INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 13, 2017 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, Casa de Consejeria y Salud Integral, 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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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of personnel records, the facility failed to conduct a written semiannual performance evaluation for employee #6, a Counselor Assistant since 2/13/17 and still in the position at the time of the inspection. The evaluation was due no later than 8/13/17. There was no documentation of the evaluation in the personnel record.The findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
At this time, the clinical supervisor made the change with the employee on her evaluation to meet this requirement.
Moving forward, the project director will update polices and procedures to align this requirement with internal processes. All new hire employee probationary periods will be extended from 3 months to 6 months and at the end of the probationary period an employee evaluation will be conducted for each employee by the employee's direct supervisor. As a means to prevent individuals from missing this deadlines, a staff roster is already in existence that is updated and emailed to all direct supervisors with new hires. At our quarterly staff meetings, the project director, will remind all direct supervisors to take a look at their most current staff roster in order to keep up with evaluations accordingly. The project director will also send out reminder emails regarding upcoming evaluations needed 30 days prior to due date provided by the staff roster. This new policy will be in effect no later than 10/31/2017. |
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.
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Observations
Based on the review of seven client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in one record.Client #1 was admitted on 2/29/16 and was active at the time of inspection. The record did not contain a signed consent to release information form to the funding source or urinalysis lab; however, there was documented evidence of the release of information.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor rechecked client file #1 and completed the release of information for funding source and urinalysis lab with the client within 24 hours from the conclusion of our licensing inspection/site visit.
The clinical supervisor will hold an in-service training to discuss essential information and forms which will facilitate compliance to general guidelines of client confidentiality framed by 4 Pa Code 255.5 regulations and 42 CFR Part 2, including the Health Insurance Portability and Accountability Act (HIPPA) The nature of the release and the circumstances by which the information may be released, the specific content and limited nature of the information to be disclosed, to whom specifically, the purpose of the disclosure, the method of releasing the information as well as the timeframes for the release, signature of client and witness, date of signatures and whether the client has received a copy will be discussed. This will be completed by 10/27/17.
The clinical supervisor and program director will also make a change on the confidentiality form in order to better adhere to the confidentiality state requirement. The line that reads "This authorization will expire 180 days after the date of my signature or on 'date' person or organization named above will not be used for any other purpose than stated" to "This authorization will expire the day after my discharge for the person or organization named above and will not be used for any other purpose stated". This change will be completed no later than 10/31/2017.
Clinical staff shall continue to attend recommended Department of Health training and provide documentation in areas such as confidentiality and client recordkeeping. This will be monitored by HR on an annual basis.
QA/I monitor will insure that internal policies and procedures comply with both Federal and State confidentiality and reporting regulations by routinely auditing all program records. Corrective action and follow-up will be made to insure the appropriate disclosure of client information in service delivery.
Examples of QA/I monitoring activities are as follows:
· Monitor for documentation that clients are informed and understand their rights to confidentiality.
· Monitor to insure that there is a current, written informed release on file whenever information is disclosed to and from the treatment facility.
· Monitor to insure that the written release is time limited, content specific, signed and witnessed.
· Monitor for family and SP (special persons) inclusion.
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