INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 14-15, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Casa De Consejeria Drug and Alcohol Counseling Program, 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 and a plan of correction is due on May 19, 2009.
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Plan of Correction
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705.24 (1) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(1) Provide bathrooms to accommodate staff, clients and other users of the facility.
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Observations
Based on an inspection of the facility ' s physical plant, the facility failed to provide bathrooms to accommodate clients. Findings:An inspection of the facility ' s physical plant was conducted on April 15, 2009 at approximately 09:40. Signs posted in the lobby stated bathrooms were for urine test only.
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Plan of Correction
The project/facility director removed on 04/15/2009 in presence of the inspector the signs posted in the lobby stated bathrooms were for urine test only. The project/facility director will oversight such standard in order to be always in full compliance by providing supervisory follow up through written notification addressed to the employees, as well as observation, so bathrooms will be available to accomodate all the clients.
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on interviews with the facility ' s project director and a review of the facility ' s policy and procedures manual, the facility failed to develop written procedures to address how the integrity of their electronic records storage system will be maintained.Findings:Interviews with the project director were conducted on April 14-15, 2009. The facility ' s policy and procedures manual was reviewed on April 14, 2009. The project director confirmed that they did not document written procedures addressing how the integrity of the electronic storage system will be maintained.
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Plan of Correction
The project/facility director along with board of directors and in consultation with the computer technical expert will collaborate to develop written procedures, as well as a policy to address how the integrity of the electronic records storage system will be maintained. A conference call will be conducted with the board of directors on 06/05/2009 in order to obtain feedback and develop a written document to be in full compliance with the stardard. A meeting will be onducted with the computer technical expert on 06/10/2009 in order to obtain appropriate information to develop written procedures. The project/facility director will oversight such activity in order to fully correct the deficiency. The written procedures will be in placed no later than 06/19/2009. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on an inspection of the facility ' s physical plant, the facility failed to secure all client records within locked storage containers. Findings:An inspection of the facility ' s physical plant was conducted on April 15, 2009 at approximately 09:40. Discharged clients ' urine drug screens were stored in boxes in an unlocked closet in the basement.
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Plan of Correction
The project/facility director has schreded on 04/16/2009 some of the old copies of 2002 of urine drug screens of discharged clients, which were kept them in a box in the basement. Originals remained in clients charts in appropiate locked storage containers. The project/facility director will provide training and orientation, as well as supervisory follow up by witten notification to the staff to assure that all documentation will be always secured in a locked storage container. Corrective action has been taken on 04/16/09. |
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 client records, the facility failed to document informed and voluntary consent from the client for the disclosure of information contained in three of five client records. Findings:Eight client records were reviewed on April 15, 2009. Documentation of informed and voluntary consent was reviewed in five records. The facility documented the release of specific client information that exceeds the limitations of 4 Pa Code 255.5 in client records # 2, 3 and 5.Client record # 2 documented the release of urine drug screens to an insurance company and to a government agency. Client record # 3 documented the release of " records pertaining to treatment " to an insurance company.Client record # 5 documented the release of urine drug screens to an insurance company, to a government agency and to probation and parole.
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Plan of Correction
The clinical supervisor will provide training and documentation to staff to teach them how to document appropriately the document informed and voluntary consent from the client for the disclosure of information contained in client recors. The training will be conducted on 05/25/09 by the clinical supervisor and it will cover the 5 elements to be released permitted by the law which are: whether the client is or is not in treatment, client's prognosis, the nature of the project, a brief description of the client's progress and a short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse. Project/facility director will oversight corrective action by supervisory follow up. Also Clinical Supervisor has provided to the staff on 04/16/09 a copy of the written standard that specifies appropriate information to be released. Full corrective action plan will be in placed no later than 05/29/09. |
709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
Based on an inspection completed April 14-15, 2009, the facility failed to demonstrate a data collection and record keeping system that allows for the efficient retrieval of data. Findings:On April 14, 2009 at approximately 09:30, the licensing specialist presented the facility with the names of six active clients. At this time the facility was asked to retrieve these clients ' records for review. All client records were not received by the licensing specialist until 11:50.
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Plan of Correction
The project/facility director in consultation with the Director of Operations have determined starting on 04/24/09 to go back to the prior documentation system, in order to print out every single document pertaining to client's treatment, as well as to keep a complete physical chart, which will be available immediately for audit purpose. Written notification has been sent to the staff by email on 04/20/09. The corrective action plan has been in placed already and it will be oversight by project/facility director. |
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 a review of client records, the facility failed to document a psychosocial evaluation in five of five client records. Findings:Eight client records were reviewed on April 15, 2009. Psychosocial evaluations were required in five client records. The facility did not document a psychosocial evaluation in client records # 1, 2, 3, 4 and 5. The facility did not document a psychosocial evaluation to include the client ' s assets/strengths that can contribute to the resolution of identified problems in client records # 1, 2, 4 and 5.The facility did not document a psychosocial evaluation to include the client ' s preferred coping mechanisms in client records # 1, 2 and 5.The facility did not document a psychosocial evaluation to include the potential or available client support systems in client records 1, 2, 3, 4 and 5.The facility did not document a psychosocial evaluation to include conclusions regarding the client ' s attitude towards and ability to participate in the treatment process in client records # 1, 2, 3, 4 and 5.
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Plan of Correction
The clinical supervisor will conduct training to the clinical staff in order to provide additional information to the existing psychosocial evaluation on the following areas: client's assets/strengths that can contribute to the resolution of identified problems in client record,client's preferred coping mechanisms in client records, potential or available client support systems and conclusions regarding the client's attitude towards and ability to participate in the treatment process. Training will be conducted on 06/05/2009 and oversight by project/facility director. Clinical Supervisor will get charts at random to verify that additional information is in place. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document counseling services provided according to the individual treatment plan in three of five client records. Findings:Eight client records were reviewed on April 15, 2009. Documentation of counseling services provided according to an individual treatment plan was reviewed in five records. The facility did not document counseling services according to the treatment plan in client record # 1, 2 and 4. Record # 1, treatment plan 1/26/08 states individual counseling sessions two times weekly, but individual counseling sessions were only documented on January 26, 28, 30, February 4, 9, 11, 18, 23, 25, March 4, 11, 18, 23, 25 and 31.Record # 2, treatment plan update 1/16/08 and 3/10/09 state group counseling sessions one time weekly, but group counseling sessions were only documented on January 16, 23, February 13, March 6 and 27. Record # 4, treatment plan 2/26/08 states individual counseling sessions two times weekly, but individual counseling sessions were only documented on February 26, March 10, 17 and 19.
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Plan of Correction
The clinical supervisor will conduct training to the clinical staff in order to document the service log and/or the progress notes when the clients do not attend to treatment according to the times stipulated by the treatment plan. Training will be conducted on 06/12/09. Activity will be supervised by project/facility director. Clinical supervisor will get charts at random to verify that information is in place. |