INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 14-17, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Clearfield- Jefferson Community Mental Health Center, Inc 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 and a plan of correction is due on August 14, 2009.
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Plan of Correction
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709.24(a)(2) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(2) Treatment models utilized by the project.
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Observations
Based on the review of the administrative manuals during the onsite licensing inspection of July 14- 17, 2009, the facility failed to document treatment models and definitions in the agency manual.
The findings included:
During the onsite inspection the agency manuals were reviewed. It was noted during the inspection that the treatment models utilized were not documented or defined in the agency manual. Administrative staff were asked to provide the required documentation. The materials presented included syllabus descriptions designed for use by the client population. It was clear from the documented training which staff received that Cognitive Behavioral Therapy was being included as part of the treatment regimen but it was not defined in the agency manual or listed as a treatment model. The manual must include a listing of the treatment models and their application as defined and implemented at the agency . These were not documented.
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Plan of Correction
The syllabus descriptions of the therapy modalities used have been implemented into policy form by Employee #1 as of 7/14/09. The policies are now part of the agency manual. The therapy modalities added include Rational Emotive Behavioral Therapy and Cognitive Behavioral Therapy. |
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
Based on a review of the facility's policy and procedure manual during the onsite licensing inspection of July 14-17, 2009, the written confidentiality policy failed to comply with the requirements of confidentiality laws and regulations at 4 Pa. Code Subsection 255.5; 71 P. S. Subsections 1690.108 and 1690.112 and 42 CFR Part 2, Subparts A through E.
The findings included:
During the onsite inspection the agency policy and procedure manual and HIPAA notification statements were reviewed for compliance with applicable confidentiality law/regulation. The policy failed to correctly address the required laws/regulations as specified below:
Definitions listed on Page 2 of the confidentiality section of the policy and procedure manual defines "records" as "...including but not limited to all written clinical information, observation and report of fiscal documents, relating to past, present or prospective clients". Confidentiality is protected in both written and verbal forms for any individual who is identified as a participant in a D&A program. Federal regulations at 42 CFR Part 2, Subpart B, Subsection 2.12(a) state that, "The restrictions on disclosure in these regulations apply to any information, whether or not recorded, which: (i) Would identify a patient as an alcohol or drug abuser either directly, by reference to other publicly available information, or through verification of such an identification by another person..."
Page 3 of the confidentiality policy and procedure, paragraph 2, stated that " Consideration should be given to advising the facility of the possible detriment to the patient's treatment should the patient be granted access to the information that is released." This contradicts 28 Pa. Code Subsection 709.28(c) which requires an informed and voluntary consent and is inconsistent with 28 Pa. Code Subsection 709.28(c)(2) and 42 CFR Part 2, Subpart C, subsection 2.31(a)(5) which require the facility to list the specific information (how much and what kind) that will be released. If the patient cannot see it, the facility may not release it.
Page 2 of the confidentiality policy and procedure, #3 (ii)- states that information will be released without the clients' written consent in response to emergency medical situations when necessary to prevent serious bodily harm or death. This is inconsistent with state law at 71 P. S. Subsection 1609.108(b) which states "...except that in emergency medical situations where the patient's life is in immediate jeopardy, patient records may be released without the patient's consent to proper medical authorities solely for the purpose of providing medical treatment to the patient..." The facility policy an procedure manual repeats the inaccurate language on page 5 of the confidentiality policy and procedure at #5 (c)- "In emergency medical situations as necessary to prevent serious risk of bodily harm or death and only to the extent necessary for relief of the emergency situation"
Page 5 of the confidentiality policy and procedure manual, section (e) regarding released of information without th client's written consent, states in part that information may be released ... "To the court or Mental Health review officer in the course of commitment proceedings". This is inconsistent with the federal regulations at 42 CFR Part 2, Subpart B, Subsection 2.13 which state in part, "The patient records to which these regulations apply may be disclosed or used only as permitted by these regulations and may not otherwise be disclosed or used in any civil, criminal, administrative, or legislative proceedings conducted by any Federal, State, or local authority...".
Page 7 of the confidentiality policy and procedure, section 8(e) refers to the release of client information based on subpoenas and fails to clarify that this is not sufficient for any information that identifies a client as a participant in drug and alcohol treatment, but that in the Commonwealth of Pennsylvania a court order issued by a judge of the court of common pleas is necessary to remove the restrictions against the release of client information without the client's written consent. This is outlined at 71 P.S. Subsection 1690.108(b) and in the federal regulations at 42 CFR Part 2, Subpart E, Subsection 2.61(a).
