INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 2, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Highland House, 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:
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Plan of Correction
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709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the 2012-2013 annual report, the governing body failed to make available to the public an annual report which included a financial statement of income and expenses.
The findings include:
The 2012-2013 annual report was reviewed on April 1, 2014 at the outpatient location. The governing body failed to include a financial statement of income and expenses in the 2012-2013 annual report.
The Project/Facility Director was interviewed on April 1, 2014 and confirmed the findings.
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Plan of Correction
The executive director will add the financial statement of income and expenses to the annual report for 2012-2013 by 4-11-14. The director will assure that the expenses and income are part of the annual summary document by adding a paragraph to the outline of this document by April 11, 2014 to avoid these items being omitted. |
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 restricted the client's ability to verbally revoke the consent to release client information forms by informing clients that their revocation must be in writing, in eight of eight client records.
The findings include:
42 CFR, Part 2, Subpart C, 2.31(a)(8) includes the following language in regard to the written content that is required to be included on a consent to disclose client information: "A statement that the consent is subject to revocation at any time except to the extent that the program or person which is to make the disclosure has already acted in reliance on it." The statement regarding the revocation of the consent to disclose client information form does not limit the revocation to being verbal and/or written.
Consent to release client information forms in eight client records were reviewed on April 2, 2014. The facility restricted the client's ability to verbally revoke the consent to release client information forms in client records # 1, 2, 3, 4, 5, 6, 7 and 8 as the consent forms indicated that the revocation must be in writing.
The Project/Facility Director was interviewed on April 2, 2014 and confirmed the findings.
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Plan of Correction
The executive director corrected, and distributed to the halfway and outpatient employees the corrected consent form 4/1/14 which now reads "I understand that I may cancel this authorization at any time by notifying the agency verbally or in writing"
Charts will be checked by the clinical supervisor and director to assure that the correct releases are in the chart.The Life skills tech will assure when she is obtaining releases from the client that they are the correct release. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to inform the client, in writing, of a decision to involuntarily terminate the client's treatment in one of one client record.
The findings include:
Eight client records were reviewed on April 2, 2014. Three client records were reviewed as discharged clients. One client record required written notification informing the client of the decision to involuntarily terminate the client's treatment. The facility failed to document written notification to the client in client record # 6.
Client # 6 was admitted on September 17, 2013 and involuntarily terminated on December 20, 2013. The record included documentation of a termination letter addressed to the client. However, there was no documentation in the record to demonstrate that the client had received, or been provided, the written termination letter.
The Project/Facility Director was interviewed on April 1, 2014 and acknowledged the findings.
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Plan of Correction
The discharge letter was in the chart, however the documentation that the client actually recieved the information was not evident. The executive director has added to the discharge letter a space for the client to sign or initial when they recieved the letter of discharge with explanation of why they were discharged, and what the process is to reenter the program with phone numbers and extensions.
There is also a space where the staff person who must mail the letter in the event the client is not available to sign. The staff person will sign and document where sent and what date.
The numbers of their county of origin and MCO will continue to be documented on the letter also.
The changes were reviewed with the staff on 4/11/13. When charts are being reviewed the clinical supervisor will review to assure that the process is being followed. All forms are locked to prevent further editing. |