INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 5-7, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Schuylkill Health System center for 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 and a plan of correction is due on June 3, 2009.
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Plan of Correction
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on review of client census lists, the self report staffing form documented by the facility director on May 5, 2009 and interviews with the facility director and the clinical supervisor on 5/5/2009 at 8:30 AM, the facility failed to maintain caseloads at the required 35:1 client to counselor limit.
The findings include:
Two out of six counselors and one out of two clinical supervisors had documented client to counselor caseloads exceeding the 35:1 caseload limitation. Employee # 3 had a caseload of 37:1; employee # 8 had a caseload of 64:1; and employee # 6 had a caseload of 39:1. This is a repeat deficiency from 2008.
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Plan of Correction
1. Two new clinical Staff have been hired (4/23/2009)and(5/16/2009). A three month probationary period and competency review is completed prior to assignment of a full caseload. At time of caseload assignment we will prioritize and when necessary transfer cases from other counselors to new staff to balance individual patient/staff ratios.
Time Frame: Ongoing to 9/30/2009
Responsiblity: Facility Director and Clinical Supervisors
2.Utilization Review will be conducted on active cases by creating a 30 day no contact list identifing assigned therapist and patients not seen in thirty days for face to face contact. This list will be reviewed in individual and or group supervision and inentify cases in need of follow up or closure and help insure appropiate processing of patients.Review will occur weekly with each counselor
Responsiblity: Facility Director and Clinical Supervisors
Timeframe: Ongoing 6/15/2009.
3. Patient Staff ratios will be calculated monthly using the Staffing Requirements Facility Summary Report (pg.5)in order to assess ratios on each counselor and adjust as determined necessary.Summary will be completed on the first day of the new calander month for the previous calander month and be adjusted as needed.
Responsible Staff: Clinical Supervisors and Facility Director.
Timeframe: Monthly beginning June 2009.
All Correcti
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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection during the onsite licensing inspection of May 5-7, 2009, the facility failed to ensure that portable space heaters were not utilized in the facility.
The findings include:
All offices and storage areas were inspected on May 6, 2009 between 8 and 8:30 AM. A portable space heater was found on the floor in office # 2 .
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Plan of Correction
1. Director will meet with employee in Office 2 upon his return from benefit leave (5/26/09) and address the finding.Director will inform him of the fact that space heaters of the type found in his office are not permitted and are a violation of policy. Future use is forbidden.
Timeframe: 5/26/2009
Responsible Person: Director
2. Written memo to all staff re-enforcing the policy of no use of portable space heaters permitted in facilities.
Timeframe: 5/27/2009
Responsible Person: Director
3. Monthly physical plant inspection to monitor office areas and insure compliance.
Timeframe: 6/01/2009 ongoing monthly thru 12/31/09.
Responsible Person: Director
4.Review of policy in General Staff Meeting under "Safety" in minutes.(June,30 2009).
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711.91(b)(3)(iii) LICENSURE Personal History
711.91. 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 records during the onsite licensing inspection of May 5-7, 2009, the facility failed to document comprehensive personal histories on each client.
The findings include:
Thirteen client records were reviewed during the annual onsite licensing inspection. Each was required to include documentation of a personal history. Client records # 3, 4, 6, 7, 8, 9, 10 and 11 failed to document complete family histories on the client as evidenced by the absence of family interrelationships in the family of origin, as well as interrelationships in the current family constellation.
Client records # 1, 2, 4, 9 and 12 failed to document employment histories which showed the client's complete work history and focused primarily only on the client's most recent employment.
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Plan of Correction
1. Clinical Staff In-Service on Intake Assessment focusing on expansion of information collected in all areas of assessment with focus on accurate completion of required information as well as more comprehensive value added recording of responses. The areas of family history and employment will be included in the presentation.
Responsible Person: Clinical Supervisors/Program Director
Timeframe: 6/30/2009
2. Clinical supervisors will review all intake assessments completed and include an evaluative review of the family and employment histories. Feedback to clinical staff will occur in weekly individual supervision.
