INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 31- April 1, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, WPIC Center for Psychiatric and Chemical Dependency Services 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 1, 2008.
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Plan of Correction
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711.81(b)(3)(i) LICENSURE Medical History
711.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records on March 31, 2008 and April 1, 2008, the facility failed to document a complete medical history in two of two records reviewed, #3 and 7. The medical histories were missing the client's symptoms/illnesses. In addition, the medical histories were completed later than the 5th session as stated in the project's policies and procedures manual.This is a repeat deficiency from the October 2007 inspection.
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Plan of Correction
The Clinical Administrator of WPIC Addiction Medicine Services will ensure, through supervision and quality assurance chart review, that the aspects of medical history comprises a history documenting the client's personal medical history, family medical history, and history of illness and symptoms. The information will be gathered and recorded within the required time frame as identified by policy, which is by the end of the 3rd outpatient session, and by the end of the first week of partial services. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 5/15/08 and continuing through the course of the licensing review period.
All staff will be trained by 6/15/08. |
711.81(b)(3)(ii) LICENSURE D & A History
711.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records on March 31, 2008 and April 1, 2008, the facility failed to document a complete drug and/or alcohol history within five sessions of the client's admission to treatment as stated in the project's policies and procedures manual. Drug and/or alcohol histories were completed during the clients' 24th and 13th treatment session in two of two records reviewed, #3 and 7. This is a repeat deficiency from the October 2007 inspection.
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Plan of Correction
The Clinical Administrator of WPIC Addiction Medicine Services will ensure, through supervision and quality assurance chart review, that the aspect of D & A histories comprises a complete history including, but not limited to, progression of use related to lengths/patterns and prior treatment history. In addition the Clinical Administrator will ensure that the documentation of D & A histories is completed for each client, completed on time and contains required information as to be in accordance with agency policy. Furthermore the Clinical Administrator will ensure that the D & A history documentation is updated within specified time frames. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 5/15/08 and continuing through the course of the licensing review period.
All staff will be trained by 6/15/08. |
711.81(b)(3)(iii) LICENSURE Personal History
711.81. 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 a review of client records on March 31, 2008 and April 1, 2008, the facility failed to document a complete personal history in two of two records reviewed, #3 and 7. The personal histories contained incomplete information regarding the client's family, employment and recreational histories. In addition, the personal histories were completed later than the 5th session as stated in the project's policies and procedures manual.This is a repeat deficiency from the October 2007 inspection.
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Plan of Correction
The Clinical Administrator of WPIC Addiction Medicine Services will ensure, through supervision and quality assurance chart review, that the aspects of personal history comprises a history documenting the client's historical and pertinent personal data including: family, legal, employment/vocational, educational, military, recreational, sexual and others where appropriate. The information will be gathered and recorded within the required time frame as identified by policy, which is by the end of the 3rd outpatient session, and by the end of the first week of partial services. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 5/15/08 and continuing through the course of the licensing review period.
All staff will be trained by 6/15/08. |
711.81(b)(6) LICENSURE Psychosocial Evaluation
711.81. 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 on March 31, 2008 and April 1, 2008, the facility failed to document a complete psychosocial evaluation in two of two records reviewed, #3 and 7. The psychosocial evaluations were mostly historical with client stated comments rather than a clinical assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, client's attitude toward treatment and overall impressions/conclusions. In addition, the psychosocial evaluations were completed later than the fifth session as stated in the project's policies and procedures manual.This is a repeat deficiency from the October 2007 inspection.
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Plan of Correction
The Clinical Administrator of WPIC Addiction Medicine Services will ensure, through supervision and quality assurance chart review, that the aspects of the psychosocial summary will be in compliance with licensing standards. The evaluation will provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions, and causes leading to the patient's current situation. The evaluation shall also include: A clear description of the client's presenting and underlying problems; Client needs or problems that can or cannot be resolved through treatment or that might inhibit treatment; Client assets, strengths or other factors that can contribute to the resolution of identified problems; The potential or available client support systems; Negative factors that might affect treatment; The client's preferred coping mechanisms; Conclusions regarding the client's appearance, behavior and reactions during the intake process; Conclusions regarding the client's attitude toward and ability to participate in the treatment process.
The information will be gathered and recorded within the required time frame as identified by policy, which is by the end of the 3rd outpatient session, and by the end of the first week of partial services. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 5/15/08 and continuing through the course of the licensing review period.
All staff will be trained by 6/15/08.
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711.82(c) LICENSURE Individualized Tx Plan
711.82. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records on March 31, 2008 and April 1, 2008, the facility failed to document a complete individual treatment and rehabilitation plan in three of three records reviewed, #3, 5 and 7. The individual treatment and rehabilitation plans were missing in client records #3 and 5. In addition, in record #7 the individual treatment and rehabilitation plan was not individualized as it contained the same goals as record #1 in outpatient treatment.This is a repeat deficiency from the October 2007 inspection.
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Plan of Correction
Compliance to developing individualized treatment plans in timely fashion will be evidenced by periodic quality reviews by the Clinical Administrator of Addiction Medicine Services at WPIC, combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Training about the regulations and completion of treatment plans will occur in individual supervisory sessions conducted by the Clinical Administrator. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 5/15/08 and continuing through the course of the licensing review period.
All staff will be trained by 6/15/08. |
711.82(c)(1) LICENSURE Short/Long Term Goals
711.82. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment, as formulated by both staff and client.
