INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 19, 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, Lehigh County Center For Recovery 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report forms for all facilities within the drug and alcohol treatment project, the project failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
The findings include:
The Staffing Requirements Facility Summary Report forms for the drug and alcohol treatment project's seventeen facilities were reviewed on March 2, 2015. The project employs a total of 106 full-time counselors and counselor assistants. This number of full-time counselors and counselor assistants would require a minimum of 13 full-time clinical supervisors. The project currently employs 8 full-time clinical supervisors, as of March 2, 2015.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Quality Management, along with the Executive Director, will ensure there is one full-time clinical supervisor for every eight full-time counselors and counselor assistants. Caseloads will be redistributed by July 1, 2015 so that clinical supervisors who carry a caseload fall within the guidelines of chapter 704.6. Facility directors and clinical supervisors will be re-educated by the Quality Management Department on permissible case load sizes for each level of care.
Compliance will be accomplished by the facility director, along with the clinical supervisor(s), monitoring the number of full-time counselors vs. clinical supervisors on a quarterly basis.
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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 an informed and voluntary consent to release information was complete and/or obtained in three of eleven client records reviewed.
The findings included:
Eleven client records requiring complete informed and voluntary consent to release information forms were reviewed on March 19, 2015. The facility failed to ensure that an informed and voluntary consent to release information was obtained in client records, #7 and 9. Additionally, the facility failed to ensure that the purpose of the disclosure of client information was completed on the consent to release information form in client records, #7 and 8.
Client #7 was admitted to treatment on October 8, 2014 and was discharged on October 13, 2014. A release of information to a government agency was in the chart, but was not signed and dated by the client or witness. Additionally, the same release of information was within the limits established by 4 Pa. Code 255.5 (b) for releases of information, but it did not provide the purpose of the disclosure.
Client #8 was admitted to treatment on September 16, 2014 and was discharged on October 2, 2014. A release of information to a government agency was signed and dated by the client on September 16, 2014, but there was no purpose of the disclosure provided.
Client #9 was admitted to treatment on December 30, 2014 and was discharged on January 12, 2015. The facility failed to include a release of information to the client's insurance company for billing purposes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff documenting or having access to the patient chart will be re-trained on Confidentiality and Completion of Consent to Release forms no later than April 29th. Clinical Supervisor and Nursing Supervisor will maintain ongoing compliance through chart audits over the next 60 days by reviewing no less than 10% of the open charts. Noncompliance will result in individual employee improvement plans. |