INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 13-15, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery house CU- Inc. 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 January 18, 2011.
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Plan of Correction
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on the review of employee records and interviews with the Facility Director and Clinical Supervisor, the facility failed to document monthly supervisory meetings between the clinical supervisor and the facility director for six months from the date of his promotion to that position.
The findings included:
During the on-site inspection held from December 13-15, 2010, one clinical supervisor was employed at the facility. His record was the only one available for review. Employee # 3 was promoted to the position of Clinical Supervisor on January 25, 2010. A discussion was held with the Facility Director about the documentation of supervisory notes required monthly for the first six months of the employee's promotion to this position. There seemed to be some confusion as to who actually supervised the Clinical Supervisor. The Facility Director acknowledged that she had not done the required documentation and that she was under the impression that the Regional Director was responsible to supervise the Clinical Supervisors. She contacted the Regional Supervisor in an effort to obtain the documentation required. The Regional Supervisor forwarded copies of two notes detailing group supervision that he had completed during the 2010 year with all of the clinical supervisors. The two notes submitted were dated June 1, 2010 and October 13, 2010. No documentation for the initial six month period of employment was presented for review..
The issue was reviewed with the Facility Director who agreed that the findings were valid.
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Plan of Correction
Effective immediately the Program Director will make sure that all new clinical supervisors participate in documented monthly meetings with their supervisor to discuss their duties and performance for the first six month of employment. The documentation will be kept on file at the facility. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of fiscal documents presented at the time of the inspection and an interview with the facility director, the facility failed to document an annual audit of financial activities for the year ended 12/31/2009.
The findings included:
During the onsite licensing inspection conducted from December 13 to 15, 2010, the fiscal documents were reviewed. The certified public accountant's dated and signed comments at the beginning of the fiscal document indicated that the document was not an audit.
The issue was reviewed with the Facility Director who agreed that the findings were valid.
This is a repeat citation.
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Plan of Correction
Discovery House will conduct an audit for FY 2011. We will submit a 2010 compellation review and an engagement letter for 2011. The director will be responsible to ensure that this is completed. |
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 policy and procedure and individual client records, the facility failed to document a policy which was consistent with applicable confidentiality law and regulation.
The findings included:
On December 13-15, 2010, Sixteen client records were reviewed and evaluated for adherence to applicable confidentiality law and regulation.
The form entitled "Confidentiality Patient Notice", documented in the first paragraph under the section labeled "Your Rights" states:
"Under HIPAA you have the right to request restrictions on certain uses and disclosures of your health information. Discovery House is not required to agree to any restrictions you request...".
This policy statement contradicts 28 Pa. Code subsection 709.28(c) which requires that "..the project shall obtain an informed and voluntary consent for the disclosure of information contained in the client record." This is further supported in Act 63 at 71 P.S. subsection 1690.108(b) which states: ".. All patient records ...and all information contained therein shall remain confidential and may be disclosed only with the patient's consent..." Furthermore the Federal regulation at 42 CFR Part 2 subsection 2.2(b) states that "..The content of any record referred to ....may be disclosed in accordance with the prior written consent of the patient with respect to whom such record is maintained...". In addition, the regulation at 42 CFR Part 2, Subpart C, subsection 2.31 (a)(5) requires that the consent to release information form include: "How much and what kind of information is to be disclosed."
Another standardized form used in the client records reviewed is the "Consent to Release Information" form. This form stated that revocation of consent must be made in writing. The Federal regulation at 42 CFR Part 2, Subpart C subsection 2.31(a)(8) specifies that the consent is: "..subject to revocation at any time except to the extent that the program or person which is to make the disclosure has already acted in reliance on it ...". The language in the Federal regulation does not limit revocations to those submitted in writing, in fact 42 CFR Part 2, Subpart C, subsection 2.31 (c)(3) states that the facility may not act in reliance of a consent that is known to have been revoked, therefore the client's right to verbally revoke a consent to release information must be addressed in policy and clients should be informed of this right.
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Plan of Correction
The Home Office and Program Director went over the form and effective immediately the document titled" Confidentiality Patient Notice" was amended to read Under HIPAA you have the right to request restrictions on certain uses and disclosures of your health information.
You have the right to request that we communicate with you by alternative means or at an alternative location. Discovery House will accommodate such requests that are reasonable and will not request an explanation from you.
Confidentiality Restrictions:
General: Patients records at Discovery House may be used only as permitted by 42 CFR Part 2 and may not otherwise be disclosed or used in any civil, criminal, administrative, or legislative proceedings conducted by any Federal, State, or local authority. Any discloser made by Discovery House must be limited to that information which is necessary to carry out the purpose of the disclosure.
Under HIPAA you also have the right, with some exceptions, to amend health care information maintained in Discovery House's records, and to request and receive an accounting of disclosures of your health related information made by Discovery House during the six years prior to your request. You also have the right to receive a paper copy of this notice.