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Observations
Based on a review of client records on March 31, 2008 and April 1, 2008, the facility failed to document individualized short and long-term goals in the treatment and rehabilitation plan in three of three records reviewed, #3, 5 and 7. The short and long-term goals in the individual treatment and rehabilitation plans were missing in client records #3 and 5. In addition, in record #7 the short and long-term goals in treatment and rehabilitation plan were not individualized as it contained the same goals as record #1 in outpatient treatment.
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Plan of Correction
Compliance to developing individualized treatment plans in timely fashion will be evidenced by periodic quality reviews by the Clinical Administrator combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Particular attention will be paid to the development of realistic and measurable short and long-term goals. Training about the regulations and completion of treatment plans will occur during individual supervisory sessions conducted by the Clinical Administrator. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 5/15/08 and continuing through the course of the licensing review period.
All staff will be trained by 6/15/08. |
711.82(c)(2) LICENSURE Type/Frequency of Treatment
711.82. Treatment and rehabilitation services.
(c) 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 a review of client records on March 31, 2008 and April 1, 2008, the facility failed to document type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan in two of three records reviewed, #3 and 5.
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Plan of Correction
The Clinical Administrator of WPIC Addiction Medicine Services will ensure, through supervision and quality assurance chart review, that the treatment plans in the partial program shall include the frequency of individual, group, and family sessions. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 5/15/08 and continuing through the course of the licensing review period.
All staff will be trained by 6/15/08. |
711.82(c)(3) LICENSURE Support Service - Tx Plan
711.82. Treatment and rehabilitation services.
(c) 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 a review of client records on March 31, 2008 and April 1, 2008, the facility failed to document proposed support services in the individual treatment and rehabilitation plan in three of three records reviewed, #3, 5 and 7.
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Plan of Correction
Compliance to developing individualized treatment plans in timely fashion will be evidenced by periodic quality reviews by the Clinical Administrator combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Training about the regulations and completion of treatment plans will occur in individual supervisory sessions conducted by the Clinical Administrator. Particular focus shall be placed upon including the patient's participation appropriate support services, including 12-step fellowships among other activities as part of the plan of recovery.
Program leadership will develop a resource manual that contains community resources and will be geared specifically to the issues experienced by individuals participating in the program. The manual will be available for staff use by 7/1/08. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later that 5/15/08 and continuing through the course of the licensing review period.
All staff will be trained by 6/15/08.
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711.82(d) LICENSURE Tx Plan Updates
711.82. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records on March 31, 2008 and April 1, 2008, the facility failed to document treatment and rehabilitation plan updates at least every 30 days in two of two records, #3 and 5. Treatment plan updates were missing.This is a repeat deficiency from the October 2007 inspection.
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Plan of Correction
Compliance to developing individualized treatment plan updates in timely fashion will be evidenced by periodic quality reviews by the Clinical Administrator combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Training about the regulations and completion of treatment plan updates will occur in individual supervisory sessions conducted by the Clinical Administrator. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 5/15/08 and continuing through the course of the licensing review period.
All staff will be trained by 6/15/08. |
711.82(e) LICENSURE Provision of Services re: TX Plan
711.82. Treatment and rehabilitation services.
(e) 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 on March 31, 2008 and April 1, 2008, the facility failed to to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in two records reviewed, #3 and 5. The inspectors were unable to ascertain whether or not counseling services were provided according to the individual treatment and rehabilitation plans in records #3 and 5. Individual treatment plan and rehabilitation plans were missing in these records.This is a repeat deficiency from the October 2007 inspection.
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Plan of Correction
The Clinical Administrator of WPIC Addiction Medicine Services will ensure, through supervision and quality assurance chart review, that a minimum of 2 individual sessions are provided on a weekly basis to all members of the partial program. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 5/15/08 and continuing through the course of the licensing review period.
All staff will be trained by 6/15/08. |
711.82(f)(1) LICENSURE Ind Counseling - 2X WK
711.82. Treatment and rehabilitation services.
(f) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records on March 31, 2008 and April 1, 2008, the facility failed to document the provision of individual counseling services, at least twice weekly, in three of three records #3, 5 and 7. Clients participating in partial hospitalization activities were not provided individual counseling at least twice weekly.This is a repeat deficiency from the October 2007 inspection.
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Plan of Correction
The Clinical Administrator of WPIC Addiction Medicine Services will ensure, through supervision and quality assurance chart review, that a minimum of 2 individual sessions are provided on a weekly basis to all members of the partial program. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 5/15/08 and continuing through the course of the licensing review period.
All staff will be trained by 6/15/08. |
711.83(a)(4) LICENSURE Progress Notes
711.83. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(4) Progress notes.
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Observations
Based on a review of client records on March 31, 2008 and April 1, 2008, the facility failed to document complete progress notes in three of three records, #3, 5 and 7. Progress notes for individual counseling sessions were missing the clinician's assessment and plan. In addition, there was no continuity between progress notes.
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Plan of Correction
The Clinical Administrator of WPIC Addiction Medicine Services will ensure, through supervision and quality assurance chart review, that all clinical documentation within the patient record meet all licensing standards, as well as standards for best practices in clinical documentation. Particular attention will be paid to the DAP format and the inclusion of objective data, assessment of the objective data, and plans developed as a result of the assessment. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 5/15/08 and continuing through the course of the licensing review period.
All staff will be trained by 6/15/08. |
711.83(c)(1)(ii) LICENSURE Staff Access to client records
711.83. Client records.
(c) Confidentiality.
(1) A written procedure shall be developed by the project director which complies 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:
(ii) Staff access to client records.
