Observations
Based on a review of personnel records, the facility failed to document annual staff work performance evaluations in one of two personnel records.
The findings include:
Four personnel records were reviewed on January 23, 2014. Annual staff work performance evaluations were required in two personnel records. The facility did not document annual staff work evaluations in personnel record #4.
Employee #4 was hired on April 4, 2011. The documented work performance was signed and dated by the employee on March 1, 2013; however it lacked the signature and date of a supervisor/evaluator verifying that this was presented to the employee by the supervisor/evaluator.
The Project Director did not dispute the findings.
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Plan of Correction
The Director of Outpatient Services will review the review policy in the year 2014 and have a new employee review template for the year 2015. Currently both employees are required to fill out the document twice and sign twice which can allow for error.
The Director of Outpatient Services will meet with the employee during the time of the review and check for signatures on the employee portion prior to starting the review. The Director will then foward the reviews to the President of the Board to ensure all signatures are on the document.
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Observations
Based on a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in nine of sixteen records reviewed.
The findings included:
Sixteen client records requiring proper releases of information were reviewed on January 23, 2014. The facility failed to stay within the limits imposed by 4 Pa. Code 255.5 (b) in client record #'s 1, 2, 3, 4, 6, 7, 10, 12, and 14.
Client #1 was admitted to treatment on 11-7-13 and was still an active client at time of the inspection. A release of information to a government agency was signed on 11-7-13 and allowed for the disclosure of information (bio-psychosocial assessment and treatment plans), which exceeded 255.5.
Client #2 was admitted to treatment on 12-24-13 and was still an active client at time of the inspection. A release of information to an insurance provider was signed on 12-24-13 and allowed for the disclosure of information (bio-psychosocial assessment and treatment plans), which exceeded 255.5. Additionally, a release of information to a government agency was signed on 12-24-13 and allowed for the disclosure of information (bio-psychosocial assessment and treatment plans), which exceeded 255.5.
Client #3 was admitted to treatment on 7-10-13 and was still an active client at time of the inspection. A release of information to a government agency was signed on 7-10-13 and allowed for the disclosure of information (bio-psychosocial assessment), which exceeded 255.5.
Client #4 was admitted to treatment on 9-17-13 and was still an active client at time of the inspection. A release of information to a government agency was signed on 9-17-13 and allowed for the disclosure of information (bio-psychosocial assessment and treatment plans), which exceeded 255.5.
Client #6 was admitted to treatment on 12-3-13 and was still an active client at time of the inspection. A release of information to a government agency was signed on 12-3-13 and allowed for the disclosure of information (bio-psychosocial assessment and treatment plans), which exceeded 255.5.
Client #7 was admitted to treatment on 11-1-13 and was still an active client at time of the inspection. A release of information to a government agency was signed on 11-1-13 and allowed for the disclosure of information (bio-psychosocial assessment and treatment plans), which exceeded 255.5.
Client #10 was admitted to treatment on 6-18-13 and was discharged on 9-27-13. A release of information to a government agency was signed on 7-17-13 and allowed for the disclosure of information (bio-psychosocial assessment and treatment plans), which exceeded 255.5.
Client #12 was admitted to treatment on 10-22-13 and was discharged on 12-18-13. A release of information to a government agency was signed on 10-22-13 and allowed for the disclosure of information (bio-psychosocial assessment and treatment plans), which exceeded 255.5.
Client #14 was admitted to treatment on 12-5-13 and was discharged on 12-23-13. A release of information to a government agency was signed on 11-7-13 and allowed for the disclosure of information (bio-psychosocial assessment and treatment plans), which exceeded 255.5.
The Project Director did not dispute the findings.
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Plan of Correction
The Director and the Lead Couneslor will review PA 255.5 with all employees in the staff meeting on 2/10/14. All staff will attend DDAP's confidentilaty training by 12/1/2014. Employees will be required to provide date of training to the Lead Couneslor and the Director by 3/1/14.
All new client files are/will be reviewed the 3rd staff meeting of the month. The Director and Lead Couneslor will check all the releases to ensure that they fall within the limits of PA 255.5.
The Director changed the release forms in the public drive to locked on 1/23/14, to ensure that the employees cannot change the information that is on the releases. The Director also contacted the IT department, and requested that the IT department lock all master files to ensure that all papework is not changed without approval from the Director. The IT department will complete this task on 2/10/14.
The Director and the lead couneslor went over the confidentiality errors and breaches with staff on 1/29/14, and will review weekly during staff meeting.
The Director and the lead couneslor will review files A-M (week 1) , M-Z (week 2), intakes (week 3), and discharges (week 4) after staff meeting and notate the errors found and review in the following staff meeting. If consistent errors or neglect is found the employee will be sent to more training or receive other consequences. |