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 21, 2010 licensure renewal inspection. The follow-up inspection was conducted on December 9, 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 9, 2010 five client records were reviewed. Five of five 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. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on the review of client records and an interview with the administrative director, the facility failed to document disclosures of client information which adhered to the limitations imposed at 4 Pa. 255.5(b). Disclosures of information which exceeded the limitations imposed at 4 Pa. 255.5(b) were documented in four of five client records reviewed.The findings included: On 12/9/10 an unannounced plan of correction follow up inspection was conducted and five client records were reviewed. Four of five client records reviewed included documentation of disclosures of client information which exceeded the limitations imposed at 4 Pa. Code subsection 255.5(b).Client record # 1- The client was admitted on 5/25/10 and discharged on 10/25/10. Disclosures of client information were documented in the record which addressed the client's history of incarceration and specific episodes of treatment and hospitalizations. Documentation of these disclosures occurred on 5/26/10. Client record # 2- The client was admitted on 9/13/10 and was last treated on 12/8/10. Disclosures of client information were documented in the record which addressed the client's history of incarceration and compliance with and episodes of treatment and hospitalizations. Documentation of these disclosures occurred on 9/13/10. Client record # 3- The client was admitted on 10/15/10 and discharged on 10/25/10. Disclosures of client information were documented in the record which addressed the client's history of incarceration and compliance with and episodes of treatment and hospitalizations. Documentation of these disclosures occurred on 10/15/10. Client record # 4- The client was admitted on 8/31/10 and was last seen on 10/6/10. Disclosures of client information were documented in the record which addressed the client's history of hospitalizations and compliance with treatment. Documentation of these disclosures occurred on June 15 & 22, 2010.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 was reviewed at our 12/9/10 staff meeting and will be reviewed again with all staff at our next staff meeting on 1/13/2010. The proper completion of consents and disclosure of client information will begin immediately. This standard and policy will also be reviewed with all therapists by the Clinical Supervisor in individual supervision to assure compliance |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of project policy and client records during the onsite inspection, the facility failed to document complete personal client histories in each record reviewed. Three of four client records reviewed failed to include documentation of complete personal histories.The findings included:On December 9, 2010 an unannounced plan of correction follow up inspection was conducted at the facility and five client records were reviewed. Four records were due to include documentation of a complete, detailed personal client history. Project policy states: "It is the position of Clear Concepts Counseling that as much personal information as possible should be collected from the client in order to provide the highest quality of care." In addition to the policy statement, the Psychosocial History forms, developed and used in each record, give detailed and specific prompts to the clinician in order to elicit the optimum amount of detail for each dimension of the client's history. An example of one of the prompts stated: "Please be as thorough and detailed as possible." Specifics of the findings from the review of five client records are addressed below:Client record # 1 - The client was admitted on 5/25/10 and discharged on 10/25/10. The personal history documented in the client record failed to include family interrelationships in the family of origin and the current family constellation. Details were not provided regarding educational history and details on interests or performance and the impact drug and alcohol use had on the client's education. No detailed employment history was documented.Client record # 2- The client was admitted on 9/13/10 and was last treated on 12/8/10. The personal history in the record failed to include documentation of family interrelationships in the family of origin. No employment or educational histories were documented - these sections were left blank.Client record # 5 - The client was admitted on 8/31/10 and last seen on 10/6/10. Documentation of family history did not include family interrelationships. The educational, employment, legal, sexual and recreational history sections were not completed.The findings were reviewed with the administrative director and clinical supervisor and they agreed that they were valid.