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Observations
Based on a review of the facility's policies and procedures on March 31, 2008, the facility failed to identify the staff that would have access to client's records. In addition the facility failed to provide for a system that ensures security of drug and alcohol treatment records in accordance with state law and federal regulations (71 P.S. and 42 CFR part 2 Subpart C Subsection 2.32). The facility's policy did not specifically identify which staff would have access to the client's records. It was possible for WPIC staff not involved in provision of substance abuse services to identify patients as participants in those services without written consent by accessing the electronic data base.This is a repeat deficiency from the October 2007 inspection.
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Plan of Correction
WPIC submits this plan of correction related to the licensing citations discussed and clarified in the meeting of Friday (2/29/08) in Harrisburg.
The plan focuses on the following key points:
- Access to medical records maintained on patients participating in WPIC Addiction Medicine Services (AMS) treatment programs which are licensed by the DAPL, by individuals who are concurrently treating those same patients in programs of WPIC which are not licensed by DAPL; and,
- The WPIC AMS operations manual describing such access as required by Pennsylvania State licensing standards; and,
- Plans regarding alterations and modifications to the Psych Consult system to address DAPL's stated concerns specific to that system.
1. At no time either currently, or historically, has access to confidential treatment information generated by WPIC AMS programs licensed by DAPL been permitted by anyone outside of WPIC. This includes the medical components of the University of Pittsburgh Medical Center (UPMC). WPIC will only permit access to those medical records created in its Psych Consult system and generated by its AMS programs to those individuals who are specifically permitted to have such access by the following strictures:
a. These individuals are "members" of the AMS treatment programs and are maintained on DAPL's licensing grid as such. Further, WPIC AMS ensures that these individuals have had specific training in the confidentiality of drug and alcohol treatment records as outlined in the state (4 PA Code 255.5) and federal (42 CFR part 2) laws.
b. Informed and voluntary consent from the WPIC AMS patient is obtained prior to the release of such protected health information.
2. WPIC AMS will adapt its written operations manual to better reflect the intent of the licensing standards regarding the Electronic Medical Record as per DOH Licensing Alert 1-05. This operations manual containing the policy and procedure regarding electronic medical records will be maintained by each licensed ambulatory program using the electronic medical records system. This operations manual description will:
a. Identify by position and job title, the specific WPIC staff who will access the database; the access restrictions assigned to each position, and a listing of staff with administrative privileges.
b. Describe the security system protecting the database including how access restrictions will be implemented, firewall protections, password protocols, and how and to whom temporary access would be afforded for evaluation procedures.
c. Describe the maintenance procedures addressing the location of the server, schedule for backing up the data, staff responsible for maintenance, location of back-up storage mediums, and timeframes for deletion.
3. WPIC Administration will ensure that modifications are made to the Psych Consult database as it currently exists. These modifications will include the documentation of system "user awareness," and the implementation of specific audit activities designed to monitor and address both appropriate and improper access of protected health information generated by the WPIC AMS programs licensed by DAPL. WPIC shall ensure through its Information Security Officer, the implementation and collaborative oversight with WPIC AMS leadership (in particular the facility directors of all WPIC AMS programs licensed by DAPL) of such activities involving the following steps:
a. Documentation of User Awareness.
i. A document will be presented to each user who works with patients who have protected health information generated by the WPIC AMS programs licensed by DAPL.
ii. The document will inform the user of the potential to access this information and the special confidentiality afforded to this information.
iii. The user will acknowledge that the appropriate training has been provided and that the purpose of reviewing the information is to deliver high quality integrated behavioral health care.
iv. The user will sign the document.
v. The completed document will be retained in the patient record. The signed document will expire after one year and will be re-evaluated and re-issued, as appropriate, at expiration.
b. Audit of Access and completion.
i. User access to patient records is recorded on a per-instance basis. This produces an audit trail. This audit trail will be conducted by Information Services Staff designated by the WPIC Information Security Officer, and monitored jointly by the WPIC Information Security Officer and the Clinical Administrator of Addiction Medicine Services.
ii. The audit trail will be compared to the patients who are and/or have been assigned to a WPIC program licensed by DAPL and to the documentation of user preparation and awareness of requirements for handling protected health information generated by WPIC AMS programs licensed by DAPL.
iii. The status of the document and the user access of patient information will be reviewed for completeness and appropriateness.
iv. All inconsistencies will be investigated and resolved through either corrective action or progressive disciplinary procedures.
v. The audit trails will be conducted a minimum of every third day to ensure compliance.
4. WPIC asserts that the Psych Consult electronic medical records system is compliant with the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Documentation to this effect will be sent in hardcopy form to DAPL through the mail.
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711.83(c)(2) LICENSURE Informed/Voluntary Consent
711.83. Client records.
(c) Confidentiality.
(2) 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 on March 31, 2008 and April 1, 2008, the facility failed to ensure that an informed and voluntary consent to release information was obtained in three of three records, #3, 5 and 7. It was possible for WPIC staff not involved in the provision of substance abuse services to identify patients as participants in those services without written consent by accessing the electronic record keeping system which contained such information.This is repeat deficiency from the October 2007 inspection.
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Plan of Correction
WPIC submits this plan of correction related to the licensing citations discussed and clarified in the meeting of Friday (2/29/08) in Harrisburg.
The plan focuses on the following key points:
- Access to medical records maintained on patients participating in WPIC Addiction Medicine Services (AMS) treatment programs which are licensed by the DAPL, by individuals who are concurrently treating those same patients in programs of WPIC which are not licensed by DAPL; and,
- The WPIC AMS operations manual describing such access as required by Pennsylvania State licensing standards; and,
- Plans regarding alterations and modifications to the Psych Consult system to address DAPL's stated concerns specific to that system.
