INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 3 -4, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare Inc. Pine Ridge 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 December 1, 2010.
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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, the facility failed to document an informed and voluntary consent from the client for disclosure of information that indicated the specific information to be disclosed and the purpose of disclosure in two of six client records.
The findings included:
Six client records were reviewed on November 3, 2010. Six client records required an informed and voluntary consent to release information from the client; including the specific information to be disclosed and the purpose of disclosure. Per regulation, the project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record; including the specific information to be disclosed and the purpose of the disclosure.
The facility failed to obtain an informed and voluntary consent from the client; including the specific information to be disclosed and the purpose of disclosure in client records # 2 and 4.
Client record # 2 - The consent to release information forms for releases of information to other treatment providers failed to indicate the specific information to be disclosed and the specific purpose for the disclosure. Several options were provided for the category of specific information to be released and for the category of the purpose of the release on the standardized "consent to release information" forms. Facility staff completing the forms had checked off all of the options in both categories.
Client record #4 - A consent to release information form for a release of information to a magistrate was not documented, however, information was disclosed in a letter to a magistrate.
On November 3, 2010, the facility director confirmed the consents to release information in client records # 2 and 4 did not include informed and voluntary consents. The facility director confirmed the release of information forms were not correctly completed in client records #2 and 4.
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Plan of Correction
Program Director will conduct an in-service training with all clinical staff in order to provide them training on how to complete informed and voluntary consents accurately. This training will take place by December 10, 2010. Program Director will then monitor the completion and accuracy of all informed and voluntary consents via open and closed chart monitor monthly for a period of 90 days. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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
Based on a review of client records, the facility failed to document case consultations in two of two client records.
The findings include:
Ten client records were reviewed on November 3, 2010. Documentation of case consultations were required in two client records. The regulation states "Where the length of treatment is less than 90 days, at least one case conference should be conducted for each client". The facility policy states case consultations are due every 90 days. The facility did not document case consultations in client records # 5 and 6.
Client # 5 was admitted on June 29, 2010 and was discharged on September 21, 2010. At least one case conference should have been documented. No documentation of a case consultation was found.
Client # 6 was admitted on May 11, 2010 and was discharged on June 26, 2010. At least one case conference should be documented. No documentation of a case consultation was found.
The conversation with the facility director on November 3, 20109 confirmed the consultations were not completed.
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Plan of Correction
Pyramid's facility policy will be changed to reflect the need for a case consultation in each chart when client is in treatment less than 90 days. This policy will state that a case consultation will be completed in 7 days of admission and then at 90 days. Pyramid's Corporate Clinical Coordinator will make this policy change by December 10, 2010. The Facility Program Director will monitor the inclusion of a case consultation at 7 days of admission via open and closed chart monitor monthly for a period of 90 days. |