INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the April 23, 2010 licensure renewal inspection. The follow-up inspection was conducted on December 7, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Clear Concepts Counseling 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 and a plan of correction is due on January 4, 2010.
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of the client records and a discussion with the Clinical Supervisor, the facility failed to document valid and complete consents to release information and failed to inform clients regarding the role of the federal HIPAA regulations in drug and alcohol treatment facilities and how they interact with existing federal and state confidentiality laws and regulations relative to consents to release information to insurance companies, health and hospital plans and other entities.The findings included: On December 7, 2010 four client records were reviewed. Four of four client records reviewed contained standard forms used at the Project. One form entitled: "Consent to to Use and Disclose Your Health Information", contained the following language: "By signing this form you are agreeing to let us use your information here and send it to others. This will take place only after a valid release of information is signed which conforms to the Federal Confidentiality Regulations (42 CFR Part II)." The document fails to indicate that the federal regulations at 42 CFR Part 2, Subpart C, subsection 2.32 specifically prohibits the use of "general consents to release information". This form also states that "If you do not sign this consent form agreeing to what is in our notices of privacy practices we cannot treat you." This statement violates Commonwealth regulations at 28 Pa. Code subsection 709.28(c) which requires that consent's be "...informed and voluntary...".This form also included the following statement : "If you are concerned about some of your information, you have the right to ask us not to use or share some of your information for treatment, payment or administrative purposes. You will have to tell us what you want in writing, although we will try to respect your wishes, we are not required to agree to these limitations...". Though this is consistent with the federal HIPAA regulations, it is a direct violation of Commonwealth law at 71 P.S. subsection 1690.108 (b) and regulation at 28 Pa. Code subsection 709.28(c) (3) and the federal regulations at 42 CFR Part 2, Subpart C, subsection 2.31(a) (5). The language is also a violation of 42 CFR Part 2, Subpart C, subsection 2.31 (c) (2) and (3) regarding the revocation of client consent. The language as stated violates the principle of voluntary and informed consent specified at 28 Pa. Code subsection 709.28 (c). The following statement is included on the same form and specifies that: "After you have signed this consent , you have the right to revoke it (by writing a letter telling us you no longer consent)...". The form does not inform the client of his/her right to revoke the consent verbally and fails to acknowledge 42 CFR Part 2, Subpart C, subsection 2.31 (c) (3) and inform the client that the facility may not act in reliance of a consent to release information form that it knows to have been revoked and must honor a client's verbal revocation of a consent to release information by documenting, in writing, that the client revoked the consent. A second form used by the project is entitled "Insurance release/assignment of benefits " and uses the language "... exchange of information.." in regard to communication with insurance entities. This phrase is inaccurate and misleading. The form needs to be altered to demonstrate that the client is giving the facility permission to release only the specific information listed on the consent to release information form executed by the client.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard was reviewed and the necessary changes/updates have been made by the Director of Administration to the "Consent to Use and Disclose Your Health Information" and "Insurance release/assignment of benefits". These changes/updates will be reviewed at our next staff meeting on 1/13/2010. To ensure correct completion of consents forms the Quality Assurance manager will verify completion during quarterly reviews. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
.The findings included: On 12.07/2010 four client records were reviewed for treatment plan development and content .Four of four records were required to have individualized, comprehensive treatment plans developed within 30 days of admission according to written agency policy. Four of four applicable records failed to document individualized treatment plans. Two of four applicable records did not document that the client and the therapist collaborated on the development of the treatment plan. Record #1 - The client was admitted on 6/29/10. The initial treatment plan was developed on 6/29/10. The comprehensive treatment plan was developed on 7/30/10. The goals included addressing the client's need to abstain from D&A , avoid people , places and things which might lead to use and productive use of time. Goals did not correlate with needs identified in the assessment portion of the record. Record #2- The client was admitted on 7/1/10. The initial treatment plan was developed on 7/6/10- policy requires that the plan is to be developed at the initial session. The comprehensive treatment plan was developed on 8/7/10. The goals included addressing the client's need to abstain from D&A , avoid people , places and things which might lead to use and productive use of time. Goals did not correlate with needs identified in the assessment portion of the record. Record #3- The client was admitted on 5/4/10. The initial treatment plan was developed on 7/6/10- policy requires that the plan is to be developed at the initial session. The comprehensive treatment plan was developed on 6/5/10. The goals included addressing the client's need to abstain from D&A , avoid people , places and things which might lead to use and productive use of time. Goals did not correlate with needs identified in the assessment portion of the record. The comprehensive plan documented on 6/5/20 was not signed by the client.Record #4 - The client was admitted on 4/26/10. The initial treatment plan was developed on 4/26/10- policy requires that the plan is to be developed at the initial session. The comprehensive treatment plan was developed on 5/27/10. The goals included addressing the client's need to abstain from D&A , avoid people , places and things which might lead to use and productive use of time. Goals did not correlate with needs identified in the assessment portion of the record. The comprehensive plan of 5/27/10 was not signed by the client.Client left after three sessions. The findings were revived with the Administrative Director and she agreed they were valid.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy relative to this standard was reviewed at our 12/09/2010 staff meeting and will be reviewed again with all counselors at our next staff meeting on 01/13/2010. The proper completion of a plan component in the progress notes will begin immediately. This standard and policy will also be reviewed with all therapists by the Clinical Supervisor in individual supervision to assure compliance. The Quality Assurance manager will conduct quarterly and random reviews to verify proper completion. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on the review of client records and a discussion with the Administrative Director, the facility failed to document progress notes which included a plan component in each client record. Three of four client records reviewed did not have plan components in the progress notes.The findings included: On 12/07/2010 four client records were reviewed for progress note content. The plan component is to reflect the counselor's actions to be taken in light of the evaluation and indicate the direction of treatment and include action steps, counselor plan(s) and client assignments or tasks. A plan component was missing from the progress notes in three of four client records reviewed.Client record #1 - The client was admitted on 6/29/10. Progress Notes written on the following dates included a plan component which failed to document the actions to be taken or assignments given for the next session but only stated that the client would be seen again in two weeks: June 29, 2010; July 13 and 27, 2010; August 10, 2010; September 6, 2010; October 10, 2010 and November 1, 2010. Client record #3- The client was admitted on 5/4/10. Progress notes included a plan component which failed to document the actions to be taken or assignments given for the next session but only stated that the client would be seen again in one week: May 4, 10 and 18, 2010; June 2, 15, 2010 and July 2, 2010. Client record #4 - The client was admitted on 4/26/10. Progress notes included a plan component which failed to document the actions to be taken or assignments given for the next session but only stated that the client would be seen again in one week: April 26, 2010, May 3 and 10, 2010. The client left after three sessions. The findings were reviewed with the Administrative Director and she agreed they were valid.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy relative to this standard was reviewed at our 12/09/2010 staff meeting and will be reviewed again with all counselors at our next staff meeting on 01/13/2010. The proper completion of a plan component in the progress notes will begin immediately. This standard and policy will also be reviewed with all therapists by the Clinical Supervisor in individual supervision. The Quality Assurance manager will also verify completion during quarterly reviews. |