1. At no time either currently, or historically, has access to confidential treatment information generated by WPIC AMS programs licensed by DAPL been permitted by anyone outside of WPIC. This includes the medical components of the University of Pittsburgh Medical Center (UPMC). WPIC will only permit access to those medical records created in its Psych Consult system and generated by its AMS programs to those individuals who are specifically permitted to have such access by the following strictures:
a. These individuals are "members" of the AMS treatment programs and are maintained on DAPL's licensing grid as such. Further, WPIC AMS ensures that these individuals have had specific training in the confidentiality of drug and alcohol treatment records as outlined in the state (4 PA Code 255.5) and federal (42 CFR part 2) laws.
b. Informed and voluntary consent from the WPIC AMS patient is obtained prior to the release of such protected health information.
2. WPIC AMS will adapt its written operations manual to better reflect the intent of the licensing standards regarding the Electronic Medical Record as per DOH Licensing Alert 1-05. This operations manual containing the policy and procedure regarding electronic medical records will be maintained by each licensed ambulatory program using the electronic medical records system. This operations manual description will:
a. Identify by position and job title, the specific WPIC staff who will access the database; the access restrictions assigned to each position, and a listing of staff with administrative privileges.
b. Describe the security system protecting the database including how access restrictions will be implemented, firewall protections, password protocols, and how and to whom temporary access would be afforded for evaluation procedures.
c. Describe the maintenance procedures addressing the location of the server, schedule for backing up the data, staff responsible for maintenance, location of back-up storage mediums, and timeframes for deletion.
3. WPIC Administration will ensure that modifications are made to the Psych Consult database as it currently exists. These modifications will include the documentation of system "user awareness," and the implementation of specific audit activities designed to monitor and address both appropriate and improper access of protected health information generated by the WPIC AMS programs licensed by DAPL. WPIC shall ensure through its Information Security Officer, the implementation and collaborative oversight with WPIC AMS leadership (in particular the facility directors of all WPIC AMS programs licensed by DAPL) of such activities involving the following steps:
a. Documentation of User Awareness.
i. A document will be presented to each user who works with patients who have protected health information generated by the WPIC AMS programs licensed by DAPL.
ii. The document will inform the user of the potential to access this information and the special confidentiality afforded to this information.
iii. The user will acknowledge that the appropriate training has been provided and that the purpose of reviewing the information is to deliver high quality integrated behavioral health care.
iv. The user will sign the document.
v. The completed document will be retained in the patient record. The signed document will expire after one year and will be re-evaluated and re-issued, as appropriate, at expiration.
b. Audit of Access and completion.
i. User access to patient records is recorded on a per-instance basis. This produces an audit trail. This audit trail will be conducted by Information Services Staff designated by the WPIC Information Security Officer, and monitored jointly by the WPIC Information Security Officer and the Clinical Administrator of Addiction Medicine Services.
ii. The audit trail will be compared to the patients who are and/or have been assigned to a WPIC program licensed by DAPL and to the documentation of user preparation and awareness of requirements for handling protected health information generated by WPIC AMS programs licensed by DAPL.
iii. The status of the document and the user access of patient information will be reviewed for completeness and appropriateness.
iv. All inconsistencies will be investigated and resolved through either corrective action or progressive disciplinary procedures.
v. The audit trails will be conducted a minimum of every third day to ensure compliance.
4. WPIC asserts that the Psych Consult electronic medical records system is compliant with the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Documentation to this effect will be sent in hardcopy form to DAPL through the mail.
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711.83(c)(2)(ii) LICENSURE Specific Information Disclosed
711.83. Client records.
(c) Confidentiality.
(2) 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:
(ii) The specific information disclosed.
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Observations
Based on a review of client records on March 31, 2008 and April 1, 2008, the facility failed to obtain an informed an voluntary consent to release information in two of three records reviewed, #3 and 7. Specific information identified in the Pennsylvania Client Placement Criteria (PCPC) exceeded the limitations imposed at 4 Pa. Code Subsection 255.5(b). Information released to third party payers was in excess of what is permitted by law. Specific information released to Children, Youth and Families Services identified in record # 3 exceeded the limitations imposed at 4 Pa. Code Subsection 255.5(b), where the releases of information were made to government officials.
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Plan of Correction
The Clinical Administrator of WPIC Addiction Medicine Services will ensure, through supervision and quality assurance chart review, that all program staff obtain an informed and voluntary consent in writing authorizing the release of protected drug and alcohol information prior to the release of such information. The consent form shall be in compliance with 4 PA 255.5 as well as directly in 42 CFR Part 2, Subpart C, subsection 2.32 and indirectly at subsection 2.31 as regards confidentiality of drug and alcohol treatment records, and shall demonstrate the patient's intent to release information voluntarily. This form shall contain the following information: The name of the person, agency, or organization to whom disclosure is made; the specific information disclosed; the purpose of disclosure and, the dated signature of the client or guardian. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 5/15/08 and continuing through the course of the licensing review period. |
711.91(b)(3)(i) LICENSURE Medical History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records on March 31, 2008 and April 1, 2008, the facility failed to document a complete medical history in five of nine records reviewed, #1, 2, 4, 6 and 11. The medical histories were missing the client's symptoms/illnesses. In addition, the medical histories were missing the family medical in four records #2, 4, 6 and 11.
