INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 9-12, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Treatment Services 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 March 12, 2010.
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Plan of Correction
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709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on the review of client records and a discussion with the Project Director and the Clinical Director, the facility failed to document treatment plan updates in compliance with written facility policy, which requires a treatment plan update every 10 days, in seven of seven partial hospitalization client records.
The findings included:
Seven partial hospitalization client records were reviewed during from February 10 through February 12, 2010 during the annual licensing inspection. Facility policy and procedure required that treatment plan updates be documented every ten days during the partial hospitalization level of care.
Client record # 11- The client was admitted on 2/25/09. The treatment plan was formulated on 2/25/09. The treatment plan update was not documented until 3/10/09.
Client record # 12- The client was admitted on 1/11/10. The treatment plan was formulated on 1/11/10. The treatment plan update was not documented until 1/25/10.
Client record # 15- The client was admitted on 7/27/09. The treatment plan was documented on 7/27/09. The treatment plan update was not documented until 8/7/09.
Client record # 16- The client was admitted on 2/9/09. The treatment plan was formulated on 3/7/09. The treatment plan update was not documented until 5/7/09.
Client record # 17- The client was admitted on 9/9/09. The treatment plan was formulated on 10/1/09. The treatment plan updates were not documented until 11/9/09 and 1/9/10.
Client record # 18- The client was admitted on 10/23/09. The treatment plan was formulated on 10/23/09. The treatment plan update was not documented until 12/23/09.
Client record # 19- The client was admitted on 11/16/09. The treatment plan was formulated on 12/14/09. The treatment plan update was not documented until 1/27/09.
The tardiness of the treatment plan updates, relative to facility policy and procedure was reviewed with the Project Director and Clinical Director throughout the inspection and they were directed to the files which were found to be out of compliance with the facility policy. Both acknowledged that the facility policy needed to be changed.
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Plan of Correction
The Partial Hospitalization Agency Manual has already been changed to read: Treatment Plans are updated every thirty days or sooner when clinically appropriate - as recommended by licensing specialist.
The Board of Directors will vote on the change at the Annual Board Meeting scheduled for 2/25/10.
The Clinical Director will present the new policy to staff at the 3/4/10 staff meeing. |
709.83(a)(8) LICENSURE Client records
709.83. 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) Record of services provided.
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Observations
Based on the review of client records, the facility failed to document a chronological listing of the significant contacts and services provided to clients on the records of services documents in three of seven client records in the partial hospitalization level of care.
The findings included:
Seven partial hospitalization client records were reviewed from February 10 through 12, 2010, during the licensing inspection . Records of Services Provided are required to include documentation of a chronological listing of the various specific services provided to the client and include the date of the service, the provider of the service, the duration of the service and the type of service provided. Three of seven client records failed to document the specific services to the client in a chronological order. The format used by the agency for a record of service consisted of a printout of the billing record. The billing record content included a date of service and a provider of services, but the type of service was listed as "Partial Hospitalization" failing to include documentation of the type of service provided.
Client record # 11- The client admitted on 2/25/09 and was in the partial hospitalization level of care from 2/25/09 to 4/8/09. The record of services listed the level of care received as "Partial" for appointments on February 21, 27 2009 ; March 2, 3, 4, 9, 10 11, 13, and 15, 2009, but failed to document the type of service that was provided. In addition to this the record of service was divided into blocks of services which were not chronological listings of services provided but were organized by the funding entity billed for each particular service.
Client record # 12- The client admitted on 1/11/10. The record of services listed the level of care received as "Partial" for appointments on January 11, 13, 15, 22, 25, 27 and 29, but failed to document the type of service that was provided. In addition to this the record of service was divided into blocks of services which were not chronological listings of services provided, but were organized by the funding entity billed for each particular service.
Client record # 15- The client admitted on 7/29/09. The record of services listed the level of care received as "Partial" for appointments on January 11, 13, 15, 22, 25, 27 and 29 but failed to document the type of service that was provided. In addition the record of service was divided into blocks of services which were not chronological listings of services provided but were organized by the funding entity billed for each particular service.
The format for tracking services was reviewed with the Project Director on 2/10/10 and he acknowledged the difficulty inherent in tracking the individual services provided to each client given the documentation format used.
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Plan of Correction
The record of service is now being tracked manually by each clinician. The Executive Director developed a new record of service form that will be used universally within the Agency. The Clinical Director introduced it to all staff at the 2/18/10 staff meeting. The form is currently being used. The Clinical Director will be responsible to make sure it is being used. |
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 the review of client records, the facility released information to third party payers which exceeded the limitations imposed at 4 Pa. Code subsection 255.5(b) in 12 of 21 client records reviewed.
The findings included:
Twenty one client records were reviewed during the inspection between February 9 and 12, 2010. The facility released information to third party payers which exceeded the limitations imposed at 4 Pa. Code Subsection 255.5(b) in 12 of those client records.
