INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 4-7, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on July 9, 2007.
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Plan of Correction
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709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
The facility failed to provide for an agency manual organized in a manner which would allow staff to easily reference policies and procedures relating to the discharge of their assigned duties and which were consistent with Commonwealth regulations. Language in the manual tended to be generic in nature and did not consistently meet regulatory requirements.
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Plan of Correction
Policy Manual will be reviewed by home office representatives to look at making it more user friendly. Policies will be made Pa specific where needed and language changed where needed to reflect what is stated in the regulations. Director will monitor along with Denise Howard of RI office of DH. Plan will be completed within 90 days. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
The facility failed to provide for a policy which addressed 4 Pa. Code subsection 255.5 in its entirety. The policy focused only on 255.5(b). Language in the policy failed to clearly distinguish between HIPAA requirements and the federal confidentiality regulations at 42 CFR ( revision 13 modified 11/2006). Forms were noted in client records which still contained language inconsistent with the intent of 42 CFR Part II Subparts C, D and E relating to the release of information without client consent. Language in the forms stated that the client could ask for releases of information to be restricted but that the agency need not honor such requests. The referral policy stated that "..In as many instances as possible, a release of information shall be signed in order to coordinate treatment for each patient." The intent of applicable laws is that the client must consent to any releases of personal information which identifies them as a consumer of Drug and Alcohol treatment services unless excepted by 42 CFR Part II subparts D & E.
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Plan of Correction
Policy in question will be reviewed at Home Office level by Denise Howard to seperate HIPAA and 42CFR so that it will be easier to see them as seperate.
Forms in question will be reviewed and changed as needed so that language on the form will clearly state the intent of the regulation. Director will discuss and clarify states position with Denise Howard. Director will monitor for compliance. Time frame- 90 days |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
The facility failed to provide complete and valid consent to release information forms signed by the client. Emergency contact consents did not specify what information would be released in the event of an emergency. Specific information to be released was identified only as "Emergency Contact", as was the purpose for the release. Specific information which is to be released may include, but not be limited to such items as: nature of the emergency, location of the client, health status of the client, etc. Staff must clearly identify what will be released.
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Plan of Correction
Clinical Supervisor will conduct an inservice training on proper way to complete a pt emergency contact form within the next 60 days.
Clinical Supervisor will discuss issue futher in weekly supervision when and where needed. Immediately and ongoing.
Program Dir will monitor for averall compliance. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
The facility failed to consistently document complete client medical histories. Medical histories did not address the family medical history in any of the files reviewed. A history documenting the client's personal medical history, family medical history, and history of illness and symptoms must be documented.
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Plan of Correction
Older form will be returned to intake packet so that this area is not missed. Form clearly includes column for family medical Hx and information. This will be done immediately by Director.
Memo will be given by Director to Med Dir and Intake Coordinator regarding the requirment of including family history. Time frame for memo is 30 days. |
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
The facility failed to consistently provide for a complete client record. Follow up was not documented in applicable closed records, (client records #3, 4, 5 and 7). Agency policy states that the paper copy of the client record is the main file. Closed records are to be complete - follow up documentation must be included in the closed paper file.
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Plan of Correction
Effective immediately, all charts that are ready to be filed away after a person leaves tx will be given to the Clinical Supervisor for review. It will be their responsibility to make sure that all the proper paperwork is in the pts chart as it is closed out and filed. Director will monitor. Time frame- Immediately and ongoing. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
The facility failed to document a written follow up policy. The policy should note who is responsible, method and frequency of contact and the manner of documentation.
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Plan of Correction
Director will contact Denise Howard at DH home office to review policy in question and include / add who is responsible, method and frequency of contact and the manner of documentation.
Time frame- 90 days. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
The facility failed to produce a current, signed provider agreement with the Department of Public Welfare and was not able to demonstrate compliance with 55 Pa. Code Part III.
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Plan of Correction
Pa DPW will be contacted so that an agreement can can be sent and/or negotiated that also identifies who our Med Dir is. Program Dir will initiate contact and monitor for compliance. Time frame- 90 days. |