INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 21, 2012 through June 22, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Women's Institute for Family Health 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 and a conversation with the Project Director, the facility failed to obtain an informed and voluntary consent to release information in seven of ten client records reviewed.
The findings include:
From June 21, 2012 through June 22, 2012, ten client records requiring documentation of an informed and voluntary consent were reviewed to ensure compliance with 4 Pa. Code 255.5. The facility failed to adhere to the requirements specified at 4 Pa. Code in seven of ten client records reviewed, # 1, 2, 3, 4, 5, 8, and 10.
4 Pa. Code subsection 255.5 (b) states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Client # 1 was admitted to the program on 10/25/11. A signed "Disclosure of Client Information" form was documented on 10/25/11. The signed "Disclosure of Client Information" documented the release of the treatment plan and discharge summary to the client's probation officer.
Client # 2 was admitted to the program on 11/15/11. A signed "Disclosure of Client Information" form was documented on 11/15/11. The signed "Disclosure of Client Information" documented the release of the treatment plan and discharge summary to the client's Department of Human Services social worker (a government office).
Client # 3 was admitted to the program on 12/27/11. A signed "Disclosure of Client Information" form was documented on 12/27/11. The signed "Disclosure of Client Information" documented the release of the treatment plan and discharge summary to the client's probation officer.
Client # 4 was admitted to the program on 11/16/11. A signed "Disclosure of Client Information" form was documented on 11/16/11. The signed "Disclosure of Client Information" documented the release of the treatment plan and discharge summary to the client's probation officer.
Client # 5 was admitted to the program on 11/1/11. A signed "Disclosure of Client Information" form was documented on 11/1/11. The signed "Disclosure of Client Information" documented the release of the treatment plan and discharge summary to the client's probation officer.
Client # 8 was admitted to the program on 1/24/12. A signed "Disclosure of Client Information" form was documented on 1/24/12. The signed "Disclosure of Client Information" documented the release of the treatment plan and discharge summary to the client's probation officer.
Client # 10 was admitted to the program on 3/28/12. . A signed "Disclosure of Client Information" form was documented on 3/28/12. The signed "Disclosure of Client Information" documented the release of the treatment plan and discharge summary to the client's probation officer.
The Project Director confirmed the findings.
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Plan of Correction
To avoid a reoccurrence of this deficiency the Project Director will revise disclosure forms that will be printed to included pre-filled information to be disclosed in accordance with PA Code 255.5 that will include and be limited to whether the client is or is not in treatment, client's prognosis, the nature of the project, a brief description of the client's progress, a short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse. Forms previously used will be destroyed. Person responsible is the Project Director to be completed by 7/3/12. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation that was evaluative in ten of ten client records.
The findings include:
From June 21, 2012 through June 22, 2012, ten client records requiring documentation of a psychosocial evaluation were reviewed. The facility failed to include evaluative material in the psychosocial evaluation in ten of ten client records reviewed, # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10.
Client # 1 was admitted to the program on 10/25/11. The psychosocial evaluation was dated 11/17/11. The facility provided a list of the client's problems/needs, assets/strengths, support systems, and negative factors, but did not evaluate the impact of those issues on this recovery effort. In addition, the facility failed to provide an assessment regarding the client's coping mechanisms.
Client # 2 was admitted to the program on 11/15/11. The psychosocial evaluation was dated 12/7/11. The facility provided a list of the client's problems/needs, assess/strengths, support systems, and negative factors, but did not evaluate the impact of those issues on this recovery effort. In addition, the facility failed to provide an assessment regarding the client's coping mechanisms.
Client # 3 was admitted to the program on 12/27/11. The psychosocial evaluation was dated 1/24/12. The facility provided a list of the client's assess/strengths and support systems, but did not evaluate the impact of those issues on this recovery effort.
Client # 4 was admitted to the program on 11/16/11. The psychosocial evaluation was dated 12/8/11. The facility provided a list of the client's problems/needs, assess/strengths, and negative factors, but did not evaluate the impact of those issues on this recovery effort. In addition, the facility failed to provide an assessment regarding the client's coping mechanisms.
Client # 5 was admitted to the program on 11/1/11. The psychosocial evaluation was dated 11/21/11. The facility provided a list of the client's coping mechanisms but did not provide an assessment.
Client # 6 was admitted to the program on 2/1/12. The psychosocial evaluation was dated 2/22/12. The facility provided a list of the client's assess/strengths and support systems, but did not evaluate the impact of those issues on this recovery effort. In addition, the facility failed to provide an assessment regarding the client's coping mechanisms.
Client # 7 was admitted to the program on 11/15/11. The psychosocial evaluation was dated 12/5/11. The facility provided a list of the client's assets/strengths, but did not evaluate the impact of those issues on this recovery effort.
Client # 8 was admitted to the program on 1/24/12. The psychosocial evaluation was dated 2/21/12. The facility provided a list of the client's support systems and coping mechanisms, but did not provide an assessment.
Client # 9 was admitted to the program on 3/6/12. The psychosocial evaluation was dated 3/6/12. The facility failed to provide an assessment regarding the client's coping mechanisms, and the counselor did not give his/her impression of the client's attitude toward treatment.
Client # 10 was admitted to the program on 3/28/12. The psychosocial evaluation was dated 4/26/12. The facility provided a list of the client's problems/needs, assets/strengths, support systems, and negative factors, but did not evaluate the impact of those issues on this recovery effort. In addition, the facility failed to provide an assessment regarding the client's coping mechanisms, and they failed to give an impression of the client's attitude toward treatment.
The Project Director did not dispute the findings.
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Plan of Correction
To avoid a future reoccurrence of this deficiency the Project Director will revise its psychosocial evaluation format to include a descriptive narrative discussion to evaluate the client's needs and problems and the impact of the client's assests/strengths, support systems and negative factors on his/her recovery effots. The narrative will incoporate all of the descriptive data provided by the client and the counselor's assessment of the client's coping mechanisms and attitude toward treatment. Project staff will receive training on the new format that will include ongoing clinical supervision. Persons responsible: The Project Director will be responsible for revising the format and providing initial instruction/training to staff; the Clinical Director will be responsible for monitoring and adherence to this protocol. To be completed by 8/2/12 |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records and a review of the facility's policy and procedures manual, the facility failed to document case consultations in two of eight client records reviewed.
The findings include:
The facility policy titled "Case Consultations" state: "Case notes shall include date of consultations, names of persons attending, their disciplines; names(s) of clients reviewed, summary of the discussion and disposition of cases reviewed. Each client's progress shall be reviewed at least quarterly at a case conference consisting of representatives from the various client service components."
From June 21, 2012 through June 22, 2012, eight client records requiring documentation of a case consultation were reviewed. The facility failed to document a case consultation note per policy in two of eight client records reviewed, specifically client records # 4 and 5.
Client # 4 was admitted to the program on 11/16/11. A case consultation was due by 2/16/12; however, the facility failed to document a case consultation as of the time of review on 6/22/12.
Client # 5 was admitted to the program on 11/1/11. A case consultation was due by 2/1/12; however, the facility failed to document a case consultation as of the time of review on 6/22/12.
The Project Director did not dispute the findings.
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Plan of Correction
To avoide a reoccurence of the Clinical Director will hold monthly meetings with staff for the purpose of conducting Case Consultations. Counselor's will be required to report on the status of of all clients in their case loads at this time and case consultations will be documented as per Pa 709.93 (8) Case Consultation notes. Person responsible, Clinical Director by 8/2/12 |