INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 3, 2015 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Resources for Human Development 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 ensure that a copy of the informed and voluntary consent form for the disclosure of information was offered to the client in four of eleven client records reviewed.
The findings included:
Eleven client records requiring documentation that the informed and voluntary consent to release information forms were offered to the client were reviewed on June 3, 2015. The facility failed to ensure that the informed and voluntary consent to release information forms were offered to the client prior to the disclosure of information in client records, # 1, 4, 6, and 10.
Client #1 was admitted to treatment on August 11, 2014 and was still an active client at the time of the inspection. A letter was sent to a government agency on 02/23/2015; however, there was not a consent to release form documented in the client chart prior to the disclosure of information. Additionally, an email was sent to the funding source dated 9/16/14; however, there was not a consent to release form documented in the client chart prior to the disclosure of information.
Client #4 was admitted to treatment on September 5, 2015 and was still an active client at the time of the inspection. An phone call and letter was sent to a government agency on 10/02/2014 and an email was sent to the same government agency on 10/20/2014; however, there was not a consent to release form documented in the client chart prior to the disclosure of information.
Client #6 was admitted to treatment on June 30, 2014 and was discharged on December 20, 2015. There were phone communications on 06/30/2014, 07/29/2014, and 11/29/2014 to the funding source; however, there was not a consent to release form documented in the client chart prior to the disclosure of information.
Client #10 was admitted to treatment on January 6, 2015 and was discharged on May 4, 2015. There were phone communications on 01/06/2015 and 03/06/2015 to the funding source; however, there was not a consent to release form documented in the client chart prior to the disclosure of information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In reference to 709.28. Confidentiality., the project shall obtain an informed and voluntary consent from the client during intake and/or treatment for the disclosure of information contained in the client record. The assigned therapist will complete all relevant/warranted releases in each of the specific cases identified (Client #1, Client #4, Client #6, Client #10) to ensure no additional information will be released without a written/signed client consent. This will be assured by the Director on 6/20/15. The consent shall be in writing prior to the release of any information and will be signed by the client and counter-signed by the assigned therapist. This will be completed by the assigned therapist and will be supervised by the Assistant Director and Director during routine audits. The action described in this plan of correction will take place starting 6/23/15. Therapists will be re-trained on the need for signed consents before disclosures take place by the Director by 9/1/2015. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual, which includes referral contact information, case consultation documentation, and aftercare plans in five of eleven client records reviewed.
The findings include:
Eleven client records requiring a complete client record on an individual were reviewed on June 3, 2015. The facility did not provide a complete client record for client records, #2, 5, 6, 10, and 11.
Client #2 was admitted to treatment on February 26, 2015 and was still active at the time of the on-site inspection. Individual session progress notes documented on 03/18/2015, 03/27/2015, and 04/16/2015 stated that the counselor sent emails to the client's referral source, which was a government agency; however, there was no documentation of the content of the emails that was sent.
Client #5 was admitted to treatment on December 18, 2014 and was discharged on March 7, 2015. The facility failed to include documentation of a case consultation in the client's record as of the date of the on-site inspection.
Client #6 was admitted to treatment on June 30, 2014 and was discharged on December 20, 2014. The facility failed to include documentation of a case consultation in the client's record as of the date of the on-site inspection.
Client #10 was admitted to treatment on January 6, 2015 and was discharged on May 4, 2015. The facility failed to include documentation of a case consultation in the client's record as of the date of the on-site inspection.
Client #11 was admitted to treatment on May 6, 2014 and was discharged on October 14, 2014. The facility failed to include documentation of a case consultation in the client's record as of the date of the on-site inspection. Additionally, the facility failed to include documentation of the client's aftercare plan as of the date of the on-site inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In reference to 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. For Client #2, a documentation note will be entered into the chart outlining the nature of the disclosures or a copy of the email will be provided. This will be completed by the assigned therapist and the Director will ensure this is completed by 7/15/2015. Program therapists will be re-trained by the Program Director to meet this standard by 7/15/15. Assurance that this action is being carried out is the responsibility of the Assistant Director and the Director. For client's #5, #6, #10, and #11 who were found to be missing case consults, they were clients discharged from the program, their chart closed and thus no completion of a case consult can take place at this time. Moving forward, case consults will be completed by the assigned therapists with an appropriate colleague within each 90 days of treatment. This will be validated by the Program Director. All therapists within the program will be re-trained on the need to complete case consults (and timeline) by 7/15/15 by the Program Director. Assurance that this action will be carried out is the responsibility of the Assistant Director and the Director. For client #11, missing a documented aftercare plan, the client has been discharged and thus a therapist/client created aftercare plan cannot be created. Moving forward, all assigned therapists will complete discharge plans which will be ensured by the Program Director. All program therapists will be retrained on the need to complete aftercare plans by 7/15/15 by the Program Director. Assurance that this action will be carried out is the responsibility of the Assistant Director and the Director. |