INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 26, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the January - December 2020 fire drill records, the facility failed to document unannounced monthly fire drills from March 2020 - December 2020.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Community Counseling Center will resume fire drills beginning immediately. Unannounced fire drills will be conducted monthly at random times, and a log will be maintained to document monthly fire drills. The Chief Administrative Officer will ensure compliance with this process. |
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.
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Observations
Based on a review of client records the facility failed to document an informed and voluntary consent from the client prior to the disclosure of information contained in the client record in seven of eight client records reviewed on January 26, 2021.The facility released the client's name and diagnosis to the funding entity for prior authorization of treatment services in client records # 2, 4, 5, 7 & 8.In addition, the facility released the status of the client's drug and alcohol treatment to the probation office/courts in client records # 2, 3, 5, 6 & 8.Client # 2 was admitted September 1, 2020 and discharged October 5, 2020. The disclosure to the funding entity occurred August 10, 2020. The disclosure to the probation office occurred September 17, 2020.Client # 3 was admitted October 7, 2020 and discharged October 22, 2020. The disclosure to the probation office occurred October 12, 2020.Client # 4 was admitted September 4, 2020 and discharged November 3, 2020. The disclosure to the funding entity occurred September 10, 2020. Client # 5 was admitted September 14, 2020 and discharged December 7, 2020. The disclosure to the funding entity occurred September 15, 2020. The disclosure to the courts occurred September 15, 2020.Client # 6 was admitted August 20, 2020. The disclosure to the courts occurred December 15, 2020.Client # 7 was admitted August 24, 2020. The disclosure to the funding entity occurred September 11, 2020. Client # 8 was admitted October 26, 2020. The disclosure to the funding entity occurred October 26, 2020. The disclosure to the probation office and courts occurred November 5, 2020 and December 24, 2020.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the January 29 - 30, 2020 licensing inspection.
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Plan of Correction
To address this citation, the Facility Director will conduct a staff retraining on proper consents and verification of valid consent prior to disclosure.
To ensure that no client information is disclosed without informed and voluntary consent, Community Counseling Center clinical and clerical staff will document that proper consent has been obtained and reviewed prior to all disclosures. To ensure that this is occurring, Community Counseling Center will require that all written release of information include a documented date of verification of valid consent, and all oral release of information include a note in the chart that valid consent was verified. The Facility Director will conduct monthly random chart audits to ensure that valid consents are checked and documented prior to release of client information.
The Facility Director will maintain a log to document date of the staff retraining and results of monthly chart audits.
To address the need to ensure valid consent is properly documented for all open clients, the Facility Director will oversee the following process: 1) The facility Director will send a letter to all open clients, requesting that they come to the Hermitage Office within two weeks to sign or revoke their consents; 2) At the end of two weeks, Clerical Staff will call anyone who has not yet come to the office to sign or revoke their consents and will give them one more week to come to the office to sign or revoke their consents; 3) At the end of this third week, Clinicians will be notified by the Facility Director of any open client who has not yet come to the office to sign or revoke consents, and clinicians will inform any open client that they must come to the office for their next scheduled session to sign or revoke the consents; 4) At this point, clerical staff and clinicians will schedule all future sessions in the office until consents are signed or revocation of consent is documented, and clerical or clinical staff will continue to request that the client sign or revoke consent.
Clerical and clinical staff will ensure that all new clients sign consents at the start of treatment.
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709.28 (c) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility did document a consent to release information form but failed to include the dated signature of the client in seven of eight client records reviewed on January 26, 2021.Consents for the following records were documented during the intake process:Client # 2 was admitted September 1, 2020 and discharged October 5, 2020. A consent for an emergency contact did not include the client's dated signature. Client # 3 was admitted October 7, 2020 and discharged October 22, 2020. Consents for an emergency contact, doctor and government agency did not include the client's dated signature. Client # 4 was admitted September 4, 2020 and discharged November 3, 2020. Consents for an emergency contact, doctor, court system and non-profit agency did not include the client's dated signature. Client # 5 was admitted September 14, 2020 and discharged December 7, 2020. Consents for an emergency contact, treatment provider and non-profit agency did not include the client's dated signature. Client # 6 was admitted August 20, 2020. Consents for an emergency contact and courts did not include the client's dated signature. Client # 7 was admitted August 24, 2020. Consents for an emergency contact and non-profit agency did not include the client's dated signature. Client # 8 was admitted October 26, 2020. Consents for a doctor did not include the client's dated signature. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address this citation, the Facility Director will conduct a staff retraining on proper consents and verification of valid consent prior to disclosure.
To ensure that no client information is disclosed without informed and voluntary consent, Community Counseling Center clinical and clerical staff will document that proper consent has been obtained and reviewed prior to all disclosures. To ensure that this is occurring, Community Counseling Center will require that all written release of information include a documented date of verification of valid consent, and all oral release of information include a note in the chart that valid consent was verified. The Facility Director will conduct monthly random chart audits to ensure that valid consents are checked and documented prior to release of client information.
The Facility Director will maintain a log to document date of the staff retraining and results of monthly chart audits.
To address the need to ensure valid consent is properly documented for all open clients, the Facility Director will oversee the following process: 1) The facility Director will send a letter to all open clients, requesting that they come to the Hermitage Office within two weeks to sign or revoke their consents; 2) At the end of two weeks, Clerical Staff will call anyone who has not yet come to the office to sign or revoke their consents and will give them one more week to come to the office to sign or revoke their consents; 3) At the end of this third week, Clinicians will be notified by the Facility Director of any open client who has not yet come to the office to sign or revoke consents, and clinicians will inform any open client that they must come to the office for their next scheduled session to sign or revoke the consents; 4) At this point, clerical staff and clinicians will schedule all future sessions in the office until consents are signed or revocation of consent is documented, and clerical or clinical staff will continue to request that the client sign or revoke consent.
Clerical and clinical staff will ensure that all new clients sign consents at the start of treatment.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultation notes every 90 days for the first year of continuous services per the facility's policy in two of two client records reviewed on January 26, 2021.No case consultation notes were documented in the following client records:Client # 6 was admitted August 20, 2020. Client # 7 was admitted August 24, 2020. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
According to agency policy, case consultations are to be conducted at least every 90 days within the first year of continuous D&A services, and annually after one continuous year of services. Facility Director will monitor and address timeliness and documentation of case consults using a primary and a backup system.
Primary ? Clinicians will conduct case consultations as part of every treatment planning process, which occurs every 60 days throughout treatment. To ensure that this is completed, IT staff will add the case consultation form to a bundle of forms in the electronic record that must be completed as part of treatment planning.
Secondary ? Within the electronic record, IT staff will create a tracking report that identifies upcoming deadlines for case consultations for each client. This tracking report will be reviewed by the Facility Director at each weekly treatment team meeting and ensure that case consults are conducted before the deadline for each client.
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