INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 13, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Renew Family Services, LLC 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Personnel records were reviewed on March 13, 2018. For employee record # 2, the facility failed to document that the clinical supervisor participated in monthly meetings with their supervisor for their first 6 months in clinical supervisor position.
Employee # 2 was hired as a counselor 9/23/16, and was promoted to the clinical supervisor position on 9/1/17. Monthly supervision meetings were required to take place from September 2017 - March 2018. The facility failed to provide documentation of monthly meetings conducted during the required time period.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
If there is any staff promotions, they will be monitored and supervised for six months, if required by the position such as clinical director. For those six months, they will have monthly supervision which is documented noting what the staff person needs to work on in order to maintain the promoted position.
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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
Seven client records were reviewed on March 13, 2018. The facility failed to obtain an informed and voluntary consent to release information, where consent was applicable, for client record # 2.
Client # 2 was admitted into treatment on 12/19/16 and was discharged from drug and alcohol treatment on 9/13/17. A consent to release information to the client's treatment funding source, an insurance company, was not documented in the client's record.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Renew Family Services is currently in litigation for the original billing release document. If the client returns for other services, staff will get an updated billing release signed.
Notes will be made in the chart if any changes are made in accordance with the litigation.
All new staff will be trained by clinical supervisor on confidentiality and protocol on paper charts (even though we no longer use). Renew Family Services no longer uses paper charts, however new staff will be trained that if any paper charts are to be used they must be locked in the cabinet with the employee door locked as well. The keys are in possession of clinical supervisor and director of the program to ensure no one else has access to this area.
Renew Family Services is in the process of switching EHR so that all future releases will be in the electronic records system. The owner is in the process of setting the system up now. This will take one month (4/28/18). The clinical supervisor will review all new patient charts to ensure that consents are in the system and signed as to be in compliance with state requirements within 7 days of intake. |
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
Seven client records were reviewed on March 13, 2018. The facility failed to document a discharge summary for client records # 4, 5, and 6.
Client # 4 was admitted into treatment on 7/10/17 and was discharged on 9/8/17.
Client # 5 was admitted into treatment on 7/7/17 and was discharged on 9/20/17.
Client # 6 was admitted into treatment on 8/10/16 and was discharged on 2/14/18.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client discharges will be completed by clinical supervisor under any circumstances where therapist is unable to complete discharge paperwork.
Client #4 therapist left and did not complete any updated notes for client is one example of where the clinical supervisor will be responsible for discharge note.
Client #5 therapist left and did not complete discharge note stating client went to different program. Clinical Supervisor is responsible for completing the discharge note if the therapist leaves without completing this note.
Client #6 is an example of all primary therapists will discharge clients from D&A track if they are to stay in treatment at Renew Family Services for other services.
This has been reviewed with staff during treatment team meeting on Thursday, March 8, 2018.
During monthly staff meetings, the clinical supervisor will review all potential discharges with therapists. Clinical supervisor will review charts to follow-up that discharge notes have been completed once encounter sheets are submitted for those clients. |