INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 21, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Alcohol and Drug Abuse Services, 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:
|
Plan of Correction
|
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:
|
Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent which documented the purpose of the disclosure in one of fourteen client records reviewed.
The findings include:
Fourteen client records which required documentation of an informed and voluntary consent were reviewed on October 21, 2015. The facility failed to obtain an informed and voluntary consent which documented the purpose of the disclosure in client record # 6.
Client # 6 was formally admitted into treatment on 4/13/15 and was discharged on 9/16/15. The client's record contained a consent to release information to an insurance company, the treatment funding source. This consent form was signed by the client on 3/4/15 and it failed to specify the purpose of the release. The client's record contained documentation of the facility's contact with the insurance company on 1/28/15, to verify the client's insurance benefits.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 10/21/15 the outpatient supervisor contacted the case manager that had completed this consent on client record #6 to explain the importance of indicating the purpose of the consent and completing the consent in its entirety. The case manager was instructed to call client #6 and schedule an appointment to discuss the need for a valid consent. The consent was signed 3/4/15 and this agency billed 4/30/15 therefore contacting the insurance company. The information in the file from the insurance dated 1/28/15 was from accessing navinet. Therefore the insurance company wasn't contacted until after the consent was signed. On 10/21/15 the outpatient supervisor contacted the case manager that had completed this consent to explain the importance of indicating the purpose of the consent and completing the consent in its entirety. The case management supervisor was also informed and will discuss the importance of complaint consents completely at her next department meeting on
The outpatient supervisor will continue to train all staff on importance of completion of client consents including purpose and what is to be released. This will occur yearly at All agency meetings.
Quarterly the outpatient supervisor will discuss completion of consents at the outpatient department meeting for all outpatient staff.
The St Marys files will be reviewed monthly by the outpatient counselors and or supervisor to ensure compliance. There will be bimonthly peer reviews to ensure compliance
et. This occurred on 10/30/15. The case management supervisor was also informed and will discuss the importance of filling consents completely at her next department meeting In November.
The outpatient supervisor will continue to train all staff on importance of completion of client consents including purpose and what is to be released. This will occur yearly at All agency meetings.
Quarterly the outpatient supervisor will discuss completion of consents at the outpatient department meeting for all outpatient staff.
The St Marys files will be reviewed monthly by the outpatient counselors and or supervisor to ensure compliance. There will be bimonthly peer reviews to ensure compliance.
|
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.
|
Observations
Based on a review of client records, the facility failed to document a treatment plan update at least every 60 days in five of fourteen client records reviewed.
The findings include:
Fourteen client records requiring documentation of a treatment plan update were reviewed during the renewal inspection on October 21, 2015. The facility failed to document a treatment plan update at least every 60 days in client records # 1, 2, 3, 5, and 14.
Client # 1 was admitted into treatment on 5/7/15 and was still active at the time of the inspection. The last two treatment plan updates for the client were completed on 7/6/15 and 9/14/15.
Client # 2 was admitted into treatment on 6/3/15 and was still active at the time of the inspection. The last two treatment plan updates for the client were completed on 8/3/15 and 10/12/15.
Client # 3 was admitted into treatment on 3/2/15 and was still active at the time of the inspection. The last two treatment plan updates for the client were completed on 7/1/15 and 9/14/15.
Client # 5 was admitted into treatment on 5/26/15 and was still active at the time of the inspection. The last two treatment plan updates for the client were completed on 7/1/15 and 9/11/15.
Client # 14 was admitted into treatment on 6/18/15 and was still active at the time of the inspection. The individual treatment and rehabilitation plan for the client was completed on 6/18/15. A treatment plan update for the client was completed on 8/24/15.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Date 10/22/15
The outpatient supervisor discussed with the St Marys counselors the importance of completion of the treatment plan update on or before 60 days on 10/22/15. They were advised that for client #2 the next treatment plan update was due on or before 12/12/15. For client #3on or before 11/14/15. For client #5on or before 11/11/15. For #4 on or before 10/24/15.
The counselors were informed by the outpatient supervisor that although we have always interpreted the licensing standard 709.92 (b) to be every 60 days from the original treatment plan date that the correct interpretation is on or before 60 days from the previous treatment plan update.
The Outpatient supervisor sent out a memo via email was sent out to all outpatient staff on 10/20/15 and on 10/27/15 indicating the correct interpretation and that it would be discussed in detail at the next department meeting on 11/3/15 by the outpatient supervisor and all outpatient counselors.
The face sheet was revised by an outpatient counselor to include a place to put the dates the treatment plan update is due to ensure compliance.
The St Marys outpatient files will be reviewed monthly by the outpatient staff and or supervisor and bi monthly at peer reviews with all outpatient staff and the supervisor to ensure compliance.
At least 1 time a month at staffing/case consult meetings with our medical director treatment plan updates will be reviewed by the medical director and the outpatient supervisor to ensure compliance.
|