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Plan of Correction
The Clinical Administrator of WPIC Addiction Medicine Services will ensure, through supervision and quality assurance chart review, that the aspects of medical history comprises a history documenting the client's personal medical history, family medical history, and history of illness and symptoms. The information will be gathered and recorded within the required time frame as identified by policy, which is by the end of the 3rd outpatient session, and by the end of the first week of partial services. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 5/15/08 and continuing through the course of the licensing review period.
All staff will be trained by 6/15/08. |
711.91(b)(3(ii) LICENSURE D & A History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records on March 31, 2008 and April 1, 2008, the facility failed to document a complete drug and/or alcohol history within three sessions of the client's admission into treatment as stated in the project's policies and procedures manual. In two of nine client records, #4 and 11, the drug and alcohol history was completed after the third session and on the day of discharge, respectively. In addition, in three of nine client records, #1, 4 and 12, the drug and/or alcohol history was missing lengths and patterns of use.
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Plan of Correction
The Clinical Administrator of WPIC Addiction Medicine Services will ensure, through supervision and quality assurance chart review, that the aspect of D & A histories comprises a complete history including, but not limited to, progression of use related to lengths/patterns and prior treatment history. In addition the Facility Director/Clinical Supervisor will ensure that the documentation of D & A histories is completed for each client, completed on time and contains required information as to be in accordance with agency policy. Furthermore the Facility Director will ensure that the D & A history documentation is updated within specified time frames. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 5/15/08 and continuing through the course of the licensing review period.
All staff will be trained by 6/15/08. |
711.91(b)(3)(iii) LICENSURE Personal History
711.91. 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 a review of client records on March 31, 2008 and April 1, 2008, the facility failed to document a complete personal history in four of nine records reviewed, #1, 4, 6 and 12. The personal histories contained incomplete information regarding the client's family, employment and recreational histories. In addition, the personal histories were completed later than the third session as stated in the project's policies and procedures manual in client records #4 and 11.
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Plan of Correction
The Clinical Administrator of WPIC Addiction Medicine Services will ensure, through supervision and quality assurance chart review, that the aspects of the aspects of personal history comprises a history documenting the client's historical and pertinent personal data including: family, legal, employment/vocational, educational, military, recreational, sexual and others where appropriate. The information will be gathered and recorded within the required time frame as identified by policy, which is by the end of the 3rd outpatient session, and by the end of the first week of partial services. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 5/15/08 and continuing through the course of the licensing review period.
All staff will be trained by 6/15/08. |
711.91(b)(4) LICENSURE Consent to Treatment
711.91. 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 on March 31, 2008 and April 1, 2008, the facility failed to document a consent to treatment form signed by the client in four of seven records reviewed. , #2, 4, 10 and 11. The University of Pittsburgh Medical Center general consent to treatment form utilized for drug and alcohol treatment services contained a parental signature line in two of seven records reviewed, #2 and 11. The parent of the adolescent signed the consent to treatment form for the adolescent seeking drug and alcohol treatment services. Consent to treatment forms were missing in two records reviewed, #4 and 10.
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Plan of Correction
The Clinical Administrator of WPIC Addiction Medicine Services will ensure, through supervision and quality assurance chart review, that the consents utilized in addiction medicine programs include neither a signature line for parental consent, nor that parental consent is offered to the family of a minor who is seeking services at the program. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 5/15/08 and continuing through the course of the licensing review period. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. 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 on March 31, 2008 and April 1, 2008, the facility failed to document a complete psychosocial evaluation in three of seven records reviewed, #1, 2 and 12. The psychosocial evaluations were mostly historical with client stated comments rather than a clinical assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, client's attitude toward treatment and overall impressions/conclusions. In addition, the psychosocial evaluations were completed later than the third session as stated in the project's policies and procedures manual in client records #4 and 11.
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Plan of Correction
The Clinical Administrator of WPIC Addiction Medicine Services will ensure, through supervision and quality assurance chart review, that the aspects of the psychosocial summary will be in compliance with licensing standards. The evaluation will provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions, and causes leading to the patient's current situation. The evaluation shall also include: A clear description of the client's presenting and underlying problems; Client needs or problems that can or cannot be resolved through treatment or that might inhibit treatment; Client assets, strengths or other factors that can contribute to the resolution of identified problems; The potential or available client support systems; Negative factors that might affect treatment; The client's preferred coping mechanisms; Conclusions regarding the client's appearance, behavior and reactions during the intake process; Conclusions regarding the client's attitude toward and ability to participate in the treatment process.
The information will be gathered and recorded within the required time frame as identified by policy, which is by the end of the 3rd outpatient session, and by the end of the first week of partial services. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 5/15/08 and continuing through the course of the licensing review period.
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711.91(b)(7) LICENSURE Preliminary Treatment Plan
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records on March 31, 2008 and April 1, 2008, the facility failed to document a preliminary treatment and rehabilitation plan within the third session as stated in the project's policies and procedures manual in three of seven records, #1, 4 and 11.
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Plan of Correction
The Clinical Administrator of WPIC Addiction Medicine Services will ensure, through supervision and quality assurance chart review, that the aspects of the preliminary treatment plan will be in compliance with licensing standards. The Preliminary Treatment Plan shall be based upon information derived from the initial interview, psychosocial and other evaluations. This plan should also identify critical client problems and strategies for their resolution. The information will be gathered and recorded within the required time frame as identified by policy, which is by the end of the 3rd outpatient session, and by the end of the first week of partial services. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 5/15/08 and continuing through the course of the licensing review period.
