Observations
Based on a review of client records, the facility failed to ensure that the consent forms for the release of information to third party payors complied with the limitations of 4 Pa. Code 255.5 (b) in six of the seven records reviewed.
Client record numbers one, two, three, five, six and seven, contained consent to release information forms that allowed for the release of (a) Psychiatric evaluation, (b) Psychosocial history, (c) Medication regime and the (d) discharge summary to third party payors. According to the code, this information is not permitted to be released to third party payors.
This exceeds what is permissible under 4 Pa. Code 255.5 (b).
Additionally, in client record number two, there was no consent to release information form to the 3rd party payor within the client's record of service. Client was admitted on January 23, 2018 and discharged on April 5, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The consent form from the third party payor has been removed and pulled from both the hard copy and electronic versions. The Facility Director replaced the non-compliant form with the TW Ponessa Authorization for Disclosure of Health Information form,effective July 27, 2018 which is 4PA Code 455.5(b) compliant. The clinical and support staff were informed by the Facility Director of the change on that date. The clinical staff was also directed by the Facility Director to have ongoing clients sign the appropriate compliant release at the next scheduled appointment. Clinical charts will be randomly pulled at the rate of 5 per week by the facility director to ensure compliance with replacing the release. Full compliance with new clients is current. Full compliance with ongoing clients is expected by 9/27/18. |
Observations
Based on a review of seven client records, the facility failed to provide documentation verifying that counseling services were provided in accordance with the clients' individual treatment plan in five of the seven records reviewed.
Client #1 was admitted on September 6, 2017 and discharged on April 24, 2018. The individual treatment plan, dated October 10, 2017, indicated the client was to receive weekly individual therapy sessions. The client's record of service had no entries indicating that the client attended, was a no show or cancelled treatment sessions between October 19, 2017 to November 1, 2017, November 3, 2017 to November 15, 2017 and November 17, 2017 to December 6, 2017. The individual treatment plan, dated December 18, 2017, indicated the client was to receive bi-weekly therapy sessions. The client's record of service had no entries indicating that the client attended, was a no show or cancelled treatment sessions between December 22, 2017 to January 10, 2018 and February 3, 2018 to February 21, 2018. Additionally there were no progress notes in the client record for those sessions.
Client #3 was admitted on August 30, 2017 and discharged on May 16, 2018. The individual treatment plan, dated September 6, 2017, indicated the client was to receive weekly individual therapy sessions. The client's record of service had no entries indicating that the client attended, was a no show or cancelled treatment sessions between September 7, 2017 to September 20, 2017, December 7, 2017 to December 19, 2017, January 4, 2018 to January 17, 2018, and January 25, 2018 to February 13, 2018. Additionally there were no progress notes in the client record for those sessions.
Client #4 was admitted on September 6, 2017 and discharged on June 20, 2018. The individual treatment plan, dated September 27, 2017, indicated the client was to receive weekly individual therapy sessions. The client's record of service had no entries indicating that the client attended, was a no show or cancelled treatment sessions between December 20, 2017 to January 8, 2018, January 10, 2018 to January 22, 2018, February 14, 2018 to February 26, 2018, March 7, 2018 to March 20, 2018, March 28, 2018 to April 9, 2018, April 11, 2018 to April 30, 2018, and May 2, 2018 to May 28, 2018. Additionally there were no progress notes in the client record for those sessions.
Client #6 was admitted on April 9, 2018 and was still active at the time of the inspection. The individual treatment plan, dated May 1, 2018, indicated the client was to receive weekly individual therapy sessions. The client's record of service had no entries indicating that the client attended, was a no show or cancelled treatment sessions between between May 2, 2018 to May 13, 2018 and May 22, 2018 to June 3, 2018. Additionally there were no progress notes in the client record for those sessions.
Client #7 was admitted on May 14, 2018 and was still active at the time of the inspection. The individual treatment plan, dated May 23, 2018, indicated the client was to receive weekly individual therapy sessions. The client's record of service had no entries indicating that the client attended, was a no show or cancelled treatment sessions between May 24, 2018 to June 10, 2018. Additionally there were no progress notes in the client record for those sessions.
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Plan of Correction
The Facility Director will educate
the Clinical staff during supervision beginning 9-10-18
regarding the requirements as
outlined in Chapter 709.92(c) of
Treatment and Rehabilitation
Services. Counseling services are to
be scheduled in accordance with the
individual treatment plan.
Documentation of barriers affecting
this goal shall be recorded in the
record of service, eg missed
appointments, hospitalization of the
client, etc. Beginning 9-10-18, at least 5 client records
will be checked randomly each
week by the Facility Director to
ensure compliance. Moving forward, scheduling appointments/frequency of treatment and providing treatment in accordance with the treatment plan will be addressed in supervision on an ongoing basis. Random chart checks will continue as needed, based on evidence of compliance.
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