Responsible Person: Clinical Supervisors
Timeframe: 7/1/09 ongoing. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) 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 on May 5-7, 2009, the facility failed to document treatment plan updates which addressed the stated goals of the treatment plan or did not document needed modifications to the existing treatment plans based on the progress made.
The findings include:
Thirteen client records were in the sample. Each client record was required to have treatment plan updates documented. Treatment plan updates were not documented in the following records:
Client record # 4, the treatment plan was completed 10/21/08, no treatment plan update was documented in the client record as of May 5, 2009.
Client record # 8, the treatment plan was documented 12/5/08, no treatment plan update was documented in the client record as of May 5, 2009.
Based on a review of client records on May 5 and 6, 2009, the clients' progress on the documented short term treatment goals was not addressed in the treatment plan updates in client records # 3 and 5.
Client record # 3 - The treatment plan documented on 8/11/08 indicated that 5 of 6 stated goals were met prior to the treatment plan updates of 9/11/08 and 11/6/2008 but no new goals or objectives were documented.
Client record # 5 - The treatment plan was documented 8/28/08. Documentation on the treatment plan indicated that goals were met by 10/13/08, but at the time of the 10/27/08 treatment plan update no new goals were documented. The comment on the update note indicated that the stated goals would continue with the client in outpatient treatment.
Each client record reviewed had a support services plan documented at the time of intake. This method of documenting support services is utilized by the agency rather than including the support services on the comprehensive treatment plan document. No update to this 'supplementary' treatment plan was documented in thirteen of thirteen client records reviewed, specifically client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 or 13.
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Plan of Correction
This Plan of Correction has a scope beyond the observation recorded but includes steps that are designed to correct the area of concern while improving the overall process:
A. New Admissions: All new patient records are reviewed by the clinical supervisor at the time of admission. The review process will be expanded to include the following steps:
1.Establish Reason for referral
2.Review problem list and develop clinical strategies to be considered on treatment plan.
3.Establish areas to be included on the master treatment plan
4. Establish an interval of clinical contact given the clinical severity and need for intervention
5.Affirm level of care decision and group assignment
6. Assign case to primary counselor.
This information will be given to the assigned counselor to be utilized in the development of the master treatment plan.
The assigned counselor is responsible for the development of the master treatment plan and for scheduling the appointment.
The master treatment plan is to be completed at the first session with the assigned therapist and this session is to occur within ten working days of case assignment.
Initial plan will then be reviewed by the clinical supervisor for appropiateness and conformance to requirements.
The review will include but not be limited to the following:
1.Appropiate problem and goal statements
2.Appropiate objectives and methods and timeframes.
3. Clinical interval for contact.
4. Signatires.
This supervisor review is the point of compliance monitoring.
Treatment Plan Update:
1. Occur every 60 days.
2. A computerized list will be generated listing all patients scheduled for review.
3. The list will include the following: Assigned therapist
Patient name
Assigned therapist
date previous plan developed
Date update due
4.Updates will occur in individual supervision where plans can be drafted with new and clinically appropiate goals and progress on previous plan reviewed.Assigned therapist will then process plan with patient.
A check list will be added to the treatment plan update form identifing services currently being utilized by the patient relative to ongoing support. These check boxes will utilize the catagories on the Support Service plan.
Timeframe:7/31/2009
Responsible Person: Clinical Supervisors and Director.
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711.92(e) LICENSURE Provision of TX RE: TX Plan
711.92. Treatment and rehabilitation services.
(e) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records on May 5-7, 2009, the facility failed to document the provision of individual counseling services according to the individual treatment and rehabilitation plan.
The findings include:
Thirteen client records were reviewed during the onsite licensing inspection. Each client record was required to include documentation of the provision of treatment services in accordance with the type and frequency specified in the comprehensive treatment plan.
Treatment plan documentation in the following records specified that the client was to receive weekly individual counseling services : Client records # 1, 2, 4, 5, 6,12. Weekly individual counseling services were not documented in these records.
Record # 1 - The client was admitted to treatment 1/16/09, the treatment plan required individual sessions weekly. As of the date of the record review on 5/5/09 individual sessions were documented on the following dates: 2/9/09, 4/6/09 and 4/27/09.
