INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 10, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on May 9, 2007.
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Plan of Correction
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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
The written procedures for the confidentiality of client identity and records contained a document designed by CODAPP titled "Confidentiality Regulations and the Drug and Alcohol Treatment Programs." This document contained various discrepancies regarding disclosure to the parents of a minor without the client's consent, the wording "with or without the client's consent" to Judges and Probation/Parole. In addition, written procedures state that "a client may revoke a consent to release information, in writing, to the clinic or project manager. The facility must honor a client's verbal revocation of a consent and the facility must document the verbal revocation in writing.
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Plan of Correction
The Director of Quality Improvement has removed the CODAPP document from the policy and procedure manual. This was replaced with copies of the 255.5 and 42CFR regulations. The Project Director will oversee that the company's confidentiality policy is revised to allow for verbal revocation of consents. The Facility Director will oversee the distribution and review of this revised policy to all staff in staff meeting. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Consent to release information forms were obtained for the purpose of releasing information to probation/parole in 2 out of 14 client records reviewed, specifically # 10 and 13; however, neither of the client's had probation/parole officers.
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Plan of Correction
The Facility Director will oversee that all staff are educated through staff meeting of the importance in obtaining only those consent to release forms which are applicable to each individual client. The identified probation/parole releases have been marked "invalid". |
709.28(c)(4) 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:
(4) Dated signature of client or guardian.
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Observations
The dated signature of the client or guardian was missing on 2 consent to release information forms in 1 out of 14 client records reviewed, specifically # 3.
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Plan of Correction
Following the licensing visit, the signature of the client was dated on the consent to release form in the identified chart. The Facility Director will oversee that all staff are reminded in staff meeting to make sure all consent to release forms are completed thoroughly. The Quality Improvement Department will oversee the internal monitoring of completed consent forms. |
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
The personal histories failed to address family relations, significant events/problems related to the family history and recreation interests in 14 out of 14 client records reviewed, specifically # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14. In addition, documentation failed to clarify one word responses from the client.
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Plan of Correction
The Facility Director will oversee that all clinical staff receive training in staff meeting to educate the therapists on gathering more detailed information regarding family relations, significant events/problems related to the family history, and recreation interests in each client's personal history. |
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
The psychosocial evaluation was historical rather than evaluative and failed to include clinical impressions and opinions regarding the client's problems/needs, assets/strengths, support systems and coping mechanisms in 14 out of 14 client records reviewed, specifically # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14.
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Plan of Correction
The Facility Director will oversee that all staff are reminded in staff meeting to give clinical impressions and opinions regarding the client's problems/needs, assets/strengths, support systems and coping mechanisms in each client's psychosocial evaluation. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
The short and long-term goals of the individual treatment plan failed to contain individualized goals with measurable action steps in 14 out of 14 client records reviewed, specifically # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14.
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Plan of Correction
The Facility Director will oversee that all clinical staff are educated in staff meeting in regards to the completion of the individual treatment plan and how to create individualized goals with measurable action steps. |
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
The treatment plan updates did not address the client's progress in the past 60 days as it relates to the treatment plan goals identified on the individual treatment plan in 4 out of 4 client records reviewed, specifically # 4, 5, 8 and 13.
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Plan of Correction
The Facility Director will oversee that all clinical staff receive training in staff meeting to educate staff on completing a thorough treatment plan update which addresses the client's progress in the past 60 days as it relates to the treatment plan goals identified on the individual treatment plan. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
The group progress notes failed to include individual assessments in 10 out of 14 client records reviewed, specifically # 1, 2, 3, 4, 7, 8, 9, 11, 13 and 14. In addition, numerous group notes were illegible.
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Plan of Correction
The Facility Director will oversee that all staff are educated in staff meeting to thoroughly complete the individual assessment of the group progress note. The Quality Improvement Department will oversee that progress notes are monitored for thorough completion. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
The case consultation failed to address the purpose of the consultation, and did not include an accurate account of which staff attended the consultation, a summary of the discussion that was held, or a disposition in 4 out of 4 client records reviewed, specifically # 4, 5, 8 and 13.
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Plan of Correction
The Quality Improvement Department will oversee the revision of the case consultation format to include the purpose of the consultation, a summary of the discussion that was held or a disposition and an accurate account of which staff attended the consultation. The Facility Director will oversee the distribution and review of the revised case consultation note to all clinical staff in staff meeting. Clinical staff will also be educated in completing the note thoroughly. |
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
The aftercare plans failed to include realistic and measurable goals and support services in 3 out of 4 client records reviewed, specifically # 9, 10 and 14. In addition. the aftercare plan was missing in client record # 13.
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Plan of Correction
The aftercare plan has been revised to prompt therapists to give more realistic and measurable goals and support services. The Facility Director will oversee the distribution and review of the revised aftercare plan to all clinical staff in staff meeting, highlighting the importance of creating realistic/measurable goals and support services. |