INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 7-9, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Counseling Center of Mercer County was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
The facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in client record #2.
Client #2 was admitted on June 8, 2016. The consent to release information to the funding source documented in client record #2 was not signed by the client, but by his father. In addition, there was no consent to release information signed by the client permitting information to be released to his father.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This deficiency is due to a lapse on the part of the support staff who was completing the registration. Immediately following the exit interview, the staff involved were informed of the violation and the need to differentiate between the requirements for Drug and Alcohol and Mental Health. At training specific to the regulations related to parental consent, or in this case, lack of the need for parental consent will given by January 30,2017.
Additionally, a modification to the form to specifically prompt for the correct signature is being explored, and , if possible, will be added by January 30,2017 also.
Lastly, a prompt to complete a consent form allowing the parent to be involved in the registration process should the client request, will be added. All portions of this plan of correction will be completed by the end of January. The Compliance Officer and the supervisor will be responsible for completing this task. |
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
The facility failed to document that treatment and rehabilitation plans were reviewed and updated at least every 60 days in four of eight client records.
Ten client records were reviewed on December 7-9, 2016. Eight of the clients reviewed were in treatment long enough to require a treatment plan update. Treatment plans were not reviewed and updated at least every 60 days in client records #2, 4, 6 and 9.
Client #2 was admitted on June 8, 2016. A treatment plan review / update was completed on August 30, 2016. The next treatment plan review / update was due to be completed by October 30, 2016. The treatment plan review / update was completed on November 15, 2016.
Client #4 was admitted on June 20, 2016. A treatment plan review / update was completed on August 10, 2016. The next treatment plan review / update was due to be completed by October 10, 2016. The treatment plan review / update was completed on October 27, 2016.
Client #6 was admitted on February 23, 2016 and discharged on August 31, 2016. A treatment plan review / update was completed on March 8, 2016. The next treatment plan review / update was due to be completed by May 8, 2016. The treatment plan review / update was completed on May 24, 2016.
Client #9 was admitted on March 1, 2016 and discharged on December 5, 2016. The last treatment plan review / update was completed on September 30, 2016. There was no treatment plan review / update completed by November 30, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
While our treatment plan goals are injected into our progress notes and progress documented as addressed in the session, we also try to do an updated treatment plan with signatures every 2 months. Some of the records were late in completing this. The plan to correct this issue is two fold:
1) Our compliance Officer will be reviewing the treatment plans for completion every 2 weeks beginning January 6, 2017.
2) Our recent D/A treatment Team meeting on December 14th was used to review the faulty charts and to highlight the need to complete the plans timely, even if the client is not present. This clarified for some the fact that the treatment plan is valid without the clients signature being attached immediately. The Supervisor will continue to highlight this every 3 months during this time. |