INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 14, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northern Tier Counseling, Inc. was found to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
|
Plan of Correction
|
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 must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
|
Observations
Based on a review of client records and a conversation with facility staff on October 14, 2016, the facility failed to utilize an informed and voluntary consent to release form for the client's funding source in client records, #1 through 10.
Facility form titled "Authorization for the Assignment of Benefits Payment by Third Party Insurance Carrier" stated that the consent form could only be revoked in writing, did not specify what information was to be released, and failed to indicate whether the client had been offered a copy of the form.
This information was reviewed with the facility staff during the licensing process.
|
Plan of Correction
On 10/27/16 a staff meeting will be held to review the Drug and Alcohol Release of Information form. Within that form a notation will be made to denote the client's Insurance Carrier. A notation has also been added to denote the purpose for releasing information to the client's insurance carrier. A release of information for a client's insurance carrier or carrier's will be obtained at the time of their initial assessment. As clients lose or gain insurance- a new release of information will be obtained by the Counselor. Releases that are no longer relevant will be noted as "expired" or "insurance terminated" with the date. Drug and Alcohol therapists and Administrative Staff will receive training as to the appropriate use of the form and all required information needed for a release of information to be considered "complete" on 10/27/2016. All newly hired staff after 10/27/2016 will receive in-service in the area of confidentiality specifically 255.5 and within this in-service there would be specific discussion and training as to the correct way to complete all aspects of the Release of Information. Continued in service on regulation 255.5 will be provided during the employee's training plan review and renewal in January 2016 and as needed. All correspondence leaving the agency will be standardized to ensure that the information that is being released is in accordance to regulation 255.5. All Correspondence will be co-signed by the Program Director. All charts noted in this deficiency have been flagged and a Release of Information for the client's insurance carrier's will be obtained at the clients next appointment. |
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:
|
Observations
Based on a review of client records conducted on October 14, 2016, the facility failed to ensure that there was a complete client record in client records, #1, 2, 5, 8, 9 and 10..
Client record #1 contained a progress note for an individual session dated 9/28/16 however there was no record of service entry for that date.
Client record #2 contained a progress note for an individual session dated 10/5/16 however there was no record of service entry for that date.
Client record #5 was admitted on 12/31/15 and was discharged 3/23/16. Facility failed to document follow up information as of the date of the licensing inspection.
Client record #8 was admitted on 4/5/16 and was discharged 6/6/16. Facility failed to document follow up information as of the date of the licensing inspection.
Client record #9 was admitted on 9/1/15 and was discharged 1/15/16. Facility failed to document follow up information as of the date of the licensing inspection.
Client record #10 was admitted on 3/4/16 and was discharged 6/6/16. Facility failed to document follow up information as of the date of the licensing inspection.
This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
On 10/27/16 a staff meeting will be held to review the current Policy for 709.93 Client Records. The current policy notes that Northern Tier Counseling will keep a complete client record on each individual who receives treatment services. Within the verbiage of this policy, number 17 states following:
"Record of Service: This form is completed at the time a client receives a services and each time a collateral contact is made. It is documented the type of service, dates of services, the person providing the services, as well as the duration of the service. For clients funded by Medical Assistance, their signature is obtained via the prelim at the conclusion of the session." Compliance with this policy will be monitored through monthly compliance checks to be completed by the Program Director. The Program Director will conduct a 10% audit of all active charts to ensure that the record of service is complete and accurate based on the billable and non-billable services provided. A final audit will be completed when charts are processed for discharge. A service history will be produced to compare the case notes, record of service and the actual billable services. Any irregularities will be reviewed with the Facility Director and appropriate correction will be made.
On 10/27/16 a staff meeting will be held to review the current Policy for 709.93 Client Records. The current policy notes that Northern Tier Counseling will keep a complete client record on each individual who receives treatment services. Policy 709.93 number 15 will be corrected to reflect the following; Clients that reflect the following types of discharge will receive Follow-up communications;
Treatment Complete
Treatment Incomplete
Therapeutic Discharge
Referral to another D&A treatment
Client will receive a phone call from the treatment facility no later than 30 days from the date of discharge. The follow up phone call will be made by either the Treatment Specialist or the Clinical Director. During the phone call the following will be asked of the client:
1. Have you had success at maintaining your sobriety?
2. Have you followed your after care plan?
3. Have you utilized the supports you identified as being helpful when you developed your after care plan?
4. Do you need any assistance with referrals for AA/NA or other community supports?
5. Are you in need of additional therapeutic intervention at this time?
This correspondence will be kept in the correspondence section of the chart. If the client is not able to be reached after adequate effort, this should be noted on the follow up form and this should also be placed in the chart in the correspondence section.
Clients referred to higher levels of care, i.e., Intensive Outpatient or Inpatient Rehabilitation Programs will be contacted within 14 days of the transfer to the higher level of care, or on the first scheduled day the client is to attend the higher level of care to ensure that they were admitted (or any time after the point of discharge which is defined as 7 days after the clients last session).
Discharge Summary will be complete per Northern Tier Counseling Discharge Summary Policy within Clients Records Section 709.93. This policy states that the Discharge Summary will be completed within one week (7) days from the date of last session by the Therapist. Follow ups will be conducted no later than day 14 for referrals to higher levels of care and no later than day 30 for successful discharges from the program.
Compliance with this policy will be monitored at each Discharge and again during random compliance checks to be completed monthly. 10% of monthly discharged charts will be reviewed by the Program Director to review that Types of Discharges were noted and if relevant- a follow up was done timely. If errors or omissions are noted, this will be reviewed with the counselor, education and training will be documented and the follow up completed as soon as possible.
|