INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 5, 2009 through August 6, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Interim House West 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 August 29, 2009.
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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 obtain an informed and voluntary consent from the client for the disclosure of information in nine of nine client records
Findings:
Nine client records were reviewed on August 6, 2009. Consent to release information forms were required in nine client records. The facility failed to inform the client that they have the right to verbally revoke their consents in records #1, 2, 3, 4, 5, 6, 7, 8 and 9.
Record #1 had a consent to release form dated 7/7/09 did not have what was being released on the consent to release form.
Record #2 had a consent to release form dated 7/7/09 did not have the signature of the witness, did not have what was being released and client was not given the right to receive a copy or not of the consent to release form.
Record #3 had a letter to family court dated 5/19/09 no consent to release form documented in record reviewed. Telephone communication with client's lawyer (7/15/09) and foster care social worker (5/27/09) was documented in client's record, but did not see consent to release form in record reviewed.
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Plan of Correction
In the charts audited, IHW staff failed to complete a release of information form correctly in 3 of the charts audited. Additionally the form utilized did not include a client's right to verbally withdraw the consent.
IHW clinical director and VP of quality assurance will hold a staff training to review 709.28 regulations as it pertains to release of information. Effective 9/8/09 the form will be revised to include a consumers right to withdraw a consent written or verbally. The program will have all current consumers releases. updated with the correct form. IHW's Clinical Director and QM department will perform quarterly chart audits to ensure compliance with this standard. The Program director will monitor the overall compliance on a monthly basis. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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:
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Observations
Based on the review of client records, the facility failed to document individualized treatment plans in eight of nine records reviewed.
Findings:
Nine client records were reviewed on August 6, 2009. Treatment plans were required in eight of nine client records. Based on the review of the facilities policy and procedure manual, reviewed on August 5, 2009, the comprehensive treatment plan is to be developed within 30 days. Comprehensive treatment plans were documented 15 days before the clients psychosocial evaluations were completed in records #1, 2, 3, 4, 5, 6, 8 and 9.
Client # 1 was admitted on 2/18/09 and their comprehensive treatment plan was developed on 3/5/09 and their psychosocial evaluations developed on 3/18/09.
Client # 2 was admitted on 6/24/09 and their comprehensive treatment plan was developed on 7/7/09 and their psychosocial evaluations developed on 7/24/09.
Client # 3 was admitted on 4/9/09 and their comprehensive treatment plan was developed on 4/23/09 and their psychosocial evaluations developed on 5/9/09.
Client # 4 was admitted on 5/18/09 and their comprehensive treatment plan was developed on 6/2/09 and their psychosocial evaluations developed on 6/18/09.
Client # 5 was admitted on 1/7/09 and their comprehensive treatment plan was developed on 1/21/09 and their psychosocial evaluations developed on 2/7/09.
Client # 6 was admitted on 2/18/09 and their comprehensive treatment plan was developed on 3/4/09 and their psychosocial evaluations developed on 3/18/09.
Client # 8 was admitted on 4/1/09 and their comprehensive treatment plan was developed on 4/16/09 and their psychosocial evaluations developed on 5/1/09.
Client # 9 was admitted on 2/2/09 and their comprehensive treatment plan was developed on 2/16/09 and their psychosocial evaluations developed on 3/2/09.
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Plan of Correction
Effective immediately, the comprehensive treatment plans will be developed within 30 days. The comprehensive treatment plan will be designed based on the pyscho-social evaluation.
The clinical director and VP of quality assurance will hold a staff training to address this regulation and IHW's compliance with this standard. The clinical director will ensure compliance through weekly individual supervisions with program therapist. The program director will ensure overall program compiance on a qaurterly basis. |