INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 24-25, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site 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:
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Plan of Correction
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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 the review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in 9 of 10 client records.
The findings include:
Ten client records were reviewed on February 24- 25, 2016. Ten client records required documentation of an informed and voluntary consent. There was no documentation that the facility obtained an informed and voluntary consent from the client for the release of information to a third party payer in client records # 1, 2, 3, 4, 5, 6, 7, 8 and 9.
Client # 1 was admitted on July 17, 2015. Documentation of a consent to release information to a third party payer did not include: the name of the individual or organization, specific information to be released, signature of a witness, date of expiration or whether the client was offered a copy of the consent.
Client # 2 was admitted on November 9, 2015. Documentation of a consent to release information to a third party payer did not include: the name of the individual or organization, specific information to be released, signature of a witness, date of expiration or whether the client was offered a copy of the consent.
Client # 3 was admitted on September 22, 2015. Documentation of a consent to release information to a third party payer did not include: the name of the individual or organization, specific information to be released, signature of a witness, date of expiration or whether the client was offered a copy of the consent.
Client # 4 was admitted on August 6, 2015. Documentation of a consent to release information to a third party payer did not include: the name of the individual or organization, specific information to be released, signature of a witness, date of expiration or whether the client was offered a copy of the consent.
Client # 5 was admitted on December 7, 2015. Documentation of a consent to release information to a third party payer did not include: the name of the individual or organization, specific information to be released, signature of a witness, date of expiration or whether the client was offered a copy of the consent.
Client # 6 was admitted on June 28, 2015 and discharged on November 13, 2015. Documentation of a consent to release information to a third party payer did not include: the name of the individual or organization, specific information to be released, signature of a witness, date of expiration or whether the client was offered a copy of the consent.
Client # 7 was admitted on July 2, 2015 and discharged on December 2, 2015. Documentation of a consent to release information to a third party payer did not include: the name of the individual or organization, specific information to be released, signature of a witness, date of expiration or whether the client was offered a copy of the consent.
Client # 8 was admitted on April 9, 2015 and discharged on January 14, 2016. Documentation of a consent to release information to a third party payer did not include: the name of the individual or organization, specific information to be released, signature of a witness, date of expiration or whether the client was offered a copy of the consent.
Client # 9 was admitted on May 21, 2015 and discharged on November 2, 2015. Documentation of a consent to release information to a third party payer did not include: the name of the individual or organization, specific information to be released, signature of a witness, date of expiration or whether the client was offered a copy of the consent
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 3/1/16, all clients will be asked to sign a Release of Information specifically for their respective insurance provider(s). This implementation will be reviewed with counselor at supervision sessions by the Facility Director to ensure compliance. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of client records, the facility failed to document a personal, drug and alcohol and medical history in 2 of 10 client records.
The findings include:
Ten client records were reviewed on February 24-25, 2016. Ten client records required documentation of a personal, drug and alcohol and medical histories. Two client records, # 1 and 2, did not document a medical, a drug and alcohol and/or a personal history.
Client # 1 was admitted on July 17, 2015. There was no documentation of a current medical, drug and alcohol or personal history. The client had been previously admitted and discharged. The histories documented in the file were completed in 2009.
Client # 2 was admitted on November 9, 2015. There was no documentation of a current medical, drug and alcohol or personal history. The client had been previously admitted and discharged. The histories documented in the file were completed in 2008.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 3/1/16, all clients admitted to our D&A services will have a current medical, personal and D&A history completed at the commencement of services. This action will be reviewed by the Facility Director at each supervision session with counselors to ensure compliance. |
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.
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Observations
Based on the review of client records, the facility failed to document a treatment and rehabilitation plan update every sixty days in two of eight client records.
The findings include:
Ten client records were reviewed on February 24-25, 2016. Eight client records required treatment plan updates every sixty days. There were missing treatment plan updates in client records # 1 and 9.
Client # 1 was admitted on July 17, 2015. An individualized treatment plan was completed on August 18, 2015. A treatment plan update was to be completed by October 18, 2015. The update was completed on November 24, 2015. A treatment plan update , due to be completed by December 18, 2015 was not documented.
Client # 9 was admitted on May 21, 2015 and discharged on November 21, 2015. An individualized treatment plan was completed on June 8, 2015. A treatment plan update, due to be completed by October 8, 2015, was not documented.
These finds were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 3/1/16, the agency will ensure that all D&A clients have their treatment plans completed in compliance with licensure regulations - including the Medical Director's signature. This compliance will be monitored by the Facility Director at each supervisory session with counselors. |