INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 4, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Counseling Center of Mercer County 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.
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Plan of Correction
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709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the facility's annual report, the facility failed to make available to the public an annual report that included a financial statement of income and expenses.
The findings include:
The annual report for the 2012/2013 fiscal year was reviewed on December 4, 2013. The annual report did not include a financial statement of income and expenses.
The Project Director was interviewed on December 4, 2013 and confirmed the findings.
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Plan of Correction
Upon completion of the Audit, a copy of the budget for the D/A Program which includes income and expenses will be attached to the Annual report. This is already presented to the board during the review of the Annual audit. The attachment would be available for the public.
The Facility Director will be responsible to monitor compliance with this regulation.
Target Date for completion is January 31,2014.
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709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of client records and the client handbook, the facility failed to provide documentation that clients were informed of their rights in ten of ten client records.
The findings include:
Ten client records and the client handbook were reviewed on December 4, 2013. Ten client records required documentation that the client was informed of their rights. The facility failed to document in client records # 1, 2, 3, 4, 5 , 6, 7, 8, 9 and 10 that the clients were informed that they had the following rights:
(3) The right to inspect his own records. That the project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.
(4) The client has the right to appeal a decision limiting access to his records to the project director.
(5) The client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records.
(6) The client has the right to submit rebuttal data or memoranda to his own records
The Compliance Officer was interviewed on December 4, 2013 and confirmed the findings.
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Plan of Correction
The following rights will be added to the Client Rights and Responsibilities information packet that each client receives:
- To never be discriminated against based on age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
- To inspect your own records and know who else has accessed them. Portions of the records may be temporarily removed prior to the inspection if it is determined that the information may be detrimental if presented to you.Reasons for removing sections shall be documented and kept on file.
- To appeal a decision limiting access to your records.
- To request the correction of inaccurate, irrelevant, outdated or incomplete information from your records.
- To submit rebuttal data or memoranda to your own records.
Compliance Officer added the changes to the packet on 12/4/13 for immediate release to clients.The Fiscal Technician will be reponsible for assuring the client receives the packet at the time of registration. The client's signature on the EMR form will indicate that they received and understand the packet.
The Compliance Officer is responsible for assuring the change is initiated.
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709.93(a) 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:
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Observations
Based on the review of client records, the facility failed to document a complete client record that included consent forms, case consultation notes, aftercare plans and/or follow-up information, in five of eight client records.
The findings include:
Ten client records were reviewed on December 4, 2013. Eight client records were reviewed for documentation of case consultation notes, aftercare plans and/or follow up information. The facility failed to document case consultation notes in client records # 3, 6 and 9. The facility failed to document an aftercare plan in client records # 6, 8, 9 and 10. The facility failed to document follow-up information in client record # 10.
Client # 3 was admitted on August 2, 2013. The facility failed to obtain a consent to treatment form that was signed by the client. The facility also failed to document that a case consultation was conducted. The record included documentation identified as a case consultation note that was dated October 25, 2013. However, the note did not include documentation that any other staff member had participated. The note was not co-signed by another staff member until October 30, 2013 and wasn't signed by the supervisor until November 1, 2013.
Client # 6 was admitted on July 9, 2013 and was successfully discharged on October 8, 2013. The facility failed to document that a case consultation was conducted. The record included documentation identified as a case consultation note that was dated September 17, 2013. However, the note did not include documentation that any other staff member had participated. The note was not signed by the supervisor until September 20, 2013 and wasn't co-signed by another staff member until November 6, 2013. The facility also failed to document an aftercare plan for the client.
Client # 8 was admitted on March 27, 2013 and successfully discharged on June 4, 2013. The facility failed to document an aftercare plan that included a contact person.
Client # 9 was admitted on March 19, 2013 and was successfully discharged on June 5, 2013. The facility failed to document that a case consultation was conducted. The record included documentation identified as a case consultation note that was dated June 5, 2013. However, the note did not include documentation that any other staff member had participated. The note was not co-signed by another staff member until June 17, 2013 and wasn't signed by the supervisor until June 21, 2013. The facility also failed to document an aftercare plan that included a contact person.
Client # 10 was admitted on April 23, 2013 and successfully discharged on June 4, 2013. The facility failed to document an individual aftercare plan with the client. The record included an aftercare plan that was dated July 19, 2013, that was not signed by the client. The record did not include any other documentation to demonstrate that the aftercare plan was developed with the client prior to his discharge. Additionally, the facility failed to document client follow-up information that was due by November 4, 2013.
The a Facility Director, Clinical Supervisor and Compliance Officer were interviewed on December 4, 2013 and did not dispute the findings.
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Plan of Correction
Beginning January 1, 2014, the electronic form will be adapted to include a list of particapants in the note to document that they were present at the consult. They will no longer have to sign the note, as their presence is recorded. The consult will continue to be signed by the clinician following review at the weekly treatment team meeting.
The quarterly audit will review this area and assure that the consults are complete and timely.The Clinical Supervisor will be responsible for assuring this change occurs.
A training will be held by January 31 to review the aftercare plan and correct documentation.Emphasis will be placed on the inclusion of the Intake Worker's contact information and the process for readmission.The Clinical Supervisor will be responsible for the training and the quarterly audit will focus on completion of the deficient area.
The current process for follow-up is automatically generated by the client closing. The electronic process will be reviewed to see if a problem is occurring in the software notification process. It is the responsility of the Clerical Supervisor to assure that the follow-up contacts occur at the 6 month point. Additional protocols wil be developed to assure that the number of notifications generated match the number of discharges for each month.
The Compliance Co-ordinator, IT person and Clinical Supervisor will be responsible for completing this correction. This will be done by March 31,2014. |