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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 the review of client records and an interview with the Facility Director, the facility failed to document consents to release information which were consistent with applicable confidentiality law and regulation in 8 of 16 records reviewed. The two way consents contained language which would allow the facility staff "...to communicate with and disclose to one another the following information from my record..." to the entity named on the consent to release information form. Additionally, another corporation is operating on the premises without any supporting documentation of the relationship the corporation has with this facility, nor was there any documentation of a Qualified Service Organization Agreement between the facility and the other corporation as stipulated at 42 CFR Part 2, Subpart B, Subsection 2.12 (c)(4) - Qualified Service Organizations.
The findings included:
On December 13-15, 2010 sixteen client records were reviewed on site. Eight of sixteen client records reviewed contained two way consents which would permit exchanges of information. The issue was discussed with the facility director who stated she was aware that this was not permitted and that administrative staff have been working to train people to discontinue the practice of executing two way consents.
Language in applicable confidentiality law and regulation makes provision for disclosure of client identifying information, not exchanging or requesting information. The Federal regulation at 42 CFR Part 2, Subpart C, Subsection 2.31 addresses the required content of a consent to release information form. There is no provision for the use of language such as "exchange of information" relative to two way consents, only the client's consent to disclose information.
Client record # 4- The client was admitted on 3/9/10. Consents to release information in the client record executed on 4/2/10; 5/26/10 and 11/1/10 were two way consents which would allow exchanges of information with medical personnel.
Client record #5 - The client was admitted on 3/10/10. Consents to release information executed on 3/9/10; 4/1/10; 4/6/10; 5/5/10; 5/7/10; 6/1/10 and 6/4/10 would allow two way communication between the facility and medical personnel, family members and governmental agencies.
Client record # 7- The client was admitted on 6/30/10. Consents to release information executed on 11/4/10 would allow two way communication between the facility and medical personnel, family members, insurance companies and governmental agencies
Client record # 11 - The client was admitted on 4/19/10. Consents to release information executed on 6/1/10; 6/2/10; 7/27/10 and 9/7/10 would allow two way communication between the facility and governmental agencies.
Client record # 12- The client was admitted on 1/11/10. Consents to release information executed on 5/28/10 and 5/13/10 would allow two way communication between the facility and governmental agencies.
Client record # 13- The client was admitted on 8/16/10. Consents to release information executed on 8/16/10 and 9/16/10 would allow two way communication between the facility and governmental agencies, family and medical personnel.
Client record # 14- The client was admitted on 9/16/10. Consents to release information executed on 5/6/10 and 9/13/10 would allow two way communication between the facility and governmental agencies and insurance companies.
Client record # 16- The client was admitted on 7/30/10. Consent to release information executed on 7/30/10 would allow two way communication between the facility and insurance agencies.
The findings were reviewed with the facility director and she agreed they were valid.
Based on an interview with the Facility Director,an additional area of concern was that the facility has made arrangements with a group of physicians from another corporation to use the medical offices located in the facility two nights per week to operate a Suboxone program . No Qualified Service Organization Agreement (QSOA) or letter of agreement was presented at the time of the inspection to document this relationship and to meet confidentiality requirements as specified at 42 CFR Part 2, Subpart B subsection 2.12 (c)(4).
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Plan of Correction
Effective an agreement was completed between Discovery House and Vita Nova to comply with 42CFR Part 2.
On 1/18/11 a training was held by the Clinical Supervisor and the Lead Counselor to make sure that all associates understand there is no provision for the use of language such as " exchange of information" relative to two way consents to disclose information. Releases will be one way releases. The Clinical Supervisor and the Lead Counselor will do sporadic checks to ensure compliance.
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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 the review of client records and interviews with staff , the facility failed to document psychosocial evaluations that provided 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 client's current situation in 13 of 16 client records reviewed..
The findings included:
On December 13-15, 2010, sixteen client records were reviewed. Based on staff interviews with the Facility Director and the Clinical Supervisor, the Project has been transitioning into a new format for completing the psychosocial evaluation and the content in many of the evaluations had a historical perspective and did not draw relevant clinical conclusions from the historical data cited.
The specific findings from the records are documented below:
Client record # 1 - The client was admitted on 8/31/10 and was last treated on 12/3/10. The psychosocial evaluation failed to include documentation of a composite picture of the client which identified the client's presenting and underlying problems, coping /defense mechanisms employed by the client or clinical impressions which were individualized to identify the comprehensive clinical needs of the client.
Client record # 2 - The client was admitted on 9/20/10, was last treated on 11/10/10 and was discharged on 12/8/10. No psychosocial evaluation was documented in the record. The Facility Director was informed of this omission and stated she would attempt to find the documentation of the evaluation. No documentation was forthcoming.
Client record # 4 - The client was admitted on 3/9/10 and was last treated on 11/9/10. The client was discharged on 11/19/10. The psychosocial evaluation failed to include documentation of a composite picture of the client in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation and failed to identify the coping/defense mechanisms used by the client.
Client record # 5- The client was admitted on 3/10/10 and last treated on 11/9/10. The psychosocial evaluation failed to include documentation of a composite picture of the client in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation or the client's coping/defense mechanisms.
Client record # 6- The client was admitted on 10/4/01 and last treated on 12/9/10. The psychosocial evaluation failed to include documentation of a composite picture of the client in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation or the client's coping/defense mechanisms. Content tended to be a review of the client's history from the client's view point and did not include documentation of pertinent clinical impressions which could be utilized for treatment plan formulation.
