INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 20 through September 21, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Spring-Ford Counseling 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 October 18, 2007.
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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 a review of the Client Records Policy, Client Bill of Rights and the Consent to Treatment Form, the facility failed to comply with state and federal confidentiality laws and failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in four of four client records reviewed, #1, 2, 3 and 4.
The Client Records Policy failed to reference confidential communications as addressed in 42 C.F.R. Part II, Subpart E, subsection 2.63 as the policy included the phrase "imminent threat of harm to self and others" as a reason for release of information without consent.
The Bill of Rights failed to reference medical emergencies as addressed in 42 C.F.R. Part II, Subpart D, subsection 2.51 and 71 P.S subsection 1690.108(b) as the policy included language regarding the release of information without consent for "extreme emergency situation".
The Consent to Treatment Form failed to reference minor patients as addressed in 42 C.F.R. Part II, Subpart B, subsection 2.14(b) and 71 P.S. subsection 1690.112 as it included language which gave the right to release information to parents of minors without consent.
The Consent to Treatment Form included language which permitted the release information to one half of a couple without consent.
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Plan of Correction
Within 60 days, the Clinical Coordinator shall research state and federal laws regarding confidentiality and its vocabulary: to delete Spring-Ford Counseling Services Client Records Policy regarding "imminent threat of harm to self or others". The Bill of Rights will be revised to add "extreme emergency situation" and Consent to Treatment form will be revised to state that no information Drug/Alcohol Outpatient Treatment Minor clients will be released without written consent from the minor to parents. Also the Consent to Treatment will be revised to address couples consent. |
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 client records, the facility failed to document a complete drug and alcohol history in four of four records reviewed, #1, 2, 3 and 4. Drug and alcohol histories did not include the lengths and patterns of use in records #1, 2, 3 and 4. Information was missing on substances abused in two of four records reviewed, #2 and 3.
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Plan of Correction
Within 60 days, the Clinical Coordinator will revise drug/alchol history within the BioPsychoSocial to include lengths and patterns of use. Clinical Coordinator shall meet with Treatment staff to discuss importance and reminder to ask and document every question and answer on substance abuse history form. Clincial Coordinator shall review charts to ensure compliance with this standard. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document treatment plan goals stated in terms of measurable criteria in two of two records reviewed, #1 and 2.
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Plan of Correction
Within 60 days, Clinical Coordinator shall meet with treatment staff and review treatment plan development which will include goals stated in terms of measurable criteria. Clinical Coordinator shall conduct chart reviews to ensure goals are stated in measurable criteria. |
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, the facility failed to document progress notes relative to treatment in four of four client records reviewed, #1, 2, 3 and 4. Progress notes included educational data and plans with little therapeutic content
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Plan of Correction
Within 60 days, Clinical Coordinator shall review files and progress notes that include educational vs. therapeutic content. Clincial Coordinator shall meet with treatment staff and discuss although education is a very important part of treatment it is not the "only" part of treatment and review other therapeutic strategies such as Cognitive Behavioral Therapy and Client-Centered Therapy etc.with clients. Clinical Coordinator will review charts to ensure compliance with standard. |
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.
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Observations
Based on a review of client records, the facility failed to document follow up in one of two client records reviewed, #3.
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Plan of Correction
Within 60 days, Clincial Coordinator shall meet with treatment staff and review follow-up proceedures. Clinical Coordinator shall conduct chart reviews to ensure 1 week and 3 month follow-ups with clients who have completed treatment. |