INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 28-29, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, PATH Incorporated 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 June 25, 2009.
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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 the review of client records, the facility failed to obtain an informed and voluntary consent for the disclosure of the information contained in eight of eight client records.
The findings include:
Eight client records were reviewed on May 28-29, 2009. Informed consents to disclose information was required in eight client records. The consent forms utilized in client records # 1, 2, 3, 4, 5, 6, 7 and 8 to obtain the client's informed consent to release information contained "release to" and "obtain from" language without differentiating between the two statements. Entities may not release information without written prior consent of the client. Having the two options on the form fails to meet the criteria of informed consent. The federal regulations only have provisions for authorization to disclose information. A consent to obtain information is not consistent with the federal confidentiality regulations found at 42 C.F.R. nor does it authorize a program to disclose information.
In addition, client record # 5 contained consents signed by the client's mother. Once it had been determined the client was to receive drug and alcohol services, the facility was required to conform to the restrictions set forth by law and regulation and obtain informed and voluntary signed consent from the client directly. Refer to state law at 71 P. S. Subsection 1690.112 and then to federal regulation at 42 CFR Part 2, Subpart B, Subsection 2.14(b). Also pertinent is 42 CFR Part 2, Subpart B, Subsection 2.20.
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Plan of Correction
In all cases, an informed written consent was obtained prior to releasing information. However, the same form was utilized to obtain information.
PATH's System and Evaluation Director will develop a form to release information that does not contain provisions to obtain information. This will be completed by July 29,2009.
All staff will be trained in utilization of the new form by the respective program director. Adult staff will be trained by the Adult Outpatient Director. Children and Youth staff will be trained by the Children and Youth Outpatient Director. Training will be completed by 7/30/2009.
Effective immediately, the D&A children and youth staff have been trained that a new release of information that does not contain a parental signature(only the client) must be obtained whenever a youth transfers to the D&A program.This was completed by the C&Y Outpatient Director on June 10,2009.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to execute an evaluative composite picture of the client in relationship to the collected historical data in five of five client records.
The findings include:
Eight client records were reviewed on May 28-29, 2009. Five client records were reviewed for psychosocial evaluations. The content of the evaluations consisted of a summary of the historical data collected and statements of what the client reported without a clinical impression (evaluation) of the information in client records # 2, 3, 6, 7 and 8.
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Plan of Correction
Staff will be retrained in the completion of the psychosocial evaluation,so that there is greater emphasis on the impressions of the information provided during the assessment period in order to present a better composite picture of the individual and identify possible
conditions which have led to the
current situation. Training will be
conducted by the program director on
6/23/2009.
Counselor assessmaents will specifically include a section on clinical impressions. Counselor assessmants will be reviewed by the program director at the time the initial treatment plan is completed. The program director will return assessmants that are not in compliance to the clinician, so they can be completed properly.This will be effective July 21,2009. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on the review of client records, the facility failed to document complete discharge summaries in two of three client records.
The findings include:
Eight client records were reviewed on May 28-29, 2009. Discharge summaries were required in four client records. The facility did not completely record the reasons for entering into drug and alcohol services in two of four records, # 1 and 2, but only mentioned mental health concerns. The services that were offered to the client during the treatment process were not documented in client records # 1 and 2. The client's status upon discharge was not completed in client records # 1 and 3.
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Plan of Correction
Staff will be retrained in completion of discharge documentation, so that the elements identified by the site reviewer will be a part of every discharge. The elements include the reason for entering into drud and alcohol services,which will be noted in the reason for referral on the discharge note; services offered,which will be noted in the comments section of the agency discharge summary;and status upon discharge, which will be noted in the current risk status of the program discharge note. Retraining will be conducted by the program director on June 23, 2009.
The program director signs off on every discharge and will return those not in compliance to the clinician, so that they can be properly completed. This will be effective 7/21/2009. |