All staff will be trained by 6/15/08. |
711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records on March 31, 2008 and April 1, 2008, the facility failed to document a complete individual treatment and rehabilitation plan in eight of nine records reviewed, #1, 2, 4, 8, 10, 11, 12 and 14. The individual treatment and rehabilitation plans were missing in client records #4 and 8. In records #1, 2, 10, 11, 12 and 14 the individual treatment and rehabilitation plan were not individualized. This is a repeat deficiency from the October 2007 inspection.
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Plan of Correction
Compliance to developing individualized treatment plans in timely fashion will be evidenced by periodic quality reviews by the Clinical Administrator combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Training about the regulations and completion of treatment plans will occur during individual supervisory session conducted by the Clinical Administrator. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 5/15/08 and continuing through the course of the licensing review period.
All staff will be trained by 6/15/08. |
711.92(c)(1) LICENSURE TX Plan Goals
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment, as formulated by both staff and client.
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Observations
Based on a review of client records on March 31, 2008 and April 1, 2008, the facility failed to document individualized short and long-term goals in the treatment and rehabilitation plan in six of six records reviewed, #1, 2, 10, 11, 12 and 14. The short and long-term goals in the individual treatment and rehabilitation plans were missing in client records #4 and 8. In records #1 and 11, the short and long-term goals were the same. In addition, in client records #2, 10 12 and 14, the short and long-term goals were not stated in terms of measurable criteria and did not include individual issues identified in the psychosocial evaluation. Lastly, client records #12 and 14 were not signed by the client as per the project's policies and procedures manual.
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Plan of Correction
Compliance to developing individualized treatment plans in timely fashion will be evidenced by periodic quality reviews by the Clinical Administrator combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Particular attention will be paid to the development of realistic and measurable short and long-term goals. Training about the regulations and completion of treatment plans will occur during individual supervisory sessions conducted by the Clinical Administrator. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 5/15/08 and continuing through the course of the licensing review period.
All staff will be trained by 6/15/08. |
711.92(c)(2) LICENSURE Type & Frequency of TX
711.92. Treatment and rehabilitation services.
(c) 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 a review of client records on March 31, 2008 and April 1, 2008, the facility failed to document type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan in three of nine records reviewed, #2, 6 and 12.
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Plan of Correction
The Clinical Administrator of WPIC Addiction Medicine Services will ensure, through supervision and quality assurance chart review, that the treatment plans in the partial program shall include the frequency of individual, group, and family sessions. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 5/15/08 and continuing through the course of the licensing review period.
All staff will be trained by 6/15/08. |
711.92(c)(3) LICENSURE Support Service
711.92. Treatment and rehabilitation services.
(c) 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 a review of client records on March 31, 2008 and April 1, 2008, the facility failed to document proposed support services in the individual treatment and rehabilitation plan in nine of nine records reviewed, #1, 2, 4, 6, 8, 10, 11, 12 and 14.
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Plan of Correction
Compliance to developing individualized treatment plans in timely fashion will be evidenced by periodic quality reviews by the Clinical Administrator combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Training about the regulations and completion of treatment plans will occur during individual supervisory sessions conducted by the Clinical Administrator. Particular focus shall be placed upon including the patient's participation appropriate support services, including 12-step fellowships among other activities as part of the plan of recovery.
Program leadership will develop a resource manual that contains community resources and will be geared specifically to the issues experienced by individuals participating in the program. The manual will be available for staff use by 7/1/08. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 5/15/08 and continuing through the course of the licensing review period.
All staff will be trained by 6/15/08.
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711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) 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 on March 31, 2008 and April 1, 2008, the facility failed to document a complete treatment and rehabilitation plan update at least every 60 days in six of nine records, #1, 6, 8, 9, 10 and 11. Treatment plan updates were missing in three records, #6, 8 and 9. Treatment plan updates were missing an assessment of the clients's progress in relationship tot he stated goals of the treatment plan in two records, #1 and 10. The treatment plan updates only stated "resolved" or "unresolved."
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Plan of Correction
Compliance to developing individualized treatment plan updates in timely fashion will be evidenced by periodic quality reviews by the Clinical Administrator combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Training about the regulations and completion of treatment plan updates will occur during individual supervisory sessions conducted by the Clinical Administrator. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 5/15/08 and continuing through the course of the licensing review period.
All staff will be trained by 6/15/08. |
711.92(e) LICENSURE Provision of TX RE: TX Plan
711.92. Treatment and rehabilitation services.
(e) 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 on March 31, 2008 and April 1, 2008, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in six of nine records, #2, 4, 6, 8, 9 and 12. Individual treatment and rehabilitation plans were missing in records #4 and 8. In addition, the type and frequency of treatment services were missing in records #2, 6 and 12; therefore, it was undetermined as to whether or not counseling services were provided accordingly.
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Plan of Correction
The Clinical Administrator of WPIC Addiction Medicine Services will ensure, through supervision and quality assurance chart review, that a minimum of 2 individual sessions are provided on a weekly basis to all members of the partial program. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 5/15/08 and continuing through the course of the licensing review period.
All staff will be trained by 6/15/08. |
711.92(f) LICENSURE Couns. Prov.- Reg & Sched.
711.92. Treatment and rehabilitation services.
(f) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records on March 31, 2008 and April 1, 2008, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan in six of nine records, #2, 4, 6, 8, 9 and 12. Individual treatment and rehabilitation plans were missing in records #4 and 8. In addition, the type and frequency of treatment services were missing in records 2, 6 and 12; therefore, it was undetermined as to whether or not counseling services were provided accordingly.
