INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 15, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Chartiers Community Mental Health and Mental Retardation Center, 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 (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
The facility failed to document an informed and voluntary consent from the client for the disclosure of information contained in the client record in ten of ten client records reviewed on December 15, 2016.
Ten client records were reviewed. Consents in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 had language that exceeded 255. 5. The language included statements that the information released may not be protected by federal privacy regulations and therefore there is a potential for unauthorized re disclosure; if person or entity receiving the information is not a provider or health plan covered by federal privacy regulations, the information may be re disclosed and is no longer protected by those regulations.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All consents will be revised in the electronic record to contain the following statement:
CONSUMER RIGHTS: I understand that signing this authorization is voluntary and Chartiers Center cannot deny me treatment for not agreeing to sign this authorization. I understand that I may see a copy of the information described on this form and that there may be a fee associated with copying.
I understand that my records are protected under the state and federal regulation and that the above information will be disclosed from records whose confidentiality is protected by the federal confidentiality of substance abuse patient records statute, section 643 of the Public Health Service Act, 42 U.S.C. 290dd-2, and its implementing regulation, 42 CFR, Part 2; the Health Insurance Portability and Accountability Act of 1996, and its implementing regulations; and the Pennsylvania Drug and Alcohol Abuse Control Act, 71 p.s. 1690.1010 et.seq. I understand that Federal regulations (42 CFR, Part 2) prohibit any further disclosure unless expressly permitted by the written consent of the person to whom it pertains, or as otherwise permitted by such regulations.
I understand that I may revoke this consent at any time by notifying this agency, verbally or in writing, except to the extent that action has been taken in reliance on my consent. If I have a question about disclosure of my health information, I may contact the Health Information Services or the Privacy Officer of Chartiers Center.
The Facility Director shall ensure that the current consents existing in the electronic record are revised as indicated above by 01/17/2017; this will prevent further use of the deficient consent forms. On an ongoing basis thereafter, the Facility Director will review completed consents via chart audits to ensure accurate completion of such.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to review and update treatment and rehabilitation plans at least every 60 days in three of seven client records reviewed on December 15, 2016.
Ten client records were reviewed. Seven of the clients required treatment and rehabilitation plans to be updated. Client records # 7, 8 and 10 did not include treatment and rehabilitation plans that were updated at least every 60 days.
Client # 7's update was due October 17, 2016 and was completed November 17, 2016.
Client # 8's update was due October 25, 2016 and was completed November 29, 2016.
Client # 10's update was due May 7, 2016 and was completed July 5. 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An ongoing schedule to ensure that Service Plan Reviews occur every 60 days has been implemented by the Facility Director on 01/10/2017. All staff are required to check the schedule so as to review and ensure timely completion of each review. In the event that the client does not show for a scheduled appointment so as to complete a Service Plan review, a review of treatment shall be documented in the electronic record by the primary counselor so as to ensure completion within the sixty (60) day time frame. On an ongoing basis, so as to ensure that further deficiencies do not occur, the Facility Director is responsible to check the schedule to review, provide necessary prompts and assistance to ensure timely completion of each review. |
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
The facility failed to document a complete client record on an individual which included a case consultation note in two of five client records reviewed on December 15, 2016.
Ten client records were reviewed. Five client records required documentation of case consultation notes. Client records # 7 and 8 did not document a case consultation note.
Client # 7 was discharged on November 11, 2016. No case consultation note was documented.
Client # 8 was discharged on November 29, 2016. No case consultation note was documented.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the policy of Chartiers Center to maintain a complete client record for each individual that includes information relative to the client's involvement in treatment. So as to ensure a complete record, a Case Consultation will be conducted for each consumer prior to discharge.
A schedule to ensure that Case Consultations occur on as required has been implemented by the Facility Director on 01/10/2017. All staff are responsible to review the schedule to ensure that Case Consultations occur as scheduled. On an ongoing basis, to ensure that further deficiencies do not occur, the Facility Director
is responsible to check the schedule to review, provide necessary prompts and assistance to ensure timely completion of Case Consultations.
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