Client record # 2 - The client was admitted on 2/27/09. A disclosure of information to a third party payer was documented on 3/23/09 which disclosed specifics about the client's drug of choice, patterns of use and amounts used as well as the client's involvement in the criminal justice system. This information exceeded the limitations imposed at 4 Pa. Code Subsection 255.5 (b) and the information listed on the consent to release information form that the facility acted on.
Client record # 4 - The client was admitted on 1/12/09. A disclosure of information to a third party payer which disclosed specifics about the client's drug of choice, patterns of use and amounts used as well as the client's involvement in the criminal justice system was documented. This information exceeded the limitations imposed at 4 Pa. Code Subsection 255.5 (b) and the information listed on the consent to release information form that the facility acted on.
Client record # 5 - The client was admitted on 10/5/09. A disclosure of information was documented on 8/18/09 to a third party funding source which disclosed specifics about the client' s history of treatment compliance, history of violent or aggressive behavior. This information exceeded the limitations imposed at 4 Pa. Code Subsection 255.5 (b) and the information listed on the consent to release information form that the facility acted on.
Client record # 8 - The client was admitted on 6/8/09. A disclosure of information to a third party funding source was documented on 7/15/09, which disclosed specifics about the client' s drug of choice, patterns of use and amounts used as well as the client's involvement in the criminal justice system. This information exceeded the limitations imposed at 4 Pa. Code Subsection 255.5 (b) and the information listed on the consent to release information form that the facility acted on.
Client record # 10 - The client was admitted on 9/9/09. A disclosure of information to a third party funding source was documented on 12/7/09 which disclosed specifics about the client' s recovery stage, 12 step involvement , personal use patterns, work in treatment on personal triggers, and motivation. This information exceeded the limitations imposed at 4 Pa. Code Subsection 255.5 (b) and the information listed on the consent to release information form that the facility acted on.
Client record # 12 - The client was admitted on 1/11/10. A disclosure of information to a third party funding source was documented on 1/25/10 which disclosed specifics about the client's drug of choice, patterns of use and amounts used as well as the client's involvement in the criminal justice system. This information exceeded the limitations imposed at 4 Pa. Code Subsection 255.5 (b) and the information listed on the consent to release information form that the facility acted on.
Client record # 13 - The client was admitted on 2/5/09. A disclosure of information to a third party funding source was documented which disclosed specifics about the client's drug of choice, patterns of use and amounts used as well as the client's involvement in the criminal justice system. This information exceeded the limitations imposed at 4 Pa. Code Subsection 255.5 (b) and the information listed on the consent to release information form that the facility acted on.
Client record # 14 - The client was admitted on 1/12/09. A disclosure of information to a third party funding source was documented, which disclosed specifics about the client's drug of choice, patterns of use and amounts used as well as the client's involvement in the criminal justice system. This information exceeded the limitations imposed at 4 Pa. Code Subsection 255.5 (b) and the information listed on the consent to release information form that the facility acted on.
Client record # 17 - The client was admitted on 9/9/09. A disclosure of information to a third party funding source was documented, which disclosed specifics about the client's drug of choice, patterns of use and amounts used as well as the client's involvement in the criminal justice system. This information exceeded the limitations imposed at 4 Pa. Code Subsection 255.5 (b) and the information listed on the consent to release information form that the facility acted on.
Client record #18 - The client was admitted on 10/23/09. A disclosure of information to a third party funding source was documented on 10/22/09, which disclosed specifics about the client' s drug of choice, patterns of use and amounts used as well as the client's involvement in the criminal justice system. This information exceeded the limitations imposed at 4 Pa. Code Subsection 255.5 (b) and the information listed on the consent to release information form that the facility acted on.
Client record #19 - The client was admitted on 11/16/09. A disclosure of information to a third party funding source was documented on 11/10/09, which disclosed specifics about the client's drug of choice, patterns of use and amounts used as well as the client's involvement in the criminal justice system. This information exceeded the limitations imposed at 4 Pa. Code Subsection 255.5 (b) and the information listed on the consent to release information form that the facility acted on.
Client record #21 - The client was admitted on 2/9/09. A disclosure of information to a third party funding source was documented on 3/18/09, which disclosed specifics about the client's drug of choice, patterns of use and amounts used as well as the client's involvement in the criminal justice system. This information exceeded the limitations imposed at 4 Pa. Code Subsection 255.5 (b) and the information listed on the consent to release information form that the facility acted on.
The Project Director and the Clinical Director were apprised of the findings throughout the inspection and reviewed the records . The findings were not disputed.
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Plan of Correction
The Clinical Director will present an in-service to all staff on Thursday February 25, 2010 referencing the confidentiality laws that oversee our facility with special emphasis on 4 Pa. Code Subsection 255.5 (b) and the information listed on the Ageny consent to release information form.
Oversight will be done by all clinical supervisors and will be a main focus of the quarterly case file reviews. |