INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the March 24, 2010 licensure renewal inspection. The follow-up inspection was conducted on September 8, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Catholic Charities Counseling and Adoption Services, Inc 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 October 11, 2010.
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of two personnel records reviewed.
The findings include:
Four personnel records were reviewed on March 23-24, 2010. Two personnel records were reviewed as counselors. One personnel record was required to include documentation that the counselor had completed 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record # 2.
Employee # 2 was hired on June 1, 2000. The facility training year is from January through December. The training year for January 2009 to December 2009 was reviewed. Employee # 2 had 15 clock hours of annual training documented for 2009.
The project/facility director confirmed on March 24, 2010 that the counselor did not have the required 25 clock hours of annual training documented for the 2009 training year.
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Plan of Correction
By December 31, 2010 (the agency's training year) both D&A counselors will have received 25 hours of training for the 2010 fiscal year.
The agency director will review the counselors' progress toward this goal monthly and advise them on the need for additional training in order to meet this goal. |
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 the client records, the client's Bill of Rights and observation, the facility failed to maintain the confidentiality of the client's identity and records in six of six client records.
The findings include:
The review of client records, the client's Bill of Rights and observation occurred on September 8, 2010.
Eleven client records were reviewed on September 8, 2010. Six were reviewed for compliance with maintaining the confidentiality of client identity and records. The facility did not maintain the confidentiality of client identity and records in client records # 6, 7, 8, 9, 10 and 11
In client records # 6, 7, 8, 9, 10 and 11, the client's Bill of Rights included the language. "The client has the right to confidential treatment of the client's personal and medical records. Information from these sources will not be released without the client's consent except in an emergency, medical situation, or as required by law, or under a third party payment contract..."
The Bill if Rights did not define "emergency". Releasing client information without the client's consent in an "emergency" exceeds the limitations imposed at 71 P.S. Subsection 1690.108(b) and 42 CFR Part 2, Subpart D, subsection 2.51(a) which states that information about a patient may be released without the client's consent to medical authorities in an emergency medical situation where the patient's life is in immediate jeopardy.
The Bill of Rights did not define "medical situation". Releasing client information without the client's consent in a "medical situation" exceeds limitations imposed at 71 P.S. Subsection 1690.108(b) and 42 CFR Part 2 Subpart D, subsection 2.51(a) which states that information about a patient may be released without the client's consent in an emergency medical situation where the patient's life is in immediate jeopardy.
The Bill if Rights did not define "as required by law". Releasing client information without the client's consent "as required by law" exceeds the limitations imposed at 4 Pa. Code Subsection 255.5(b).
The Bill of Rights included language that stated "The client has the right to confidential treatment of the client's personal and medical records. Information from these sources will not be released without the client's consent except in an emergency, medical situation, or as required by law, or under a third party payment contract..." . Under a third party payment contract exceeds exceeds the limitations imposed at 4 Pa. Code Subsection 255.5(b).
For the follow up inspection, a drug and alcohol counselor's office was provided for the review. In the counselor's office, the counselor had several client records, unsecured, on top of the desk. The client records were easily accessible to staff members who were not permitted access to the client records.
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Plan of Correction
The Client Bill of Rights has been changed to comply with the state regulations. The current Bill of Rights reads "You have the right to confidential treatment of your personal and medical records. Information from these sources will not be released without your prior consent except in an emergency (imminent life-threatening) situation or under direct court order."
By November 30, 2010 the agency director all ensure that all D&A clients will have an updated signed copy of the new Bill of Rights in their case files. |
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 failed to obtain an informed and voluntary consent from the client that included specific information to be disclosed, that was compliant with 4 Pa. Code, Subsection 255.5 (b), in one of one record reviewed.
The findings include:
Eleven client records were reviewed on September 8, 2010. Per regulation, the project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include the specific information to be disclosed. One client record was reviewed for compliance with this regulation. The consent for the release of information listed information to be disclosed that exceeded the limitations imposed at 4 Pa Code, Subsection 255.5 (b) in client record #6.
In client record # 6, a release of information for the Erie County Office of Drug and Alcohol Abuse for the purpose of "third party billing" was signed by the client on July 20, 2010. The specific information disclosed to the funding source exceeded the limitations imposed at 4 Pa. Code, Subsection 255.5(b) in that the consent to release information form documented the specific information to be released to include; reason for treatment, level of intoxication- including quantity, frequency and duration of use, specific diagnosis, prognosis, emotional and behavioral problems requiring treatment, level of functioning, treatment history, progress in treatment, participation in program, motivation to change, risk level to resume the use of substance- based on pattern of use, relapse history and coping skills, social supports, environmental supports and stressors that could impact recovery.
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Plan of Correction
The Release of Information had been changed to reflect this information, but some employees were still using old forms.
These old forms have been deleted from the system and new forms will be signed.
By November 30, 2010 all clients will have a copy of the new Release of Information signed and placed into their client chart.
The agency director will be responsible for ensuring that this change is enacted. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on the review of facility census sheets, the facility failed to notify the Department of Health and failed to obtain approval from the Department of Health for a change in the authorized maximum capacity.
The findings include:
During the follow up licensing inspection conducted on September 8, 2010, client census material provided included documentation that the census for active clients was 54 on September 1, 2010 and at 51 on September 8, 2010. The maximum approved capacity for the facility is 50.
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Plan of Correction
As of October 1, 2010 this facility is at its expected capacity of 50 clients and will remain at, or below, this number until such time as an increase in capacity is received from the State office.
The agency director has taken the following steps to ensure the current and sustained adherence to this requirement:
1. Most Suboxone clients have been discharged due to the limited need for on-going counseling sessions.
2. This agency has notified local physicians who were referring Suboxone clients to us that we are limiting the number of such clients that we can serve at any one period of time.
3. The agency director has made clear to the D&A counselors the seriousness of adhering to maximum case load size and the resulting disciplinary action that will occur should caseloads exceed these standards.
4. Client files are closed on a more timely basis to reduce the appearance of exceeding the facility capacity with clients who are no longer receiving services here. |