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Plan of Correction
The Clinical Administrator of WPIC Addiction Medicine Services will ensure, through supervision and quality assurance chart review, that a minimum of 2 individual sessions are provided on a weekly basis to all members of the partial program. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later than 5/15/08 and continuing through the course of the licensing review period.
All staff will be trained by 6/15/08. |
711.93(c)(1)(ii) LICENSURE Confidentiality-Staff Access to Records
711.93. Client records.
(c) Confidentiality.
(1) A written procedure shall be developed by the project director which complies 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:
(ii) Staff access to client records.
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Observations
Based on a review of the facility's policies and procedures on March 31, 2008, the facility failed to identify the staff that would have access to client's records. In addition the facility failed to provide for a system that ensures security of drug and alcohol treatment records in accordance with state law and federal regulations (71 P.S. and 42 CFR part 2 Subpart C Subsection 2.32). The facility's policy did not specifically identify which staff would have access to the client's records. It was possible for WPIC staff not involved in provision of substance abuse services to identify patients as participants in those services without written consent by accessing the electronic data base.This is a repeat deficiency from the October 2007 inspection.
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Plan of Correction
WPIC submits this plan of correction related to the licensing citations discussed and clarified in the meeting of Friday (2/29/08) in Harrisburg.
The plan focuses on the following key points:
- Access to medical records maintained on patients participating in WPIC Addiction Medicine Services (AMS) treatment programs which are licensed by the DAPL, by individuals who are concurrently treating those same patients in programs of WPIC which are not licensed by DAPL; and,
- The WPIC AMS operations manual describing such access as required by Pennsylvania State licensing standards; and,
- Plans regarding alterations and modifications to the Psych Consult system to address DAPL's stated concerns specific to that system.
1. At no time either currently, or historically, has access to confidential treatment information generated by WPIC AMS programs licensed by DAPL been permitted by anyone outside of WPIC. This includes the medical components of the University of Pittsburgh Medical Center (UPMC). WPIC will only permit access to those medical records created in its Psych Consult system and generated by its AMS programs to those individuals who are specifically permitted to have such access by the following strictures:
a. These individuals are "members" of the AMS treatment programs and are maintained on DAPL's licensing grid as such. Further, WPIC AMS ensures that these individuals have had specific training in the confidentiality of drug and alcohol treatment records as outlined in the state (4 PA Code 255.5) and federal (42 CFR part 2) laws.
b. Informed and voluntary consent from the WPIC AMS patient is obtained prior to the release of such protected health information.
2. WPIC AMS will adapt its written operations manual to better reflect the intent of the licensing standards regarding the Electronic Medical Record as per DOH Licensing Alert 1-05. This operations manual containing the policy and procedure regarding electronic medical records will be maintained by each licensed ambulatory program using the electronic medical records system. This operations manual description will:
a. Identify by position and job title, the specific WPIC staff who will access the database; the access restrictions assigned to each position, and a listing of staff with administrative privileges.
b. Describe the security system protecting the database including how access restrictions will be implemented, firewall protections, password protocols, and how and to whom temporary access would be afforded for evaluation procedures.
c. Describe the maintenance procedures addressing the location of the server, schedule for backing up the data, staff responsible for maintenance, location of back-up storage mediums, and timeframes for deletion.
3. WPIC Administration will ensure that modifications are made to the Psych Consult database as it currently exists. These modifications will include the documentation of system "user awareness," and the implementation of specific audit activities designed to monitor and address both appropriate and improper access of protected health information generated by the WPIC AMS programs licensed by DAPL. WPIC shall ensure through its Information Security Officer, the implementation and collaborative oversight with WPIC AMS leadership (in particular the facility directors of all WPIC AMS programs licensed by DAPL) of such activities involving the following steps:
a. Documentation of User Awareness.
i. A document will be presented to each user who works with patients who have protected health information generated by the WPIC AMS programs licensed by DAPL.
ii. The document will inform the user of the potential to access this information and the special confidentiality afforded to this information.
iii. The user will acknowledge that the appropriate training has been provided and that the purpose of reviewing the information is to deliver high quality integrated behavioral health care.
iv. The user will sign the document.
v. The completed document will be retained in the patient record. The signed document will expire after one year and will be re-evaluated and re-issued, as appropriate, at expiration.
b. Audit of Access and completion.
i. User access to patient records is recorded on a per-instance basis. This produces an audit trail. This audit trail will be conducted by Information Services Staff designated by the WPIC Information Security Officer, and monitored jointly by the WPIC Information Security Officer and the Clinical Administrator of Addiction Medicine Services.
ii. The audit trail will be compared to the patients who are and/or have been assigned to a WPIC program licensed by DAPL and to the documentation of user preparation and awareness of requirements for handling protected health information generated by WPIC AMS programs licensed by DAPL.
iii. The status of the document and the user access of patient information will be reviewed for completeness and appropriateness.
iv. All inconsistencies will be investigated and resolved through either corrective action or progressive disciplinary procedures.
v. The audit trails will be conducted a minimum of every third day to ensure compliance.
4. WPIC asserts that the Psych Consult electronic medical records system is compliant with the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Documentation to this effect will be sent in hardcopy form to DAPL through the mail.
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711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) 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 client records reviewed on March 31, 2008 and April 1, 2008, the facility failed to ensure that an informed and voluntary consent to release information form was obtained in nine of nine records reviewed, #1, 2, 4, 6, 8, 10, 11, 12 and 14. It was possible for WPIC staff not involved in the provision of substance abuse services to identify patients as participants in those services without written consent by accessing the electronic record keeping system which contained such information. In addition, in records #10 and 11, the parent signed the consent to release information form for the adolescent client participating in drug and alcohol treatment services without the client's written consent.