HIPAA documentation, notification and clarification to clients did not include the appropriate disclaimers that releases of information permitted by the HIPAA regulations are prohibited by the drug and alcohol confidentiality regulations, specifically in relation to the following facility information sections:
Section A. 2- "To obtain payment for treatment"
Section B. 6 "To avoid harm "
Section B 8 "For workers Compensation "
Section C # 1- Disclosures to Family members, friends or other selected person"
Question II section A - "The right to request limits in uses and disclosures of your health information"
section C- "The Right to see or get a copy of your protected health information"
Section D- "The right to Receive a list of certain disclosures of your health information"
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Plan of Correction
The Confidentiality Policy has been changed by Employee #1 as of 8/3/09. The changes in the definition for records listed on page 2 of the policy now include information that is documented and obtained verbally.
On page 3 the paragraph stating,
" Consideration should be given to advising the facility of the possible detriment to the patient's treatment should the patient be granted access to the information that is released." The information granted has already been approved to be released by the client to the facility by use of a release of information. Otherwise, nothing could be given to the other facility. This paragraph simply states that CJ will advise the facility of any reservations about the information being relayed that would be a detriment to ongoing treatment.
The language regarding release of information in a medical emergency has been changed to reflect, "In response to emergency medical situations where the client's life is in immediate peril, only information pertinent to the relief of the emergency may be released."
This has been changed on both Page2, #3(ii) as well as Page 5, section (e).
On page 5, the statement "To the court or Mental Health Review officer in the course of commitment proceedings" has been removed from the policy.
On page 7, section 8(e) has been corrected to state, "Clients receive notice if their chart has been subpoenaed by the court in the pre-treatment information as well as in Statement of Clients Rights and Responsibilities. If a client chart is subpoenaed then the facility will attempt to obtain a release of information to the court system. Only under court order of a judge of the court of common pleas, will information be disclosed without the use of a release of information."
The following corrections were changed by employee #1 on 8/11/09 regarding HIPPA .
Section A as a whole references is referenced to the Confidentiality Policy. A.2 now specifies that a release of information is necessary to obtain payment for treatment.
Section B. 6 "To Avoid harm" has been removed from the policy.
Section B. 8 specifies with the appropriate consent to release information documented.
Section C. 1 specifies with the appropriate consent to release information documented.
Question II Section A indicates that we will honor their request to limit their PHI, however with the exception of the event that their life is in immediate peril.
Section C. states that we will honor their request to see or get a copy of their protected health information but we may deny if it is in the client's best interests. There is a reference to the Confidentiality Policy as well.
Section D. states that the client has a right to receive a list of the disclosures that have been made with an appropriate release of information documented.
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709.91(a)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(1) Criteria for admission.
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Observations
Based on the review of the agency policy and procedure manual during the onsite licensing inspection on July 14-17, 2009, the facility failed to document criteria for admission which contained limitations on the populations which could be served by the project.
The findings included:
The policy and procedure on criteria for admission did not document the limitations on the special populations that could be served by the project, nor did the policy describe criteria which included age, sex or geographic requirements in the criteria for admission.
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Plan of Correction
The admission Policy was changed on 8/3/09, by employee #1 to state the following,
"Consumers admitted into the Drug and Alcohol Department are described in Policy D&A #27 Target Populations and D&A #23 Priority Populations. Consumers admitted to the clinic will be treated based on the clinic's capacity. Those consumers that are non-English speaking will be referred to another facility if at the time CJCMHC does not possess staff does not speak the same language. The facility is handicap equipped. If a consumer is deaf, the agency will make arrangements for an interpreter to be present for the sessions. If a consumer were to present actively psychotic, a referral would be make for MH treatment and a referral to be admitted to an inpatient MH facility, if admission requirements are met. All other presenting issues will be handled on an individual basis."
The policies referenced identify age and sex. Geographic restrictions would be encompassed in the statement regarding cases handled on an individual basis.
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client record documentation during the annual onsite licensing inspection of July 14. 17, 2009, the facility failed to document personal histories which addressed family relationships, employment histories and educational experiences.
The findings included:
Eight client records were reviewed during the annual licensing inspection . Each client record was required to include documentation of a complete personal history. Client records # 1, 2, 3, 4, 5, 6, 7 and 8 failed to include documentation of family interrelationships, an essential component of the family history. Client records # 1, 6, 7 and 8 did not include documentation of work histories, but addressed only most recent or current employment. Client record # 4 was illegible.
