INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 29, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Child Guidance Resource Centers 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 December 22, 2007.
|
Plan of Correction
|
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:
|
Observations
Based on a review of client records and staff interview, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one of one client record reviewed. The facility did not obtain a signed consent from the client to disclose information to the funding source; rather the facility was using a consent sent by the funding source to obtain information. The facility did not obtain a signed consent from the client to disclose information to the parents, yet the parents were involved in the history gathering process.
|
Plan of Correction
Two informed and voluntary consents specific to Drug and Alcohol clients were revised on November 30, 2007 by CGRC's Medical Records Director and Privacy Officer with the following: consent (authorization to release and disclose) from the client for disclosure of information to funding sources (Managed Care Organization, Magellan Behavioral Health)and parents/guardians. CGRC's Drug and Alcohol Clinical Supervisor will be responsible for ensuring that all consents (authorization to release and disclose) are appropriately completed. In addition, these consents (authorization to release and disclose)will be reviewed monthly during our agency's Peer Review Process and Medical Records Committee meetings, chaired by our Privacy Officer. Finally, any deficiencies are aggregated and percentages are submitted monthly to our Quality Improvement Department. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
|
Observations
Based on a review of client records and staff interview, the facility failed to document whether a copy of the consent was offered to the client in one of one client record reviewed. There was no documentation to show whether the client was offered a copy of the signed consent form.
|
Plan of Correction
An item line for consent, release, and disclosure copy confirmation and documentation was added to all of CGRC's Drug and Alcohol consent forms (Authorization to Release and Disclose).
These forms include: PCP, funding source/s, parent/guardian, and any out sourced services that the client is receiving in addition to CGRC. This was revised and implemented on November 30, 2007 by CGRC's Medical Records' Director and Privacy Officer. CGRC's Clinical Supervisor will be responsible for monitoring the above during weekly and/or monthly supervisions. In addition, consent, release, and disclosure copy confirmation on all of CGRC's Drug and Alcohol consent forms (Authorization to Release and Disclose)will be reviewed in both our monthly Peer Review Committee Meetings and Medical Records Compliance Reviews. Please be advised that all aggregated data from these committees are reported monthly to our Quality Improvement Department. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a review of fire drill records, the facility failed to consistently document the exit routes used on the fire drill record. The exit route used was missing on fire drill records for the months of January, February, March, April, September, October and November of 2007.
|
Plan of Correction
Documentation of the exit routes utilized on CGRC's fire drill records specific to our Drug and Alcohol Program for February, March, April, September, October, and November were reviewed effective November 30, 2007 by CGRC's Safety Officer and Environment of Care Chairperson. In addition, our Safety Officer developed (effective November 30, 2007) a fire drill and alarm activity form specific to Drug and Alcohol. Documentation of each exit route utilized during a fire drill is included on this form. This will ensure that this deficiency will not recur. Moreover, CGRC's Safety Officer and Risk Manager will be responsible for compliance monitoring and documentation. Finally, all fire drill and fire alarm activity is reviewed monthly during our Environment of Care Committee meetings. This information is also aggregated and submitted both quarterly and annually to our Quality Improvement Department (JCAHO requirement). |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to document a complete psychosocial evaluation in one of one client record reviewed. One word answers were written with little to no clinical assessment of the client by the clinician.
|
Plan of Correction
In efforts to stregnthen and monitor effecient Drug and Alcohol clinical assements, training is being initiated via CGRC's Drug and Alcohol Clinical Supervisor to appropriately capture all clinical information included in the Bio-psychosocial Assessment, treatment planning, and the PCP. In addition, this process will be reviewed monthly by CGRC's Peer Review Committee. This is effective December 4, 2007. |
709.92(a)(3) 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:
(3) Proposed type of support service.
|
Observations
Based on a review of client records and staff interview, the facility failed to document proposed support services on the treatment plan in one of one client records reviewed. Proposed support services were missing.
|
Plan of Correction
Documentation of proposed support services on the client's treatment plan was corrected on November 30, 2007. Moving foward, effective immediately, CGRC's Drug and Alcohol Clinical Supervisor will provide treatment planning training to all D & A staff and treatment plan documentation will be reviewed during clinical supervisions. Finally, treatment plan documentation will also be reviewed in CGRC's Peer Review Committee on a monthly basis. |
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.
|
Observations
Based on a review of client records and staff interview, the facility failed to review and update the treatment plan at least every 60 days in one of one client record reviewed. The treatment plan was dated for a four month time period and there were no treatment plan updates.
|
Plan of Correction
In accordance with CGRC's procedures for treatment and rehabilitation services (709.92), within 15 days of intake, an individualized treatment plan will be completed according to procedure #710.01 for all clients who remain in treatment. This plan shall be reviewed and updated every 60 days using the CGRC comprehensive treatment plan. A summary of all services received by a client is contained in the plan of care form. This form shall be updated every 6 months in accordance with procedure #710.05. Training will be provided in this area, effective November 30, 2007. Treatmnent planning procedures and requirements will be reviewed ongoing during clinical supervisions with CGRC's Drug and Alcohol Clinical Supervisor, in addition to monthly review via CGRC's Peer Review Committee. |
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.
|
Observations
Based on a review of client records and staff interview, the facility failed to document a case consultation in one of one client record reviewed. The case consultation documented in the client record occurred only between the counselor and the client.
|
Plan of Correction
In accordance with the state regulation 709.93 and CGRC's procedure # 710.04, Case Consultations, policy relationship # 700, Care of the Individual, each client's progress should be reviewed at least quarterly (every 90 days) at a case conference consisting of respresentatives from the various client service components. Where a multi-disciplinary staff does not exist, case consultation should include the primary counselor and one other clinican or the Clinical Director.
Psychiatry is included in this process as well. Effective November 30, 2007, additional training is being provided in this area in efforts to support CGRC's policies and procedures. In addition, case consultation clinical documentation will also be reviewed monthly in through CGRC's Peer Review Committee. |