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Plan of Correction
Our facility will be in full compliance with this standard by 01/13/2010. Necessity of addressing all areas required by the guidelines was reviewed at our 12/09/2010 staff meeting and will be reviewed with all staff at our next staff meeting on 01/13/2010. The Clinical Supervisor will also review proper completion of personal client histories in individual supervision as an added measure to assure compliance. |
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 project policy and client records, the facility failed to document complete psychosocial evaluations in the client records reviewed. Psychosocial evaluations failed to include documentation of the required information in four of four client records.The findings include:On December 9, 2010 an unannounced plan of correction follow up inspection was conducted at the facility and five client records were reviewed. Four of five client records reviewed were due to include documentation of a complete psychosocial evaluation. Project policy states: "It is the position of Clear Concepts Counseling that a psychosocial evaluation will be completed for each client." In addition to the policy statement the facility requires that the Psychosocial Evaluation be signed by the physician within 15 days. Forms developed and used by the Project in each record give detailed and specific prompts to the clinician in order to elicit the optimum amount of detail for each dimension of the client's evaluation. Written policy stated that, "The consolidated assessment will provide an overall summary of the client based on the collected data so that it will be possible to identify possible factors which have led to his/her current situation." Specifics of the findings from each record are addressed below:Client record # 1 - The client was admitted on 5/25/10 and discharged on 10/25/10. The psychosocial evaluation failed to include documentation of a complete description of the composite picture of the client. Underlying problems were not identified or documented. Coping mechanisms were not documented in the evaluation. There was no documentation of the client's attitude toward treatment. Clinical impressions/conclusions regarding the status of the client, based on the collected data - so that it would be possible to identify possible factors which have led to his/her current situation, were not documented. Client record # 2- The client was admitted on 9/13/10 and was last treated on 12/8/10. The psychosocial evaluation failed to include documentation of the client's assets and strengths. Underlying problems were not identified. Coping/defense mechanisms were not documented in the evaluation. There was no documentation of the client's attitude toward treatment. Clinical impressions/conclusions regarding the status of the client, which was to be based on the collected data so that it would be possible to identify possible factors which have led to his/her current situation, were not documented. Client record # 4 - The client was admitted on 6/15/10 and last treated on 9/18/10. The psychosocial evaluation failed to include documentation of a complete description of the composite picture of the client. Underlying problems/needs were not identified. Coping mechanisms were not documented in the evaluation. Clinical impressions/conclusions regarding the status of the client, based on the collected data - so that it would be possible to identify possible factors which have led to his/her current situation, were not documented. Support systems were not documented. Record # 5 - The client was admitted on 8/31/10 and last seen on 10/6/10. The psychosocial evaluation failed to include documentation of a clear description of the composite picture of the client. Underlying problems/needs were not identified. Coping mechanisms were not documented in the evaluation. Clinical impressions/conclusions regarding the status of the client, based on the collected data - so that it would be possible to identify possible factors which have led to his/her current situation, were not documented. Support systems were not documented. The findings were reviewed with the administrative director and she agreed that they were valid.
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Plan of Correction
Our facility will be in full compliance with this standard by 01/13/2010. 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 and timing of completion of the psychosocial evaluation will begin immediately. This standard and policy will also be reviewed with all therapists by the Clinical Supervisor in individual supervision to assure compliance. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records and an interview with the administrative director, the facility failed to document the type and frequency of services to be offered to each client in their treatment record. Three of four client records failed to include documentation of the type and frequency of services to be offered. The findings included: On 12/9/10 an unannounced plan of correction follow up inspection was conducted and five client records were reviewed. Four of five client records were due to include documentation of treatment plans which addressed the type and frequency of treatment to be offered. Client record # 1- The client was admitted on 5/25/10 and discharged on 10/25/10. The comprehensive treatment plan was developed on 6/25/10. The treatment plan documentation did not include the type and frequency of treatment services that would be scheduled for the client.Client record # 4- The client was admitted on 6/15/10 and discharged on 9/18/10. The comprehensive treatment plan was developed on 7/16/10. The treatment plan documentation did not include the type of treatment service that would be scheduled for the client.Record # 5- The client was admitted on 8/31/10 and was last seen on 10/6/10. The comprehensive treatment plan was developed on 10/1/10. The treatment plan documentation did not include the type of treatment service that would be scheduled for the client.The findings were reviewed with the administrative director and she agreed that they were valid.
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Plan of Correction
Our facility will be in full compliance with this standard by 01/13/2010. 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 documentation of frequency of treatment in the client records 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 review these issues during quarterly reviews to ensure correct completion. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on the review of client records and an interview with the administrative director, the facility failed to document the support services to be offered to each client on their treatment plan. Two of four client records failed to include documentation of support services on the treatment plans. The findings included: On 12/9/10 an unannounced plan of correction follow up inspection was conducted and five client records were reviewed. Four of five client records were required to have documentation of treatment plans which included the support services the client was to obtain. Client record # 1- The client was admitted on 5/25/10 and discharged on 10/25/10. The comprehensive treatment plan was developed on 6/25/10. The treatment plan documentation did not identify support services to be offered to the client.Client record # 4- The client was admitted on 6/15/10 and discharged on 9/18/10. The comprehensive treatment plan was developed on 7/16/10. The treatment plan documentation did not identify support services to be offered to the client.The findings were reviewed with the clinical staff and the administrative director and the agreement was that they were valid.
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Plan of Correction
Our facility will be in full compliance with this standard by 01/13/2010. 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 documentation of proposed type of support services will begin immediately. This standard and policy will also be reviewed with all therapists by the Clinical Supervisor in individual supervision to assure compliance. |