INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 19, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Rehab Management Inc./ Rehab After Work, 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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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based upon the physical plant inspection, the the facility failed to ensure that there were no heaters within the facility that were not permanently mounted or installed.
The findings include:
The physical plant inspection was conducted with the Facility Director on March 19, 2012. Upon entering office # 3, Licensing Staff observed a heater that was not permanently mounted or installed, and that was leaning to the side as it was missing 1 of its 4 wheels.
The Facility Director confirmed the findings.
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Plan of Correction
The site director of Center City removed the heater from the premises on 3/20/12. Site Director met with the counselor and informed the counselor she was not allowed to have a space heater in the office. Site Director will check all offices monthly to ensure the counslor is in compliance. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based upon the physical plant inspection and dialogue with the facility director, the facility failed to ensure that all exits from the facility were unobstructed.
The findings include:
The physical plant inspection was conducted with the Facility Director on March 19, 2012. The facility maintains two exits that are clearly marked by exit signs mounted on the ceiling. When checking the exits, Licensing Staff and the Facility Director were unable to immediately use the exit located near the facility bathroom. In order to use the exit, the Facility Director had to unlock the door by turning a deadbolt that was located above the door handle. The Facility Director stated that the facility never uses that exit and keeps the door locked for confidentiality purposes. However, since the door is clearly marked as an exit, its use was obstructed by the deadbolt.
The findings were confirmed with the Facility Director.
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Plan of Correction
The Site Director will consult with the maintenence department of the building and have the deadbolt disengaged. The job will be completed by April 30, 2012. Site Director has opened the deadbolt and will leave it open until the lock is formally disengaged. Site Director will check the lock each morning to ensure it remains open. |
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 a review of the facility policy and procedure manual, the facility failed to document a confidentiality policy and procedure compliant with 4 Pa. Code subsection 255.5.
The findings included:
4 Pa. Code subsection 255.5 (a)(6), states: "Projects may disclose with the consent of a client, in writing, the information to employers of a client to further the rehabilitation of a client; or, to a prospective employer who affirmatively expresses that information is sought to enable the employer to engage the client as an employee. Such information shall be limited to whether the client has or is receiving treatment with the project."
The facility policy and procedure manual was reviewed as part of the annual onsite licensing inspection of March 5 - 6, 2012. Policy # 60,006, section C, subsection 2, letter f, exceeded 4 Pa. Code subsection 255.5 (a)(6), as it allowed for the following: "Life Management may disclose with the client's consent, the information to employers of a client to further the client's rehabilitation; or, to a prospective employer who affirmatively expresses that information is sought to enable the employer to engage the client as an employee. Information released shall be limited to that provided for in subsection 4.a. in this section."
Subsection 4.a. states: " Nature of Client Information to be Disclosed. a. Information released to judges, probation or parole officers, insurance company, health or hospital plan or government officials, pursuant to section C.2.a-i of this section, is for the purpose of determining the advisability of continuing th client in treatment with Life Management and shall be restricted to the following:
i. Whether or not the client isn't in therapy
ii. The prognosis of the client
iii. The nature of the project
iv. A brief description of the client's progress
v. A short statement as to whether the client has relapsed into drug or alcohol abuse and the
frequency of such relapse."
The project's Confidentiality policy permits for the release of information under ii, iv, and v, which is restricted under 4 PA Code 255.5(a)(6).
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Plan of Correction
The Executive Director of Rehab After Work will change the policy & procedures section in our manual (#66006) to reflect that "information specifically released to employers will be limited to whether a client has or is receiving treatment with the project". This will be circulated to all offices.
All staff will be required to attend a 6 hour training on Confidentiality (255.5) on 4/13/2012 presented at our Phoenixville location. This policy addendum will be reviewed for all staff as part of the training.
Site directors will perform random, monthly charts audits to ensure that this policy change is being reflected by all clinicians.
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709.28 (c)(1) 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 shall include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based upon a review of client records, the facility failed to obtain informed and voluntary consents that included the name of the person, agency or organization to whom disclosure is made.
The findings include:
Seven client records requiring documentation of informed consent forms were reviewed on March 19, 2012. One of seven records, specifically record # 4, contained a consent form that failed to include the name of the person, agency or organization to whom disclosure was to be made.