Record # 2 - The client was admitted to treatment 11/6/08, the treatment plan required individual sessions weekly. As of the date of the record review on 5/5/09 individual sessions were documented on the following dates: 12/8/08, 12/29/08, 1/15/08, 1/29/09, 2/9/09, 2/12/09, 2/27/09, 3/10/09, 3/13/09 and 3/23/09.
Record # 4 - The client was admitted to treatment 10/21/08, the treatment plan required individual sessions weekly. As of the date of the record review on 5/5/09 individual sessions were documented on the following dates: 10/21/08, 1/7/09, 1/15/09, 1/22/09 and 1/29/09.
Record #5 - The client was admitted to treatment 8/6/08, the treatment plan required individual sessions weekly. As of the date of the record review on 5/5/09 individual sessions were not documented for the periods 9/11/08 through 10/13/08 and 11/3/08 through 12/17/08.
Record # 6 - The client was admitted to treatment 12/20/08, the treatment plan required individual sessions weekly. As of the date of the record review on 5/5/09 individual sessions were documented on the following dates: 12/30/08, 3/16/09, 3/30/09, 4/8/09, 4/22/09.
Record # 12 - The client was admitted to treatment 1/22/09, the treatment plan required individual sessions weekly. As of the date of the record review on 5/5/09 individual sessions were documented on the following dates: 10/31/08, 3/4/09, 3/11/09 and 3/311/09.
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Plan of Correction
This Plan of Correction has a scope beyond the observation recorded but includes steps that are designed to correct the area of concern while improving the overall process: A. New Admissions: All new patient records are reviewed by the clinical supervisor at the time of admission. The review process will be expanded to include the following steps: 1.Establish Reason for referral 2.Review problem list and develop clinical strategies to be considered on treatment plan. 3.Establish areas to be included on the master treatment plan 4. Establish an interval of clinical contact given the clinical severity and need for intervention 5.Affirm level of care decision and group assignment 6. Assign case to primary counselor. This information will be given to the assigned counselor to be utilized in the development of the master treatment plan. The assigned counselor is responsible for the development of the master treatment plan and for scheduling the appointment. The master treatment plan is to be completed at the first session with the assigned therapist and this session is to occur within ten working days of case assignment. Initial plan will then be reviewed by the clinical supervisor for appropiateness and conformance to requirements. The review will include but not be limited to the following: 1.Appropiate problem and goal statements 2.Appropiate objectives and methods and timeframes. 3. Clinical interval for contact. 4. Signatires. This supervisor review is the point of compliance monitoring. Treatment Plan Update: 1. Occur every 60 days. 2. A computerized list will be generated listing all patients scheduled for review. 3. The list will include the following: Assigned therapist Patient name Assigned therapist date previous plan developed Date update due 4.Updates will occur in individual supervision where plans can be drafted with new and clinically appropiate goals and progress on previous plan reviewed.Assigned therapist will then process plan with patient.
Weather it is the Master Treatment Plan formulation or update the supervisor will insure a frequency is identified and will then check records of service to determine if frequency identified is being followed with the patient and if changes in intervals are warrented and are clinically indicated modifications to the plan can be made.
In-service on treatment plan formulation and modifications by 7/31/2009.
Timeframe:7/31/2009
Responsible Person: Clinical Supervisors and Director.
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711.92(f) LICENSURE Couns. Prov.- Reg & Sched.
711.92. Treatment and rehabilitation services.
(f) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records during the annual onsite licensing inspection of May 5-7, 2009, the facility failed to consistently schedule individual counseling services on a regular basis.
The findings include:
Each of the thirteen client records reviewed was required to document regular and scheduled counseling services for the client. The following records did not include documentation that individual counseling services were scheduled as stipulated on the treatment plan, specifically client records # 1, 2, 4, 5, 6, 12.
Record # 1 - The client was admitted to treatment 1/16/09, the treatment plan required individual sessions weekly. As of the date of the record review on 5/5/09 individual sessions were documented on the following dates: 2/9/09, 4/6/09 and 4/27/09.
