to release information form dated 5/10/10 did not include documentation of the purpose of the release, whether the client was offered a copy of the form and did not include documentation of the date of the signature. The third consent to release information form dated 5/10/10 did not include documentation of the purpose of the release and whether the client was offered a copy of the form.
Client record #2 included documentation of a consent to release information form dated 2/1/10 which did not include documentation of the purpose of the release of information and whether the client was offered a copy of the form.
Client record #3 included documentation of a consent to release information form dated 4/8/10. The consent to release information form did not include documentation of the purpose of the release and whether the client was offered a copy of the form. There was no documentation of a consent to release information form for the addressee of a letter dated 3/24/10. Another letter, dated 5/21/10, gives a family member permission to pick up a child but the client record did not include documentation of a consent to release information to the person named in the letter.
Client record # 4 included documentation of a consent to release information form dated 11/10/09 which failed to include documentation of what information was to be released and the date the client signed the consent to release form. Another consent to release information form, dated 11/10/09, to the client's parole officer did not include documentation of the purpose of the release, and misinformed the client that revocations of the consent to release information must be in writing, failing to inform the client that verbal revocations of the consent must be honored by the facility.
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Plan of Correction
In the charts audited, IHW failed to complete the release of information form correctly. In four of the six charts audited, IHW failed to document the purpose of the release and/or offered the clients a copy of the release. Additionally in one of the charts audited, the person's name to whom the information was going to be released was not clearly identified on the form.
Effective immediately, IHW's director will address staff in morning briefing on 8/5/2010 to address this deficiency as well as train the staff on 709.28 regulations as it pertains to release of information. All current releases will be reviewed and updated to meet this regulation.
Completion Date:
08/04/2010
Status:
Submitted
Date: 8/4/2010
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709.53(a)(9) LICENSURE Aftercare plans
709.53. 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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records, the facility failed to document aftercare plans addressing the clients' goals with time frames in two of three closed client records.
The findings include:
Six client records were reviewed on July 15, 2010. Aftercare plans were required in two of three closed records reviewed, #5 and 6. Client records #5 and 6 included documentation of aftercare plans, but the plans did not include documentation of the clients' goals with time frames.
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Plan of Correction
Due to staff oversight,IHW failed to document client goals with time frames in two of three charts audited.
Effective 9/4/10, IHW's clinical director will revise the after care plans to include client's goals that will include specific time frames upon treatment completion or unexpected departure from the program. The clinical director will hold a staff in-service to introduce and train staff on the form and policy(1809) as it relates to the newly revised aftercare plans. The new form will include the following:
1.Goals and timeframes for the goals.
2.Name and addresses of outpatients including next appointment
3.Crises Response Center-Resources
NA/AA meeting directory
The clinical director along with PHMC's Qm department will perform quarterly chart audits to ensure compliance with this regulation. |