INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 10, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, T.W. Ponessa and Associates Counseling 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:
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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 client records, the facility failed to limit disclosures of client information to the specific information that was identified on a consent to release information form contained in one of eleven client records.
The findings include:
Eleven client records were reviewed on June 10, 2014. The facility failed to limit disclosures of client information to the specific information identified on an informed and voluntary consent to release information form contained in client record #8.
Client # 8 was admitted March 12, 2014. The consent to release client information form for the client's case manager, dated March 12, 2014, only allowed for the release of the client's presence in treatment. The facility failed to limit disclosures to the client's case manager to the client's presence in treatment. The record contained documentation of disclosures to the client's case manager dated June 4, 2014, May 27, 2014, May 14, 2014, April 23, 2014, and April 16, 2014 that exceeded the client's presence in treatment. The documents that were faxed included a county treatment update report, program information, attendance, responsiveness, attitude, a statement of relapse, progress status, discharge status, and recommendations.
The facility director confirmed the findings.
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Plan of Correction
Confidentiality laws and proper execution of a consent to release information form was reviewed with clinical staff at a meeting on 6-18-14. Moving forward, client charts will be reviewed on a weekly basis by the D&A Director or the Clinical Supervisor to ensure compliance with confidentiality regulations with respect to releasing information according to the information specified in the release. In addition, ongoing discussions about appropriate application of the confidentiality regulations and releases of information will take place in supervision sessions. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of three client records reviewed.
The findings include:
Three client records requiring the completion of a termination letter were reviewed on June 10, 2014. The facility failed to notify the client in writing of a decision to involuntarily terminate the client's treatment at the project in client record # 4.
Client # 4 was admitted into treatment on October 28, 2013 and was involuntarily terminated from the outpatient program on February 6, 2014. There was no documentation of written notification provided to the client as of the on-site inspection conducted on June 10, 2014.
The facility director confirmed the findings.
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Plan of Correction
The requirement to provide written notification to the client of the decision to terminate treatment was reviewed with clinical staff at a meeting on 6-18-14.Client # 4 was sent a discharge notification on 6-18-14. Moving forward, charts for discharged clients will be reviewed by the D&A Director or the Clinical Supervisor on an ongoing basis to monitor compliance with this requirement. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to document a signed and dated consent to treatment in four of eleven client records.
The findings include:
Eleven client records requiring documentation of consent to treatment were reviewed on June 10, 2014. The facility failed to document a signed and dated consent to treatment form in client records # 1, 3, 8 and 9.
Client # 1 was admitted on March 27, 2014. A signed and dated consent to treatment was not documented in the client's record.
Client # 3 was admitted on April 3, 2014. A signed and dated consent to treatment was not documented in the client's record.
Client # 8 was admitted on March 12, 2014. A signed and dated consent to treatment was not documented in the client's record.
Client # 9 was admitted on January 14, 2014. A signed and dated consent to treatment was not documented in the client's record.
The facility director confirmed the findings.
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Plan of Correction
The requirement to have a signed and dated consent to treatment was reviewed with clinical staff at a meeting on 6-18-14.Support staff was also informed of the requirement since they build the charts. Clients #1 and #9 have signed their Consent to Treatment. Client # 2 will sign her Consent at her next appointment scheduled on 6-30-14,Client # 8 was discharged on 6-10-14 and is no longer available to sign her consent to treatment. Moving forward, charts will be reviewed on a weekly basis by the D&A Director or the Clinical Supervisor to ensure compliance with this requirement. |
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.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates every 60 days in four of ten records.
The findings include:
Ten records requiring treatment plan updates were reviewed on June 10, 2014. Treatment plans were not updated at least every 60 days in client records # 2, 4, 7 and 9.
Client #2 was admitted to the outpatient program on August 5, 2013. The client's last treatment plan update was completed on August 27, 2013. The facility failed to complete another treatment plan review and update that was due on or before October 27, 2013.
Client #4 was admitted to the outpatient program on October 28, 2013. The client's last treatment plan update was completed on November 18, 2013. The facility failed to complete another treatment plan review and update that was due on or before January 18, 2014.
Client #7 was admitted to the outpatient program on November 13, 2013. The client's last two treatment plan updates were completed on March 25, 2014 and May 14, 2014. The facility failed to complete a treatment plan update that was due on or before January 13, 2014.
Client #9 was admitted to the outpatient program on January 14, 2014. The client's comprehensive treatment plan was completed on January 14, 2014. The first treatment plan update was due on or before March 14, 2014 but was not completed until April 7, 2014.
The facility director confirmed the findings.
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Plan of Correction
The requirement to complete and document treatment plan updates every 60 days was reviewed with the clinical staff at a meeting on 6-18-14. Client # 2 was discharged on 12-6-13, Client # 4 was discharged on 2-6-14-a treatment plan update cannot occur with those clients at this time. Client # 7 completed her Master Treatment Plan on 2-18-14, not 11-13-13. Her treatment plan update was therefore due by 4-18-14. The first treatment plan update was actually completed on on 5-14-14, which is beyond the 60 days from 2-18-14. Therefore a treatment plan update for 4-18-14 was completed with the client.Client # 9's treatment plan update that was due on 3-14-14 has been completed with him. Moving forward, treatment plans will be reviewed monthly by the D&A Director or the Clinical Supervisor to monitor compliance with this requirement. |