Record # 2 - The client was admitted to treatment 11/6/08, the treatment plan required individual sessions weekly. As of the date of the record review on 5/5/09 individual sessions were documented on the following dates: 12/8/08, 12/29/08, 1/15/08, 1/29/09, 2/9/09, 2/12/09, 2/27/09, 3/10/09, 3/13/09 and 3/23/09.
Record # 4 - The client was admitted to treatment 10/21/08, the treatment plan required individual sessions weekly. As of the date of the record review on 5/5/09 individual sessions were documented on the following dates: 10/21/08, 1/7/09, 1/15/09, 1/22/09 and 1/29/09.
Record #5 - The client was admitted to treatment 8/6/08, the treatment plan required individual sessions weekly. As of the date of the record review on 5/5/09 individual sessions were not documented for the periods 9/11/08 through 10/13/08 and 11/3/08 through 12/17/08.
Record # 6 - The client was admitted to treatment 12/20/08, the treatment plan required individual sessions weekly. As of the date of the record review on 5/5/09 individual sessions were documented on the following dates: 12/30/08, 3/16/09, 3/30/09, 4/8/09, 4/22/09.
Record # 12 - The client was admitted to treatment 1/22/09, the treatment plan required individual sessions weekly. As of the date of the record review on 5/5/09 individual sessions were documented on the following dates: 10/31/08, 3/4/09, 3/11/09 and 3/311/09.
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Plan of Correction
This Plan of Correction has a scope beyond the observation recorded but includes steps that are designed to correct the area of concern while improving the overall process:
A. New Admissions: All new patient records are reviewed by the clinical supervisor at the time of admission. The review process will be expanded to include the following steps:
1.Establish Reason for referral
2.Review problem list and develop clinical strategies to be considered on treatment plan.
3.Establish areas to be included on the master treatment plan
4. Establish an interval of clinical contact given the clinical severity and need for intervention
5.Affirm level of care decision and group assignment
6. Assign case to primary counselor.
This information will be given to the assigned counselor to be utilized in the development of the master treatment plan.
The assigned counselor is responsible for the development of the master treatment plan and for scheduling the appointment.
The master treatment plan is to be completed at the first session with the assigned therapist and this session is to occur within ten working days of case assignment.
Initial plan will then be reviewed by the clinical supervisor for appropiateness and conformance to requirements.
The review will include but not be limited to the following:
1.Appropiate problem and goal statements
2.Appropiate objectives and methods and timeframes.
3. Clinical interval for contact.
4. Signatires.
This supervisor review is the point of compliance monitoring.
Treatment Plan Update:
1. Occur every 60 days.
2. A computerized list will be generated listing all patients scheduled for review.
3. The list will include the following: Assigned therapist
Patient name
Assigned therapist
date previous plan developed
Date update due
4.Updates will occur in individual supervision where plans can be drafted with new and clinically appropiate goals and progress on previous plan reviewed.Assigned therapist will then process plan with patient.
A check list will be added to the treatment plan update form identifing services currently being utilized by the patient relative to ongoing support. These check boxes will utilize the catagories on the Support Service plan.
Timeframe:7/31/2009
Responsible Person: Clinical Supervisors and Director.
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711.93(c)(1)(i) LICENSURE Confidentiality - Client Identity/Records
711.93. Client records.
(c) Confidentiality.
(1) A written procedure shall be developed by the project director which complies 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:
(i) Confidentiality of client identity and records.
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Observations
Based on interviews with the facility director on May 5 at 10:30 AM and May 7 at 3:30 PM and documentation in client records and the agency manual from May 5-7, 2009, the facility failed to document policies consistent with applicable confidentiality law and regulation.
The findings include:
The notice of privacy practices document which is given to each client and documented via client sign off , was noted in 13 of 13 client records reviewed, specifically client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13. This document incorrectly identified circumstances when the facility might release client information without the client's specific, signed consent to do so . Examples of these circumstances include releases to medical personnel, related service providers such as home health agencies and laboratories, funding entities, domestic violence reporting . This document also incorrectly informs the client that they may request restrictions on the release of their health information, but that the agency is not obligated to honor these requests. This contradicts state law at 71 P. S. Subsection 1690.108(b) and federal regulations at 42 CFR Part 2, Subpart C, Subsection 2.32.
