INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 10, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services Renaissance 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 April 14, 2008.
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Plan of Correction
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply 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:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the facility's policies and procedures, the facility failed to have a written procedure that complied with 4 Pa. Code 255.5. The facility's written procedures for the confidentiality of client identity and records contained a document entitled "Confidentiality Regulations and the Drug and Alcohol Treatment Programs". This procedure included the wording that allowed for the release of client information "with or without the client's consent" to judges and probation/parole.
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Plan of Correction
The Director of Quality Improvement has revised the "Confidentiality Regulations and the Drug and Alcohol Treatment Programs" procedure to state that client information can only be released with the client's consent to judges and probation/parole. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records and staff interview, the facility failed to comply with the limitations imposed at 4 Pa. Code 255.5. Information disclosed to the probation/parole officer included the client's balance owed for treatment in five of fourteen client records reviewed, #1, 3, 4, 5 and 10.
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Plan of Correction
The Facility Director will oversee that staff are re-educated through staff meeting regarding the limitations imposed by 4 Pa. Code 255.5 and specifically regarding limitations which affect information that may be disclosed to the probation/parole officer. The Quality Improvement Department will oversee the revision of the form staff use to communicate with probation/parole, the area that documents the client's balance owed will be removed. |
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 complete psychosocial evaluation in fourteen of fourteen records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14. Psychosocial evaluations did not provide a composite picture of the client. The clinician used one or two word answers with little to no clinical assessment of the client's problems/needs, assets/strengths, potential or available support systems, coping mechanisms, negative factors that may inhibit treatment, and the client's attitude toward treatment.
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Plan of Correction
The Facility Director will oversee that staff are re-educated in staff meeting to provide a composite picture of the client in the psychosocial evaluation. Staff will be reminded to give more clinical insight and to avoid using one or two words answers when assessing the client's needs, strengths, support systems and other factors that may affect treatment. The Quality Improvement Department will also oversee the revision of our psychosocial evaluation to include additional room for staff to document more detailed clinical impressions. The Quality Improvement Department will also monitor the content of our psychosocial evaluations through ongoing chart audits. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document a complete treatment plan update in five of fourteen records reviewed, #1, 3, 4, 11 and 13. A treatment plan update was missing in one record reviewed, #11. A treatment plan update was illegible in one record reviewed, #3. The treatment plan update did not include an assessment of progress in relationship to the goals stated on the comprehensive treatment plan in three records reviewed, #1, 4 and 13.
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Plan of Correction
The Facility Director will remind staff in staff meeting to complete all treatment plan updates legibly and in a timely manner. Staff will be reminded of the opportunity to type to avoid legibility issues. Staff will also be re-educated to include an assessment of the client's progress in relationship to the goals stated on the comprehensive treatment plan. The Project Director and Quality Improvement Department will also oversee an ongoing internal monitoring system by the office administration to ensure the timely completion of treatment plan updates and to monitor any legibility concerns. The Quality Improvement Department will also monitor the content quality of the treatment plan updates through ongoing chart audits. |