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Plan of Correction
WPIC submits this plan of correction related to the licensing citations discussed and clarified in the meeting of Friday (2/29/08) in Harrisburg.
The plan focuses on the following key points:
- Access to medical records maintained on patients participating in WPIC Addiction Medicine Services (AMS) treatment programs which are licensed by the DAPL, by individuals who are concurrently treating those same patients in programs of WPIC which are not licensed by DAPL; and,
- The WPIC AMS operations manual describing such access as required by Pennsylvania State licensing standards; and,
- Plans regarding alterations and modifications to the Psych Consult system to address DAPL's stated concerns specific to that system.
1. At no time either currently, or historically, has access to confidential treatment information generated by WPIC AMS programs licensed by DAPL been permitted by anyone outside of WPIC. This includes the medical components of the University of Pittsburgh Medical Center (UPMC). WPIC will only permit access to those medical records created in its Psych Consult system and generated by its AMS programs to those individuals who are specifically permitted to have such access by the following strictures:
a. These individuals are "members" of the AMS treatment programs and are maintained on DAPL's licensing grid as such. Further, WPIC AMS ensures that these individuals have had specific training in the confidentiality of drug and alcohol treatment records as outlined in the state (4 PA Code 255.5) and federal (42 CFR part 2) laws.
b. Informed and voluntary consent from the WPIC AMS patient is obtained prior to the release of such protected health information.
2. WPIC AMS will adapt its written operations manual to better reflect the intent of the licensing standards regarding the Electronic Medical Record as per DOH Licensing Alert 1-05. This operations manual containing the policy and procedure regarding electronic medical records will be maintained by each licensed ambulatory program using the electronic medical records system. This operations manual description will:
a. Identify by position and job title, the specific WPIC staff who will access the database; the access restrictions assigned to each position, and a listing of staff with administrative privileges.
b. Describe the security system protecting the database including how access restrictions will be implemented, firewall protections, password protocols, and how and to whom temporary access would be afforded for evaluation procedures.
c. Describe the maintenance procedures addressing the location of the server, schedule for backing up the data, staff responsible for maintenance, location of back-up storage mediums, and timeframes for deletion.
3. WPIC Administration will ensure that modifications are made to the Psych Consult database as it currently exists. These modifications will include the documentation of system "user awareness," and the implementation of specific audit activities designed to monitor and address both appropriate and improper access of protected health information generated by the WPIC AMS programs licensed by DAPL. WPIC shall ensure through its Information Security Officer, the implementation and collaborative oversight with WPIC AMS leadership (in particular the facility directors of all WPIC AMS programs licensed by DAPL) of such activities involving the following steps:
a. Documentation of User Awareness.
i. A document will be presented to each user who works with patients who have protected health information generated by the WPIC AMS programs licensed by DAPL.
ii. The document will inform the user of the potential to access this information and the special confidentiality afforded to this information.
iii. The user will acknowledge that the appropriate training has been provided and that the purpose of reviewing the information is to deliver high quality integrated behavioral health care.
iv. The user will sign the document.
v. The completed document will be retained in the patient record. The signed document will expire after one year and will be re-evaluated and re-issued, as appropriate, at expiration.
b. Audit of Access and completion.
i. User access to patient records is recorded on a per-instance basis. This produces an audit trail. This audit trail will be conducted by Information Services Staff designated by the WPIC Information Security Officer, and monitored jointly by the WPIC Information Security Officer and the Clinical Administrator of Addiction Medicine Services.
ii. The audit trail will be compared to the patients who are and/or have been assigned to a WPIC program licensed by DAPL and to the documentation of user preparation and awareness of requirements for handling protected health information generated by WPIC AMS programs licensed by DAPL.
iii. The status of the document and the user access of patient information will be reviewed for completeness and appropriateness.
iv. All inconsistencies will be investigated and resolved through either corrective action or progressive disciplinary procedures.
v. The audit trails will be conducted a minimum of every third day to ensure compliance.
4. WPIC asserts that the Psych Consult electronic medical records system is compliant with the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Documentation to this effect will be sent in hardcopy form to DAPL through the mail.
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711.93(c)(2)(ii) LICENSURE Specific Info. Disclosed
711.93. Client records.
(c) Confidentiality.
(2) 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:
(ii) The specific information disclosed.
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Observations
Based on a review of client records on March 31, 2008 and April 1, 2008, the facility failed to obtain an informed an voluntary consent to release information in one of nine records reviewed, #1. Specific information identified in the Pennsylvania Client Placement Criteria (PCPC) exceeded the limitations imposed at 4 Pa. Code Subsection 255.5(b). Information released to third party payers was in excess of what is permitted by law. In addition, client record #1 was missing the specific information to be disclosed on one consent to release information form.
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Plan of Correction
The Clinical Administrator of WPIC Addiction Medicine Services will ensure, through supervision and quality assurance chart review, that all program staff obtain an informed and voluntary consent in writing authorizing the release of protected drug and alcohol information prior to the release of such information. The consent form shall be in compliance with 4 PA 255.5 as well as directly in 42 CFR Part 2, Subpart C, subsection 2.32 and indirectly at subsection 2.31 as regards confidentiality of drug and alcohol treatment records, and shall demonstrate the patient's intent to release information voluntarily. This form shall contain the following information: The name of the person, agency, or organization to whom disclosure is made; the specific information disclosed; the purpose of disclosure and, the dated signature of the client or guardian. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Administrator beginning no later that 5/15/08 and continuing through the course of the licensing review period. |