INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 22 - 23, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Care Center dba SPHS Care Center 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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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
The facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in four of sixteen client records reviewed during the annual licensing inspection conducted on June 22 - 23, 2016.
A consent to release information form was not documented for the funding entity, and the facility disclosed the client's name and diagnosis during an online request for counseling authorization.
Client # 10 was admitted into treatment on February 24, 2016. The disclosure occurred on February 29, 2016.
Client # 12 was admitted into treatment on August 11, 2015 and discharged on November 14, 2015. The disclosure occurred on September 23, 2015.
Client # 14 was admitted into treatment on December 29, 2015 and discharged on January 26, 2016. The disclosure occurred on December 29, 2015.
Client # 15 was admitted into treatment on February 8, 2016 and discharged on March 11, 2016. The disclosure occurred on February 8, 2016.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will obtain appropriate Consents to Release Information for client #10, #12, #14,and #15 where obtaining the consents are possible and remains relevant. The Clinical Supervisors will develop and provide a training update of the accurate and appropriate completion of consents to release information by August 1, 2016. Information to be covered will include appropriate type of release, the appropriate release for funding sources, appropriate choice of information to be released; and limitations of 4 Pa. code subsection 255.5, at a minimum. Consents/Releases will be completed every time an individual's insurance changes at the time of the change. This will be completed by August 1, 2016. A check sheet to be completed after an intake will be used to ensure that releases are obtained prior to approving services to be billed. Lastly, when requesting authorization support staff will check for releases to make sure they are up to date prior to requesting authorization. This will be completed by August 1, 2016. The Clinical Supervisor will continue to review and monitor consents and releases through internal chart reviews and supervision. |
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
The facility failed to document a complete client record which includes follow up information in three of ten outpatient records reviewed during the annual licensing inspection on June 22 - 23, 2016.
Client # 11 was admitted into treatment on June 16, 2015 and discharged on October 27, 2015.
Client # 12 was admitted into treatment on August 11, 2015 and discharged on November 4, 2015.
Client # 13 was admitted into treatment on September 9, 2015 and discharged on November 25, 2015.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A mandatory staff meeting will be held with all staff to review, follow-up, timelines and regulations. This will occur no later than 8/1/16. Each staff member will be provided with a copy of our agency's policy and regulations in regard to follow up timelines. The staff members responsible for client records #11, #12, and #13 will send a follow up letter where appropriate. The clinical staff will also do a follow up call after discharge within two weeks of discharge. A follow up letter will still be sent at 6 months and will be cross reference with a discharge list to ensure that no one gets missed. To assure staff members are improving in this area internal chart reviews and supervision will take place by the Clinical Supervisor throughout the year.
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