INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 27 - November 29, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mon Yough Community 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 December 24, 3007.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on review of the "Staffing Requirements Facility Summary Report" form, 3 employees did not have HIV/AIDS or TB/STD training in the required time frames per the regulation. Employee # 5 did not have HIV/AIDS or TB/STD training within the year time frame. Employees # 6 and 7, were one hour short of the 4 required hours of STD/TB training within the two year time frame.
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Plan of Correction
Employee #6 and 7 do have the required 4 hours. This was a misquote on the staffing report. The 4 hours occurred with 2 trainings therefore there were 2 certificates which I am faxing at the same time of the POC submission. The trainings occurred in 1997 and 2002.
Employee #5 will completed HIV/AIDS and TB/STD as as as a training can be located within a resonable driving distance by March 24, 2008. |
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:
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Observations
Based on discussions with the employees ( IT employees and facility director) it was determined that the electronic data base that includes client identifying information of clients receiving substance abuse treatment is secure and that the information is not maintained in accordance with the security requirements at 42 CFR Part 2, Subpart A, Subsection 2.16. The facility allows employees who are not involved in the provision of drug and alcohol treatment, the referral for the need for drug and alcohol treatment and/or the diagnosis of the need for drug and alcohol treatment to have access to these electronic files. The facility fails to obtain informed and voluntary consents from clients for the disclosure of information contained in the electronic client records. Client identifying Information documented in the computer can be accessed after the client record is closed by employees who are not part of the drug and alcohol treatment unit and without the clients' written consent.
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Plan of Correction
0277 Deficiency Plan rejected. 1/15/08 revision submitted.
MYCS is working closely with Askesis Development Group, the software vendor for PsychConsult Provider, as a beta test site for a software enhancement that will limit access to Drug and Alcohol clinical documentation. MYCS will begin to test this enhancement in January 2008. The enhancement will maintain current clinical documentation security (limiting access to clinical documentation based on an employee's role within the organization) and additionally limit access to the Drug and Alcohol related clinical documentation of clients enrolled in Drug and Alcohol treatment to those employees who are involved in the provision of drug and alcohol treatment, the referral for the need for drug and alcohol treatment and/or the diagnosis of the need for drug and alcohol treatment. The enhancement testing and promotion to the production environment is to be completed by March 24, 2008. Until that time, All D/A clients will receive a higher security access level. Additionally, the staff associated with D/A clients will be set to an equivalent security access level. Limiting access will allow continued use of MYCS's existing Release of Protected Health Information.
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709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of the client records it was determined that the facility failed to expand on lengths and patterns of use. Drug and alcohol histories failed to include lengths and patterns of use in four out of five client records reviewed, client records # 1, 2, 3 and 5. The clients prior treatment history was missing from client record # 3.
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Plan of Correction
The Program Supervisor and Utilization Review Coordinator will provide and document training in the area of drug and alcohol lengths and patterns of use focused within the drug or alcohol history by March 24, 2008 |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on review of the client records it was determined that the facility failed to document the clients' complete personal history. Personal histories failed to include a complete family history in client records # 1, 2, 3, 4 and 5, five out of five records reviewed. The legal histories in client records # 1, 2, 3 and 5 failed to answer all the questions in the legal section of the history or gave conflicting information. Employment histories were not complete in client records # 2, 3, 4 and 5. Educational histories were not complete in client records # 1, 2, 4 and 5. Recreational histories were missing or incomplete in client records # 3 and 4, failing to indicate whether the clients' recreational activities had been impacted by their drug and alcohol use. Sexual histories were incomplete in client records # 1, 2, 3 and 5.
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Plan of Correction
The Program Supevisor and Utilization Review Coordinator will provide documented training in the area of clinical evaluation with a focus on personal history by March 24, 2008. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records it was determined that the facility failed to provide a psychosocial evaluation. In client record # 3, one out of five records reviewed, the psychosocial evaluation was missing. In client records # 1, 2, 4 and 5, support systems, coping mechanisms, negative factors, attitude toward treatment, and counselor conclusions were missing. In client records # 4 and 5, two out of five client records, assets/strengths were missing. The psychosocial evaluations were incomplete in five out of five client records reviewed.
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Plan of Correction
Program Supervisor and Utilization Review Coordinator will provide and document training in the area of psychosocial evaluation by March 24, 2008. |
709.92(a) 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:
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Observations
Based on a review of the client records it was determined that the facility failed to document individualized treatment and rehabilitation plans for all clients. In client records # 2, 3 and 5, the treatment plans documented were identical (goals and objectives) and failed to demonstrate any individualization on the plans in three out of five client records reviewed.
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Plan of Correction
Program Supervisor and Utilization Review Coordinator will provide and document training in the area of treatment planning. This will include review of relevant policies and procedures and will occur by March 24, 2008. |
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 on a review of client records it was determined that the facility failed to document the data, assessment and plan on group therapy notes on five out of five client records reviewed, client records # 1, 2, 3, 4 and 5. Group notes lacked a direct tie into the comprehensive treatment plans in client records # 1, 2, 3, 4 and 5, representing five out of five client records reviewed.
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Plan of Correction
Program Supervisor and Utilization Review Coordinator will provide and document training which shall include review of any relevant policy and procedure in the areas of treatment planning with a focus on documenting the data, assessment and plan within a group therapy note by March 24, 2008 |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of the client records it was determined that the facility failed to document aftercare plans. In two of the two closed client records reviewed no aftercare plans were documented though both clients had successfully completed treatment.
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Plan of Correction
Program Supervisor and Utilization Review Coordinator will provide and document training with review of relevant policy and procedure in the area of Aftercare Plans by March 24, 2008. |