Observations
Seven client records were reviewed on June 23, 2017. The facility failed to obtain a consent to release information form for information released in two of seven client records reviewed, specifically client records #3 and #5.
Client #3 was admitted into treatment on March 2, 2017 and was still an active client at the time of the inspection. The client record contained documentation indicating that the facility released patient identifying information to a funding source on June 22, 2017 and failed to obtain an informed and voluntary consent prior to the disclosure.
Client #5 was admitted into treatment on October 20, 2016 and was discharged on March 15, 2017. The client record contained documentation indicating that the facility released patient identifying information to a treatment provider on February 16, 2017 and failed to obtain an informed and voluntary consent prior to the disclosure.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
An all staff in service training will be held on 7-7-17. PA Code 255.5 will be reviewed. All staff will be reminded that no information will be released to outside sources without a client signed release of information. All correspondence documented in the client chart will be monitored monthly by Program Management in the CQI process to ensure compliance. All new clinical hires will be required to enroll in Confidentiality training. Client # 5 has been discharged - unable to obtain appropriate release. The clinician of client # 3 has been notified on 6-23-17 that written consent needed to be obtained by the client. A follow up for compliancy will be completed by the Division Director by 7-31-17. |
Observations
Seven client records were reviewed on June 23, 2017 for treatment and rehabilitation services. The facility failed to provide counseling services as stated on the treatment plan in three of seven client records reviewed.
Client #1 was admitted into treatment on February 15, 2017 and was still an active client at the time of the inspection. The client's treatment plan indicated that individual sessions were to occur once per week. The progress notes and record of service forms contained in the record indicated that the client had no individual sessions during the weeks of April 9, 2017 through April 15, 2017, April 30, 2017 through May 6, 2017, May 14, 2017 through May 20, 2017, May 28, 2017 through June 3, 2017 and June 11, 2017 through June 17, 2017.
Client #4 was admitted into treatment on December 27, 2016 and was discharged on April 25, 2017. The client's treatment plan indicated that individual sessions were to occur once per week and groups were to occur once per week. The progress notes and record of service forms contained in the record indicated that the client had no individual sessions during the weeks of March 5, 2017 through April 1, 2017. Additionally, the client had no group sessions during the weeks of March 5, 2017 through March 18, 2017.
Client #7 was admitted into treatment on September 15, 2016 and was discharged on April 26, 2017. The client's treatment plan update, dated November 15, 2016 indicated that individual sessions were to occur once per week and groups were to occur twice per week. The progress notes and record of service forms contained in the record indicated that the client had no individual sessions during the weeks of December 11 2017 through December 31, 2017. The client's treatment plan update, dated January 10, 2017, indicated that individual sessions were to occur once per week and groups were to occur once per week. The progress notes and record of service forms contained in the record indicated that the client had no individual sessions during the weeks of January 29, 2017 through February 18, 2017 and February 26, 2017 through March 4, 2017. The client's treatment plan update, dated March 10, 2017, indicated that individual sessions were to occur once per month and groups were to occur once per week. The progress notes and record of service forms contained in the record indicated that the client had no group session during the week of March 11, 2017 through March 18, 2017.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
An all staff in service training will be held on July 7, 2017 to address clinical staff on treatment management procedures specific to assuring that counseling services are provided according to the individual and treatment plan updates. All staff will be directed to schedule clients according to their treatment recommendation and document weekly on the client record of service. Any deviation from the set course of treatment will also be documented on the record of service. The Division Director will review treatment plans recommendations and compare it to the record of service for compliancy during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions as well as weekly during clinical meeting. |