INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on October 6, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site complaint investigation, the allegations made against White Deer Run, Allenwood were substantiated and a plan of correction is due on November 4, 2008.
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Plan of Correction
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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 a review of client records during the onsite complaint investigation of October 6, 2008, the facility failed to ensure that consents to release client identifying information were in place before correspondence was mailed.
FINDINGS:
In one of five client records reviewed ( # 2) the client revoked consents to release information to her probation officer and attorney and her father on 9/2/2008, before her discharge from the facility. Correspondence was documented in the client's record which was dated 9/4/2008, to her Probation officer and her attorney stating that the client did not complete treatment successfully. On 9/9/2008 one of the clinical supervisors sent a letter of apology to the client's Probation officer and attorney stating that she had successfully completed treatment . This letter was also on file in the client record. Client identifying information was released without the client's consent and the information that was released was erroneous.
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Plan of Correction
White Deer Run of Allenwood self-reported to Licensing via an Unusual Incident Report that a breach of confidentiality had occurred. Senior Staff at Allenwood learned of the breach through communication from the patient and within the hour addressed the confidentiality breach. The staff member responsible for the breach of information was re-trained on October 8, 2008 by the Director of Medical Records. The Clinical Director will arrange for the employee to participate in an Ethics training that focuses on the legal aspects related to confidentiality within the next 3 months. Compliance with confidentiality standards will be evaluated by the Medical Records Department and any infractions reported to the Clinical Director and Regional Administrator. |
709.30(2) LICENSURE Client Rights
709.30. Client rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of employee personnel records during the onsite complaint investigation held October 6, 2008, the facility did not ensure that client's were not discriminated against in the provision of treatment services.
FINDINGS:
Disciplinary action in the record of employee #1 indicated that he behaved inappropriately toward two male clients during strip searches and searches of personal belongings conducted as a routine part of the intake process. Based on documentation in the employee's file he made demeaning comments and gestures. One of the individuals was targeted by employee #1 for harassment as a result of this individual identifying himself as a member of a sexual minority.
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Plan of Correction
All employees are scheduled in their first month of employment for Orientation training, which includes ethics specific to boundaries with patients. Employee #1 did receive this orientation training and was counseled previous to this incident about sharing personal information with patients. As a result of this flagrant violation of the CRC ethical guidelines, employee #1 was given a final warning as part of an Employee Improvement Plan process which also required his participation in ethics training and regular direct supervision, specific to boundaries with patients. Employee self terminated his employment while on suspension status, and therefore did not complete the ethics training. |
709.54(d)(2) LICENSURE Alerting Persons - Outreach
709.54. Project management services.
(d) The project shall develop a written plan providing for outreach services which includes, but is not limited to:
(2) Alerting persons and their families to the availability of project services.
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Observations
Based on a review of administrative and marketing materials during the onsite licensing investigation of 10/6/08, the facility did not accurately alert the public to the availability of services.
FINDING:
The White Deer Run Web Site- www.whitedeerrun.com- advertises the availability of services for Gay/Lesbian/Bisexual individuals. The agency policy manual describes the "Rainbow" group as "a program ...developed in response to a letter written by 14 former clients who indicated that White Deer Run's clinical programs...lacked sensitivity to issues faced by chemically dependent gay and lesbian clients." The policy continues with an explanation addressing the homosexual client's integration into a predominantly heterosexual society. The reality of the extent of services provided in the "Rainbow" track is that one treatment group a week addressing alternative lifestyles will be provided only when there are enough clients available to make for a viable group treatment setting. The marketing materials are misleading to those who may be in need of specific services to address these lifestyle issues. A chatroom discussion with the on call intake counselor on 10/3/08 revealed that the Gay/Lesbian/Bi-Sexual program was "shelved" due to lack of interest. The WEB site continues to advertise the "Rainbow Group" (Gay/ Lesbian/Bisexual) for gay/lesbian/bisexual patients in recovery.
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Plan of Correction
The Rainbow Group provides a group atmosphere to assist those who identify as a member of a sexual minority, integration into a recovery lifestyle within a predominately heterosexual society. Within the general treatment program, there are coed and gender specific groups which focus on issues such as treatment blocks, the coming out process, overcoming stereotypes, dealing with discrimination, leisure activities other than bars, sober support systems, HIV/AIDS education, etc.
White Deer Run of Allenwood will notify the IT Department's website manager to change the "Rainbow Track" demarcation that is posted on the White Deer Run website. The "Rainbow Services" description on the website will identify for browsers the actual services (frequency and focus) that are provided. With the Allenwood restructuring in its clinical services, these services will include one individual assessment session and thereafter, two available group sessions per week. This change in the website will be completed within 30 days. The written plan for clinical services will be updated and approved by Senior Leadership on November 18, 2008.
The part of the citation that identifies "the chat" online with the intake counselor who relayed the program was "on hold" has resulted in a lot of searching, but no identified person responsible for this conversation. The admissions staff were instructed as to the specific services provided for those who identify as a member of a sexual minority. The Rainbow Services have not consistently included groups because of insufficient numbers of patients. Nonetheless, individual sessions have consistently been provided for patients with respect to issues related to their sexual orientation and barrier/obstacles to recovery. Continuing care planning also takes into consideration special needs combined with available resources.
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