Client # 4 was admitted on February 6, 2012, and was still an active client on the day of inspection. Record # 4 contained a consent form, signed and dated by the client on February 6, 2012, that failed to include the actual name of the person, agency or organization to whom disclosure was to be made.
The findings were confirmed by the Facility Director during the exit interview.
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Plan of Correction
Training will begin immediately and will be ongoing. The site director of the center city office will review policy regarding the completion of consents/releases in a staff training on 4/12/12. All counselors will participate in the training and sign off that they understand that guidelines with releases/consents specifically should include the actual name of the person, agency or organization to whom disclosure was to be made.
The site director will follow up with monthly, random chart audits to ensure that the standard is being met. Charts audits will be ongoing until the center is in full compliance.
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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 upon a review of client records, the facility failed to follow the restrictions set forth in 4 PA Code 255.5 (a)(1-10) and (b)(1-5) regarding the release of confidential information.
The findings include:
Seven client records were reviewed for compliance with 4 PA Code 255.5(a)(1-10) and (b)(1-5) on March 19, 2012. Documentation contained in one of seven records, specifically record # 3, exceeded 4 PA Code 255.5(a)(8) as it pertains to 4 PA Code 255.5(b)(5). Record # 3 contained a letter dated March 6, 2012, that was addressed to the client's case worker, and included the following disclosure:
"Redacted name completed a Urine Drug Screen on 1/17/12, 2/15, 2/28, and 3/6/12. There were no abnormalities noted, except on 2/28/12 there was Creatinine noted due to her drinking a bottle of water just before testing. The results of test (sic)on 3/6/12 will not be available until 3/13/12."
The facility's release of information regarding drug screening results exceeded 4 Pa. Code 255.5(a)(8) as it states: "Projects may disclose information as set forth in subsection (b) of this section with the client's consent, in writing, to government officials for the purpose of obtaining governmental benefits due the client as a result of his drug or alcohol abuse or dependence."
Subsection (b)(5) states the the information to be released shall be restricted to the following: "A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse."
The letter in record # 3 exceeds 4 PA Code 255.5(a)(8) as it relates to (b)(5) as it released the outcome of drug test results.
The findings were reviewed with the Facility Director during the exit interview.
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Plan of Correction
The site Director of center city will instruct all counselors be required to attend a 6 hour training on Confidentiality (255.5) on 4/13/2012 presented at our Phoenixville location. This training will cover all guidelines regarding confidentiality and the release of information, specifically regarding UDS - "A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse."
Site director of center city will perform random, monthly charts audits to ensure that this change is being reflected by all clinicians & that tthe center is in full compliance.
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709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based upon a review of client records, the facility failed to ensure that progress notes contained in client records were signed by the individual making the entry.
The findings include:
Seven client records requiring documentation of progress notes were reviewed on March 19, 2012. Two of seven records, specifically record #'s 4 and 5, contained progress notes that were not signed by the individual making the entry.
Client # 4 was admitted on February 6, 2012, and was still an active client at the time of inspection. Record # 4 contained group notes on the following dates that were not signed by the individual making the entry:
Group
February 8, 9, 13, 14, 15, 20, 21, 22, 27, 28, 29, 2012
March 6, 7, 8, 12, 13, 2012.
Client # 5 was admitted on November 29, 2011, and was still an active client at the time of inspection. Record # 5 contained individual and group notes on the following dates that were not signed by the individual making the entry:
Individual
November 30, 2011
January 29, 2012
Group
December 1, 5, 6, 7, 10, 12, 13, 14, 15, 29, 2011
January 5, 9, 10, 11, 17, 19, 24, 26, 31, 2012
February 2, 14, 21, 28, 2012
March 13, 2012
The findings were reviewed with the Facility Director during the exit interview.
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Plan of Correction
Training will begin immediately and will be ongoing. The site director of the center city office will review the policy regarding documentation of group notes in a staff training on 4/12/12. All counselors will participate in the training and sign off that they understand the guidelines regarding documentation of group notes & staff signatures.
The site director will follow up with monthly, random chart audits to ensure that the standard is being met. Charts audits will be ongoing until the center is in full compliance.
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