INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 11, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, 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 and a plan of correction is due on April 14, 2009.
|
Plan of Correction
|
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:
|
Observations
Based on a review of client records, the facility failed to document informed and voluntary consent from the client for the disclosure of information contained in three of five client records.
Findings:
Eight client records were reviewed on March 11, 2009. Documentation of informed and voluntary consent from the client for the disclosure of information was reviewed in five client records. The facility did not document informed and voluntary consent from the client for the disclosure of information in client records # 1, 2 and 3.
The facility documented the release of client information to Calloway Laboratories, but a signed consent for the release of information was not documented in client records # 1, 2 and 3.
|
Plan of Correction
The Executive Director of Rehab After Work will work with Calloway Labs Associate to update the Business Associate Agreement to include language pertaining to 42 CFR Part 2 Subpart B Subsection 2.12(c)(4). Effective immediately, the Site Director of Jenkintown will inform all staff to have each client sign a consent to release form for exchange of information with Calloway Labs. This will be done until the new agreement has been recieved by the facility. A Copy of the new agreement will be kept on site. Also, the consent to release information forms will be reprinted without the language "obtained from" on them. The Executive Director of Rehab After Work will monitor progress on both tasks until we are in full compliance with the standard. |
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:
|
Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan developed with the client in five of five client records.
Findings:
Eight client records were reviewed on March 11, 2009. Individual treatment plans were reviewed in five client records. The facility did not document an individual treatment plan developed with the client in records # 1, 2, 3, 4, and 5.
The treatment plans were not signed by the client, and there was no documentation, in the client ' s progress notes, to indicate the client participated in the development of the treatment plans.
|
Plan of Correction
The Site Director of Jenkintown will meet with all staff and conduct an inservice training on 4/9/09 to inform staff that each client must sign off on their Master Treatment Plan when they meet with them to discuss treatment goals/objectives. All staff must sign off that they attended this training and are aware of the intent of this documentation. The Site Director will perform monthly, random chart audits until the center is in full compliance. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan to include type and frequency of treatment and rehabilitation services in two of five client records.
Findings:
Eight client records were reviewed on March 11, 2009. Individual treatment plans were reviewed in five client records. The facility did not document treatment plans to include type and frequency of treatment and rehabilitation services in client records # 1 and 4.
Client record # 1, treatment plan (12/17/08) documented " Individual, or IOP, or OP, or Family one time per week " .
Client record # 4, treatment plan (12/9/08) documented " Individual " but it did not document the frequency.
|
Plan of Correction
The Site Director of Jenkintown will meet with the counselor of client record #1 & 4 on 4/9/09 to discuss the proper way to document type & frequency of treatment/rehabilitation services in client records. The counselor of records #1 & 4 will sign off that they understand the intent of this documentation & that they have attended this training. The Site Director will perform monthly, random chart audits until this standard is in full compliance. |
709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
|
Observations
Based on a review of client records, the facility failed document counseling to clients on a regular and scheduled basis in three of five client records.
Findings:
Eight client records were reviewed on March 11, 2009. Counseling on a regular and scheduled basis was required in five client records. The facility did not document counseling on a regular and scheduled basis in client records # 2, 3 and 5.
The facility did not document individual counseling sessions at least once every sixty days to discuss treatment plan updates with clients.
|
Plan of Correction
The Site Director of Jenkintown will conduct an inservice training on 4/9/09 regarding documentation of a least one individual session every 60 days to review treatment plan updates for every client. All staff will sign off that they understand the intent of this documentation & that they attended this training. The Site Director will conduct monthly, random chart audits until this standard is in full compliance. |
709.93(a)(11) 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:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to document follow-up information in two of three client records.
Eight client records were reviewed on March 11, 2009. Follow-up information was required in three client records. The facility did not document follow-up information in client records # 6 and 7.
Record # 6 discharged 1/30/09, follow-up information not documented at time of inspection.
Record # 7 discharged 1/29/09, follow-up information not documented at time of inspection.
|
Plan of Correction
The Site Director of Jenkintown will conduct an inservice training on 4/9/09 regarding the documentation of follow-up information on the client record. All staff will sign off that they attended this training & that they understand the intent of this standard. The Site Director will conduct monthly, random chart audits until the facility is in full compliance. |