INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 7, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Life Management, Inc 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(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
Based on a review of the facility policy and procedure manual, the facility failed to document a confidentiality policy and procedure compliant with 4 Pa. Code subsection 255.5.
The findings included:
4 Pa. Code subsection 255.5 (a)(6), states: "Projects may disclose with the consent of a client, in writing, the information to employers of a client to further the rehabilitation of a client; or, to a prospective employer who affirmatively expresses that information is sought to enable the employer to engage the client as an employee. Such information shall be limited to whether the client has or is receiving treatment with the project."
The facility policy and procedure manual was reviewed as part of the annual onsite licensing inspection of March 5 - 6, 2012. Policy # 60,006, section C, subsection 2, letter f, exceeded 4 Pa. Code subsection 255.5 (a)(6), as it allowed for the following: "Life Management may disclose with the client's consent, the information to employers of a client to further the client's rehabilitation; or, to a prospective employer who affirmatively expresses that information is sought to enable the employer to engage the client as an employee. Information released shall be limited to that provided for in subsection 4.a. in this section."
Subsection 4.a. states: " Nature of Client Information to be Disclosed. a. Information released to judges, probation or parole officers, insurance company, health or hospital plan or government officials, pursuant to section C.2.a-i of this section, is for the purpose of determining the advisability of continuing th client in treatment with Life Management and shall be restricted to the following:
i. Whether or not the client isn't in therapy
ii. The prognosis of the client
iii. The nature of the project
iv. A brief description of the client's progress
v. A short statement as to whether the client has relapsed into drug or alcohol abuse and the
frequency of such relapse."
The project's Confidentiality policy permits for the release of information under ii, iv, and v, which is restricted under 4 PA Code 255.5(a)(6).
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Plan of Correction
The Executive Director of Rehab After Work will change the section in the Policy & Procedure msnusl(#66006) to reflect that "informstion specifically released to employers will be limited to whether a client has or is receiving treatment with the project". This policy change will be circulated to all offices.
All Staff will attend a six hour training on Confidentiality (255.5) on April 13, 2012 at the Phoenixville location of Rehab After Work.The policy addendum will be reviewed to all staff as part of the Confidentiality training.
Site Directors will perform random chart audits on a monthly basis to ensure that the Confidentiality policy change is reflected by all clinicians and that the standard is met. |
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
Based on a review of client records and the facility's policies and procedures, the facility failed to document an aftercare plan in accordance with the project's policies and procedures.
The findings include:
In reference to aftercare plans the project's policy states:
A Continuing Care Plan is to be completed within one month of the scheduled discharge date ....in relation to ongoing individual sessions. To be completed and signed by the counselor and client prior to discharge.
On March 7, 2012 two client records were reviewed for aftercare plans. Two out of two client records lacked documentation of an aftercare plan that included the client's signature and the date the aftercare plan was completed, specifically client records # 5 and 6.
Client #5 was admitted on September 15, 2011 and discharged on December 20, 2011. An aftercare plan was documented; however it was undated and unsigned by the client.
Client #6 was admitted on May 9, 2011 and discharged on August 24, 2011. An aftercare plan was documented; however it was undated and unsigned by the client.
The findings were confirmed by the Site Director during the exit interview.
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Plan of Correction
The staff will be educated on the project's policies and procedures regarding Continuing Care Plans. Counselors will review aftercare plans with clients within one month of scheduled dischaerge date. The aftercare plan will be signed by counselor and client prior to discharge. Random chart audits will be taken and aftercare plans will be reviewed until the standard is met. |