Client record # 8- The client was admitted on 1/4/10 and last treated on 12/8/10. The psychosocial evaluation failed to include documentation of a composite picture of the client in relation to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation or the client's coping/defense mechanisms.
Client record # 9- The client was admitted on 11/1/10 and last treated on 11/23/10. The psychosocial evaluation failed to include documentation of a composite picture of the client in relation to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation or the client's coping/defense mechanisms. The evaluation tended to contain more client reported historical information than clinical impressions from the counselor. Content tended to be a review of the client's history from the client's view point and did not include documentation of pertinent clinical impressions which could be utilized for treatment plan formulation.
Client record # 11- The client was admitted on 4/19/10 and last treated on 12/13/10. The psychosocial evaluation failed to include documentation of a composite picture of the client in relation to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation, the client's coping/defense mechanisms or available or potential support systems.
Client record # 12 - The client was admitted on 1/11/10 and was last treated on 12/7/10. The psychosocial evaluation failed to include documentation of, or portray a composite picture of the client in relation to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation or the client's coping/defense mechanisms.
Client record # 13- The client was admitted on 8/16/10 and was last treated on 12/9/10. The psychosocial evaluation failed to include documentation of a composite picture of the client in relation to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation or the client's coping/defense mechanisms.
Client record # 14- The client was admitted on 9/16/10 and last treated on 12/15/10. The psychosocial evaluation failed to include documentation of a composite picture of the client in relation to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation or the client's coping/defense mechanisms. Patient needs were written from the client's perspective. Support systems were not identified. .Content tended to be a review of the client's history from the client's view point and did not include documentation of pertinent clinical impressions which could be utilized for treatment plan formulation.
Client record # 15- The client was admitted on 4/12/10 and was last treated on 12/15/10. The psychosocial evaluation failed to include documentation of a composite picture of the client in relation to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation or the client's coping/defense mechanisms.
Client record #16 - The client was admitted on 7/30/10 and was last treated on 11/24/10. The psychosocial evaluation failed to include documentation of a composite picture of the client in relation to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation or the client's coping/defense mechanisms.
The findings were reviewed with the Clinical Supervisor and facility director and they did not dispute them.
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Plan of Correction
The Clinical Supervisor held a meeting on 1/18/11 to address the importance of making sure the psychosocial evaluations 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 client's current situation. The Clinical Supervisor will also contact the Executive Clinical Director to assist in the correction of the psychosocial evaluations within the next 90 days. Prior to signing psychosocial complete the Clinical Supervisor and the Lead Counselor will review for compliance. This be monitored by the Clinical Supervisor and the Lead Counselor until in compliance. The Program Director and will do sporadic check to monitor compliance.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) 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 the review of client records and facility policy and procedure, the facility failed to follow policy and procedure regarding signature documentation on the treatment plans in eleven of sixteen client records reviewed..
The findings included:
On December 13-15, 2010, sixteen client records were reviewed. Written facility policy stated that the client, the counselor and the clinical supervisor were required to sign the treatment plans.
Client record # 1- The client was admitted on 8/31/10. The treatment plans formulated on 9/29/10 and 11/26/10 did not include the signature of the counselor as required by facility policy.
Client record # 4 - The client was admitted on 3/9/10. The treatment plan formulated on 8/11/10 did not include the signature of the counselor as required by facility policy.
Client record # 5 - The client was admitted on 3/10/10. The treatment plan formulated on 4/15/10 did not include the signature of the counselor as required by facility policy.
Client record # 6 - The client was admitted on 10/4/10. The treatment plan formulated on 11/1/10 did not include the signature of the counselor as required by facility policy.
Client record # 8 - The client was admitted on 1/4/10. The treatment plan formulated on 10/8/10 did not include the signature of the counselor as required by facility policy.
Client record # 9 - The client was admitted on 11/1/10. The treatment plan formulated on 11/30/10 did not include the signature of the counselor as required by facility policy.
Client record # 11 - The client was admitted on 4/19/10. The treatment plans formulated on 7/21/01 and 9/19/10 did not include the signature of the counselor as required by facility policy.
Client record # 12 - The client was admitted on 1/11/10. The treatment plans formulated on 6/11/10 and 12/13/10 did not include the signature of the counselor as required by facility policy.
Client record # 13 - The client was admitted on 8/16/10. The treatment plan formulated on 11/16/10 did not include the signature of the counselor as required by facility policy.
Client record # 14 - The client was admitted on 9/16/10. The treatment plan formulated on 12/15/10 did not include the signature of the counselor as required by facility policy.
Client record # 15 - The client was admitted on 4/12/10. The treatment plan formulated on 9/10/10 did not include the signature of the counselor as required by facility policy.
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Plan of Correction
A training was held on 1/18/11 by the Clinical Supervisor regarding the importance of following our policy and procedure regarding signature documentation on the treatment plans. Effective immediately each clinician will view each treatment plan to make sure their signature is present on their treatment plan. The Clinical Supervisor and Lead Counselor will randomly check treatment plans to make sure signatures are present. |