INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 15, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Gaudenzia Montgomery County Outpatient 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 (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.
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Observations
Based on the review of eleven client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in client record #3 and #4. Additionally, client record #1 had consent to release forms that were missing the date of the client's signature.
Client #1 was assessed in the intake, evaluation, and referral level of care on 05/23/2017. There were consent to release information forms to the emergency contact, a government agency, the urinalysis lab, the funding source, and an outside treatment provider that were signed by the client; however, there was no date of the client's signature on any release form.
Client #3 was assessed in the intake, evaluation, and referral level of care on 5/19/2017. There was documentation of contact with another treatment provider on behalf of the client on 5/19/17; however, there was no proper consent to release information form signed by the client prior to disclosure.
Client #4 was assessed in the intake, evaluation, and referral level of care on 5/9/2017. There was documentation of contact with another treatment provider on behalf of the client on 5/16/17 and 5/17/17; however, there was no proper consent to release information form signed by the client prior to disclosure.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Division Director will meet with the clinical staff of Montgomery County Outpatient program on 6/28/17 to address the need for to document an informed and voluntary consent to release information form prior to the disclosure of information. As well as, the need for all release forms to be dated by the client at time of signature. Division Director will review clinical charts on a monthly basis to ensure compliance. This process will be overseen for compliance by the Deputy of Eastern Region by 6/28/17. |
709.93(a) 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:
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Observations
Based on a review of seven client records, the facility failed to provide a complete client record, which is to include a record of service and follow-up information in client record #'s 6, 7, and 9.
Client #6 was admitted into the outpatient level of care on 11/18/2016 and was discharged on 05/13/2017. The record did not contain documentation of any follow-up information at the time of the inspection.
Client #7 was admitted into the outpatient level of care on 10/07/2016 and was discharged on 04/24/2017. The record did not contain documentation of any follow-up information at the time of the inspection.
Client #9 was admitted into the outpatient level of care on 07/08/2016 and was still an active client. The record did not contain documentation of a record of service at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Division Director will address the clinical team during the staff meeting on 6/28/17 regarding the need for follow-up information to be documented on the follow-up form in discharged charts. All closed charts will be reviewed on a monthly basis to ensure compliance by the Division Director.
In addition, during this staff meeting on 6/28/17, the administrative staff will be addressed on the requirement of a record of service in every client chart. Division Director will review active and closed charts on a monthly basis to ensure compliance. There is now a current record of service in chart #9. Compliance to this process will be ensured by the Deputy of Eastern Region by 6/28/17. |
709.43(e) LICENSURE Consent to TX
709.43. Client management.
(e) A consent to treatment form should be completed and signed by the client and intake worker at intake.
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Observations
Based on a review of four client records, the facility failed to document a consent to treatment in client record #'s 2, 3, and 4.
Client #2 was assessed in the intake, evaluation, and referral level of care on 05/26/2017.
Client #3 was assessed in the intake, evaluation, and referral level of care on 05/19/2017.
Client #4 was assessed in the intake, evaluation, and referral level of care on 05/09/2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Division Director will address clinical intake staff on 6/28/17 in the staff meeting on the importance of obtaining a consent to treatment from all clients prior to the intake evaluation process. The Division Director will review charts on a monthly basis to ensure compliance. This process will be overseen for compliance by the Deputy of Eastern Region by 6/28/17. |
709.44(a)(3) LICENSURE Psychosocial evaluation
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(3) Psychosocial evaluation.
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Observations
Based on a review of four client records, the facility failed to provide a complete client record, which is to include psychosocial evaluations, referral contacts, and record of services in client record #'s 1, 2, and 3.
Client #1 was assessed in the intake, evaluation, and referral level of care on 05/23/2017. The record did not contain documentation of a record of service, as well as documentation of referral contact at the time of the inspection.
Client #2 was assessed in the intake, evaluation, and referral level of care on 05/26/2017. The record did not contain documentation of a record of service, as well as documentation of a psychosocial evaluation at the time of the inspection.
Client #3 was assessed in the intake, evaluation, and referral level of care on 05/19/2017. The record did not contain documentation of a record of service at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Division Director will address clinical intake staff on 6/28/17 during the staff meeting regarding the need for a complete client record, which is to include psychosocial evaluations, referral contacts, and record of services in client record. Division Director will review intake charts on a monthly basis to ensure compliance. This process will be overseen for compliance by the Deputy of Eastern Region by 6/28/17. |