INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 17, 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, RHD Lower Merion Counseling Services 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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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 obtained in three of ten client records reviewed.
The findings included:
Ten client records requiring complete informed and voluntary consent to release information forms were reviewed on June 17, 2015. The facility failed to ensure that the specific information to be released and/or the purpose of the disclosure was completed on the consent to release information form in client records, #1, 8, and 10.
Client #1 was admitted into treatment on January 12, 2015 and was still an active client at the time of the inspection. A release of information form to a family member was signed on 3/30/2015, but did not indicate the specific information to be disclosed. Additionally, there were three separate release of information forms dated 1/14/2015-one to a family member, one to a funding source, and one to a doctor's office-that did not indicate the specific information to be disclosed and the purpose of the disclosure.
Client #8 was admitted into treatment on July 10, 2014 and was discharged on October 30, 2014. A release of information form to another treatment facility was signed on 9/18/2014, but did not indicate the purpose of the disclosure. Additionally, there was a release of information form to a government agency that was signed on 7/10/2014 that did not include the purpose of the disclosure and the specific information to be disclosed.
Client #10 was admitted into treatment on November 24, 2014 and was discharged on April 22, 2015. A release of information form to a family member was signed on 10/24/2014, but did not indicate the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
One of the three client records (Client #1) that received the deficiency is an open/active case. For this client, the consents will be re-completed and signed and dated appropriately. The therapist assigned to this client will ensure that all consents will be specific about the party to whom information will be released including the individual's name, company or agency, telephone number and address. These consents for client #1 will also be specific with appropriate information being disclosed and the purpose of disclosing the information.
In addition, to correcting the consents to release information in any active chart, an internal audit process will be completed by the Quality Review Specialist on a regular basis to ensure that these types of errors are corrected. The Program Director will provide training semi-annually for all clinical staff to ensure that they understand how these consent forms should be completed. These trainings will take place during regular peer review meetings and will be documented in the meeting minutes. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on the review of client records, the facility failed to ensure that a copy of the client consent was offered to the client in four of ten client records reviewed.
The findings included:
Ten client records requiring documentation that a copy of the consent was offered to the client were reviewed on June 17, 2015. The facility failed to ensure that there was documentation of the client being offered a copy of the consent form in client records, #1, 3, 4, and 8.
Client #1 was admitted into treatment on January 12, 2015 and was still an active client at the time of the inspection. In the client record, there was a release of information form to another treatment provider that was dated 2/20/2015, two separate release of information forms to a doctor's office and another treatment provider that were dated on 3/19/2015, and a release of information form to a family friend that was dated 3/30/2015; however; there was no documentation that any of the four release of information forms were offered to the client at the time of the inspection.
Client #3 was admitted into treatment on April 6, 2015 and was still an active client at the time of the inspection. In the client record, there was a release of information form to a family member and a release of information form to a pharmacy, both dated 4/06/2015; however, there was no documentation that either release of information form was offered to the client at the time of the inspection.
Client #4 was admitted into treatment on May 9, 2014 and was still an active client at the time of the inspection. In the client record, there was a release of information form to a government agency that was dated 5/09/2014; however, there was no documentation that the release of information form was offered to the client at the time of the inspection.
Client #8 was admitted into treatment on July 10, 2014 and was discharged on October 30, 2014. In the client record, there was a release of information form to a government agency that was dated 7/10/2014; however, there was no documentation that the release of information form was offered to the client at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Three out of the four charts with this deficiency are active client cases therefore the clinician assigned to these clients will complete new consents with each of these clients and offer copies of consents and document that a copy was offered and taken, or offered and declined by the client.
In addition to correcting the active records with this deficiency, the Quality Review Specialist will complete a regular internal audit process to ensure that these types of errors are corrected immediately. Additionally the Program Director will provide training semi-annually for all clinical staff to ensure that they understand how these consent forms are to be completed and that all clients are offered copies of their consents and documentation of whether clients accepted or declined copies will be present. These trainings will take place during regular peer review meetings and will be documented in the meeting minutes. |
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 a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in five of ten client records reviewed.
The findings include:
Ten client records were reviewed on June 17, 2015. Eight client records required the treatment and rehabilitation plans to be reviewed and updated at least every 60 days. The facility failed to document updated treatment and rehabilitation plans in client records # 1, 3, 4, 6, and 7.
Client #1 was admitted into treatment on January 12, 2015 and was still an active client as of the date of the on-site inspection. The treatment and rehabilitation plan was developed on 1/12/2015 and there should have been updates no later than 3/12/2015 and 05/12/2015; however, there was only one treatment and rehabilitation plan update, dated 5/14/2015, documented in the record as of the date of the inspection.
Client #3 was admitted into treatment on April 6, 2015 and was still an active client as of the date of the on-site inspection. The treatment and rehabilitation plan was developed on 4/13/2015 and there should have been an update no later than 6/13/2015; however, there was no treatment and rehabilitation plan update documented in the record as of the date of the inspection.
Client #4 was admitted into treatment on May 9, 2014 and was still an active client as of the date of the on-site inspection. The treatment and rehabilitation plan was developed on 5/09/2014. The documented treatment and rehabilitation plan updates were completed on 11/06/2014, 2/12/2015, 5/06/2015. None of the treatment and rehabilitation plans documented in the client record were within 60 days of each other as of the date of the inspection.
Client #6 was admitted into treatment on March 19, 2014 and was discharged on October 13, 2014. The client's treatment and rehabilitation plan was completed on 3/19/2014 and there should have been updates no later than 5/19/2014, 7/19/2014, and 9/19/2014; however, there were no treatment and rehabilitation plan updates documented in the client record at the time of the inspection.
Client #7 was admitted into treatment on November 10, 2014 and was discharged on June 11, 2015. The client's treatment and rehabilitation plan was completed on 11/10/2014 and there should have been updates no later than 1/10/2015, 3/10/2015, and 5/10/2015; however, there were no treatment and rehabilitation plan updates documented in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Quality Review Specialis will conduct a regular internal audit process to ensure that these treatment plans and treatment plan updates are being completed every 60 days. Additionally the Program Director will provide training semi-annually for all clinical staff to ensure that they understand the 60 day time-frame for updated treatment plans. This training will also include the need to document in a progress note when a client cancels or "no-shows" on a date that the intent was to update the treatment plan. These trainings will take place during regular peer-review meetings and will be documented in the meeting minutes. |
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:
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual, which includes case consultation notes, and follow-up information in three of ten client records reviewed.
The findings include:
Ten client records requiring a complete client record on an individual were reviewed on June 17, 2015. The facility did not provide a complete client record for clients, #5, 6, and 8.
Client #5 was admitted into treatment on May 12, 2014 and was discharged on August 27, 2014. The facility failed to include documentation of case consultation notes in the client record at the time of the inspection.
Client #6 was admitted into treatment on March 19, 2014 and was discharged on October 13, 2014. The facility failed to include documentation of case consultation notes in the client record at the time of the inspection. Additionally, the facility failed to include follow-up information documentation in the client record at the time of the inspection.
Client #8 was admitted into treatment on July 10, 2014 and was discharged on October 30, 2014. The facility failed to include documentation of case consultation notes in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director will review active caseloads with clinical staff on a monthly basis. Director will hold at a minimum one peer review per month to ensure that clients are receiving adequate case consultation and that this is appropriately documented in the client record. Additionally training will occur semi-annually for all clinical staff to ensure that they understand the 90 day time-frame for case consultations as well as the need to document these consultations in the client's record. These trainings will occur during regular peer review meetings and will be documented in the meeting minutes. |