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Plan of Correction
In order to ensure that personal history, family interrelationships and work histories are documented and complete, the intake supervisor has created an intake audit tool. At least two intakes are randomly chosen and audited per week. The tool was created and put into effect on 7/21/09.
Employee #1 also retrained all staff on this aspect during the staff meeting on 7/21/09. The staff was given an overview to demonstrate how this is to be completed comprehensively.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client record documentation during the onsite licensing inspection of July 14- 17, 2009, the facility failed to document psychosocial evaluations which addressed coping mechanisms, support systems and clinical impressions.
The findings included:
Eight client records were reviewed during the onsite inspection. Each client record reviewed was required to document a psychosocial evaluation.
Client records # 1, 2, 3, 4, 5, 6, 7 and 8 did not include documentation of coping mechanisms used by each client.
Client record # 6 did not include documentation of strengths and assets demonstrated by the client.
Client records # 1, 2, 5, 6 and 8 did not include documentation of clinical impressions which identified possible relationships, conditions and causes leading to the client's current situation.
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Plan of Correction
In order to ensure that coping mechanisms, support systems and clinical impressions are documented and included in the psychosocial evaluation, the intake supervisor has created an intake audit tool. At least two intakes are randomly chosen and audited per week. The tool was created and put into effect on 7/21/09.
Employee #1 also retrained all staff on this aspect during the staff meeting on 7/21/09. The staff was given an overview to demonstrate how this is to be completed comprehensively along with a template on how to complete.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the client record review during the onsite licensing inspection held July 14-17, 2009, the facility failed to document treatment plan updates which addressed progress achieved on the stated goals of the treatment plan during the previous 60 day period.
The findings included:
Eight client records were reviewed during the inspection. Four of these were required to have treatment plan updates. Client records # 3 and 8 included documentation of treatment plan updates which failed to document the client's progress on the stated goals of the comprehensive treatment plan over the previous 60 day period.
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Plan of Correction
In order to ensure that treatment plans are completed correctly and according to time frames, employee #1 has created a sample treatment plan to be used for training purposes. The staff members were retrained during a staff meeting on 7/21/09 on the completion of treatment plans. In addition, an audit tool has been created. Employee #1 will randomly audit charts during individual supervisions as well as have peer chart audits completed in monthly group staff meetings. The tool was created and put into effect on 7/29/09.
The charts that have been deemed insufficient have been returned to the therapist for treatment plan revisions on 8/19/09 by employee #1. Charts which were cited during this audit were discharged prior to the visit. Appropriate compliance reports have been completed as of 8/20/09. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records at the onsite licensing inspection of July 14-17, 2009, the facility failed to document complete aftercare plans in three of three client records where required.
The findings included:
Eight client records were reviewed. Three client records were required to include documentation of aftercare plans.
Client records # 4 and 7 did not include documentation of goals with timeframes or support services on the aftercare plans.
Client record # 8 was a successful discharge based on documentation noted elsewhere in the client record, but no aftercare plan was documented.
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Plan of Correction
In order to ensure that Aftercare Plans are completed in entirety, all staff members were retrained, by employee #1, on the use of the plans during a staff meeting on 7/21/09. The form used has also been redeveloped and there are triggers for timeframes for each goal that is related back to the treatment stay. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on the review of client records during the onsite licensing inspection of July 14-17, 2009, the facility failed to document timely discharge summaries which addressed the client response to treatment and the client status.
The findings included:
Eight client records were reviewed at the time of the inspection. Six client records were required to include documentation of discharge summaries. Client records # 7 and 8 failed to include documentation of the client status at discharge. Client record # 3 included documentation stating that the client was discharged on 3/10/09, but the discharge summary was dated 6/17/09. Discharge summaries are required to be documented within seven days of the discharge date.
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Plan of Correction
In order to ensure that discharge summaries are completed in entirety and timely, employee #1 retrained all staff members during a staff meeting on 7/21/09. Also as a training aid, a sample discharge summary has been distributed to all staff. In addition, an audit tool has been created. Employee #1 will randomly audit charts during individual supervisions as well as have peer chart audits completed in monthly group staff meetings. The tool was created and put into effect on 7/29/09. This tool will be used in addition to the chart review that is done by medical records when a case is discharged. |