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Plan of Correction
The form referenced is the"Notice of Privacy Pratices" uesd in all areas of the instuition. In light of this the following Plan of Correction is offered:
1. An attachment will be added to the form that is department specific.The attachment will detail the additional provisions for confidentiality afforded to patients in treatment for substance abuse that go beyond the Privacy Pratice Notice.
Both federal and state confidentiality
provisions will be addressed and will include the need for a specific release of information authorizing any release of information as well as circumstances under which a release may occur without consent.Responsible Person: Program Director
Timeframe: 6/30/2009
3. In-service to all clinical staff on modification of confidentiality attachment on Privacy Pratice Notice.Person: Program Director
Timeframe: 6/30/2009 |
711.93(c)(2)(ii) LICENSURE Specific Info. Disclosed
711.93. Client records.
(c) Confidentiality.
(2) 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:
(ii) The specific information disclosed.
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Observations
Based on interviews with the facility director on May 5, 2009 at 10:30 AM and 5/7/09 at 3:30 PM, and a review of client records, the facility failed to limit disclosures of client identifying information to the parameters identified at 4 Pa. Code subsection 255.5(b).
The findings include:
Thirteen client records were reviewed from May 5-7, 2009. A third party payer required staff to complete a level of care assessment which demanded client identifying information regarding specifics of the clients' high risk behaviors over the previous 12 month period which exceeded the limitations imposed at 4 Pa. Code Subsection 255.5(b). The specific information requested by the third party payer included: suicide attempts, homicide attempts, inability to care for self, violent/aggressive behavior, victim of sexual/physical abuse, imprisonment, homelessness, D&A abuse and social isolation. Based on an interview with the facility director, it was confirmed that the agency has been completing this document for each client and releasing that information to that third party payer. In the sample of thirteen client records, this information was released to a third party payer in five client records, specifically client records #1, 2, 3, 11 and 12.
Consents to release information to next of kin and/or significant others were documented in five of thirteen client records. These consent to release information forms did not list the specific information that would be released in the event of an emergency . The following client records did not include documentation of the specific information to be disclosed in these situations: specifically client records # 1, 2, 5, 7 and 8.
Client record # 4 included documentation of a release of client identifying information to a significant other, without the client's written consent, for a family treatment session.
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Plan of Correction
1.Contacted the third party payor representative and informemed him of confidentiality issue related to form (via e-mail 5/20/2009).Faxed him a blank form as per his request(5/21/2009).
Facility has informed payor that we will no longer complete the section of the form that exceeds PA.255.5(5/21/2009)We will indicate on the form that the information requested in that section exceeds PA.255.5
Third party payor representative contacted facility and has agreed to accept forms within appropiate parameters of PA 255.5.(5/21/2009)
Responsible Person: Program Director
Timeframe: Noted Above
2.The program will continue to monitor forms prior to sending to insure the information beyond scope of PA 255.5 is not part of transmission.
Responsible Person:Program Director/System Specialist
Timeframe: 5/26/2009 ongoing.
3. In-service with clinical staff regarding confidentiality modifications in program will occur in June 2009.
Responsible Person: Program Director/Clinical Supervisors.
Timeframe: By 6/30/2009
Emergency Contact Release
1. The Release of Information for Emergency Contact will be made into a template to insure that the scope is consistant for all patients.
The purpose of the release will read:
" contact of the identified person in the event of an emergency related to the patient".
Information will be limited to the following:
1.Nature of emergency
2.Location of patient
3.Patient demographics.
2.In-service with clinical staff regarding confidentiality modifications in program will occur in June 2009.
Family Session Release:
1. Clinical Staff will be informed of the need to have a signed release in place prior to any session involving a family member. The purpose and limitations will be individualized depending on the clinical purpose of the session.
2. A Clinical staff in-service will occur in June 2009 to review all confidentiality modifications in the program.
Responsiblity: Program Director/Clinical Supervisors
Timeframe:By June 30,2009 |