INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on January 28, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Genesis House (Bloomsburg) 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)(1) 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 shall include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of the client records, the facility failed to document consents to release information which identified the specific information to be disclosed in six of six client records.
The findings include:
Six client records were reviewed on January 29, 2013. A review of records # 1, 2, 3, 4, 5 and 6 revealed that all consent to release forms failed to identify the purpose of the release.
Client # 1 was admitted on May 07, 2012 and release of information forms were signed on May 07, 2012. The facility failed to identify the information to be released and the purpose of the release on all consent forms signed by the client.
Client # 2 was admitted on August 30, 2012 and release of information forms were signed on August 30, 2012. The facility failed to identify the information to be released and the purpose of the release on all consent forms signed by the client.
Client # 3 was admitted on December 03, 2012 and release of information forms were signed on December 03, 2012. The facility failed to identify the information to be released and the purpose of the release on all consent forms signed by the client.
Client #4 was admitted on December 03, 2010 and the last counseling session was documented as January 03, 2012. Release of information forms were signed on December 03, 2012. The facility failed to identify the information to be released and the purpose of the release on all consent forms signed by the client.
Client #5 was admitted on February 11, 2011 and discharged on June 15, 2012. The facility failed to the information to be released and the purpose of the release on all consent forms signed by the client.
Client # 6 was admitted on December 06, 2010 and discharged on June 13, 2012. The facility failed to identify the information to be released and the purpose of the release on all consent forms signed by the client.
The Facility/Project Director confirmed this finding On January 29, 2013. The facility failed to identify what information and the purpose of the release on all consent forms.
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Plan of Correction
The Facility Director met with the treatment team on 2/7/13 and reviewed the findings of the DOH inspector. The Facility Director discussed with the clinical staff the possible solutions and the implications of the releases of informaton not documenting the purpose of the release.
All files were pulled by the clinical staff and reviewed by the Director from the year 2011 through the current year and reviwed for further deficiencies; making note to correct with the client if so necessary when the client arrives in the facility.
A agency wide training (all treatment staff must attend) will be conducted on 3/14/13 by the Director of Outpatient Services; training will include overview of confidentiality (PA255.5), the scope of confidentiality, how to identify the purpose for release, the 5 points of information that can be released, and how to properly fill out a release of information.
The agency was advised to remove the "other" denotation on the release of information. The Director will remove all "other" denotations on the releases of information from the master copies by 3/1/13. The Director will then shred all copies of releases used prior to 3/1/13 |
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 and an interview with the clinical director, the facility failed to document progress notes in two of six client records.
The findings include:
Six client records were reviewed on January 29, 2013. Six of the client records were required to have progress notes. The progress notes are required to be completed after each significant contact. The facility failed to document progress notes in client records # 3 and 4.
Client # 3, was admitted on December 3, 2012. Record of service entries documented that service occurred on December 3, 2012. There was no additional documentation in the client record following the admission date of December 3, 2012 session.
Client # 4, was admitted on September 13, 2012 and discharged on January 3, 2013. Record of service documentation identified that services occurred September 13, 2012 through January 3, 2012. There was no documentation of a progress note in the client record during this period of time. The record of service documented the client attended a session on January 3, 2013.
This was confirmed with the Facility/ Project Director on January 29, 2013.
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Plan of Correction
1. Checking individual client folders ? staff meetings will be increased from 1 hour to 2 hours, allotting time for peer review and Facility Director review of files in addition to other staff meeting issues. Intake files will be reviewed week 1 of the month, A-M week 2 of the month, N-Z week three of the month, and discharged files week four of the month.
2. The Facility Director will make a copy of the Case Management Supervision document and will review the deficiencies in the bi-weekly individual supervision meeting with the employee; the employee will bring the corrected/completed file to the meeting.
3. If the employee does not correct or complete the file, the supervisor and supervisee will come up with a corrective action plan which will denote a due date for the completion of the work.
4. The facility director will meet with the supervisee on due date and go over completed work. If supervisee does not complete the work, a written warning will be issued to the supervisee, a corrective action plan will be created, due date submitted, meeting scheduled,re-training completed, and all information forwarded to Board of Directors.
5. Each staff member will provide an updated client list to the Facility Director which will include the client name, funding source, initial appointment date, (appointment date for TX plan due), and last seen date), the Facility Director will data enter into a data base; when the Facility Director receives the paperwork she/he will enter into the spreadsheet accepted/completed.
6. During individual supervision the Facility Director will review with the employee the data base; this will allow the Facility Director and the employee time to discuss missing information, if necessary make a corrective action plan. During this time if the employee is behind on paperwork the corrective action plan will be done in writing with the supervisee denoting a due date. Both supervisor and supervisee will sign this document.
7. Facility Director and supervisee will meet again on the due date and go over completed work. If supervisee does not complete the work, a written warning will be issued to the supervisee, a corrective action plan will be created, due date submitted, meeting scheduled, and all information forwarded to Board of Direcors.
8. All staff members will submit to Facililty on Monday by 9 am, client list, promise check list, in addition when PCPC's are due the employee will send a copy of the screen shot from the STAR data base system that the authorizations were sent to the SCA.
9. If the previous is not received, the Facility Director will contact the supervisee immediately and request the information and give a new time for submission (this time cannot exceed 24 hours). If the information is not received the employee will be issued a written warning which will be forwarded to the Board of Directors for further direction.
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