INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 15, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services Lancaster City 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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709.26(a)(12) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(12) Employe grievances.
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Observations
Based upon a review of the Policy and Procedures Manual, the facility failed to adopt a grievance policy that identified grievable issues, steps of appeal, required time frames for each step and who has authority to resolve grievances.
The findings include:
The Policy and Procedures Manual was reviewed on February 22, 2012. The policy entitled "Employee Grievances" failed to identify grievable issues, the steps of appeal, the required time frames for completion of each step, and who has the authority to resolve grievances.
The findings were confirmed by the Director of Quality Improvement during the exit interview.
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Plan of Correction
The Project Director will oversee that the Grievance and Appeal policy is revised to include identified grievable issues, steps of appeal, required timeframes for each step and who has the authority to resolve grievances. The Facility Director or designee will oversee that the new policy is reviewed with all staff via staff meetings. |
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 Project ' s policy and procedure regarding client confidentiality for clients identified as " drug abusers " and/or " drug dependent persons " (71 P.S. 1690.102(b)), the facility failed to provide a set of written policy and procedures consistent with Commonwealth law and regulation at 71 P.S. 1690.102 through 1690.115 and 4 Pa. Code 255.5 and failed to clarify that releases of information permitted under the federal HIPAA regulations at 45 CFR Subtitle A, Subchapter C, but prohibited by Commonwealth law and regulation and federal regulation at 42 CFR Part 2, Subparts A through E, were still prohibited.
The findings include:
The Project policy and procedure contains the following introduction: " (i) - The D&A Counselor will have primary responsibility for maintaining client records. All D&A counselors are given confidentiality education in their D&A orientation, this includes the restrictions of 255.5 and 42 CFR. Staff are oriented to follow these guidelines when releasing any information for a D&A client. (ii) Staff are also oriented to the PCS Hipaa (sic) policy which specifies the procedure for revocation of releases, confidentiality of records and staff access to records. "
The section of Policy identified by the Project as (ii) is not consistent with the Commonwealth law and regulation or the federal regulation that specifically addresses client confidentiality in drug and alcohol treatment activities. Project policy on client confidentiality in a drug and alcohol treatment facility consisted of copies of Department of Health guidelines and federal publications, but did not include Project specific procedures relative to the drug and alcohol confidentiality requirements.
The " Pennsylvania Counseling Services, Inc. - Privacy Practice Compliance Plan " is a HIPAA document and fails to address the fact that some of the conditions described that would permit releases of information under this compliance plan would in fact be prohibited releases of information under the drug and alcohol confidentiality regulations at both the Commonwealth and federal levels.
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Plan of Correction
The Project Director will oversee that the Confidentiality policy is
revised to be consistent with Commonwealth law and regulation at 71 P.S. 1690.102
through 1690.115 and 4 Pa. Code 255.5. The new policy will clarify that releases of information permitted under federal HIPAA regulations at 45 CFR Subtitle A, Subchapter C, but prohibited by Commonwealth law and regulation and federal regulation at 42 CFR Part 2, Subparts A through E, are still prohibited. Our policy will also be revised to include Project specific procedures relative to the drug and alcohol confidentiality requirements. The HIPAA document "Pennsylvania Counseling Service, Inc.-Privacy Practice Compliance Plan" will be removed and replaced with the new Confidentiality Policy. The Facility Director or designee will oversee that the new policy is reviewed with all staff via staff meetings.
The Quality Improvement Department will ensure that staff complete forms in compliance with 255.5 and 42 CFR via random chart audits.
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709.28(a)(2) 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:
(2) Staff access to client records.
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Observations
Based upon a review of the project's Confidentiality Policy, the policy failed to specify by name, position, or title, which staff members had access to client records. Additionally, the policy failed to define the process by which staff members gained access to client records.
The findings include:
The project's policies and procedures on Confidentiality were reviewed on February 10, 2012. Policy [709.28], Confidentiality (i) stated: "The D&A Counselor will have primary responsibility for maintaining client records. All D&A counselors are given confidentiality education in their D&A orientation, this includes the restrictions of 255.5 and 42 CFR. Staff are oriented to follow these guidelines when releasing any information for a D&A client."
In addition, the portion of the Confidentiality policy that addressed staff access to client records was labeled "Access Control" and included the following verbiage:
"Due to the operating nature of PCS programs and facilities, all employees within each separate facility have a "need to know" and are granted access to all confidential records for purposes up to and including responding to emergencies. Centralized administrative management personnel who travel to all counties and have responsibilities which cover all facilities have full access to confidential information. Upon termination of employment, access is denied from the facility where previously employed, or in the case of centralized administrative management - from all facilities."
42 CFR subpart B (c)(3) only exempts the restrictions on disclosure within a facility under the following conditions:
(c)(3) Communication within a program or between a program and an entity having direct administrative control over that program. The restrictions on disclosure in these regulations do not apply to communications of information between or among personnel having a need for the information in connection with their duties that arise out of the provision of diagnosis, treatment, or referral for treatment of alcohol or drug abuse if the communications are
(i) Within a program or
(ii) Between a program and an entity that has direct administrative control over the program.
The facility's policy, as written, did not comply with 4 PA Code 255.5 and the restrictions imposed by 42 CFR, Part II, as it permitted all staff members, even those not connected with the provision of diagnosis, treatment, or referral, to have access to the records.
In addition, the policy failed to outline the process by which staff members gained access to client records.
The findings were reviewed with the Director of Quality Improvement.
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Plan of Correction
The Project Director will oversee that the Confidentiality policy is revised to identify Project staff, by title, who have access to client records and will define the process by which staff members gain access to client records. The Project Director will also ensure that the policy follows 4 PA Code 255.5 and the restrictions imposed by 42 CFR, Part II. The Facility Director or designee will oversee that the new policy is reviewed with all staff via staff meetings.
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709.28 (c)(1) 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 shall include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based upon a review of client records, the facility failed to obtain informed and voluntary consents that included the name of the person, agency or organization to whom disclosure is made.
The findings include:
Ten client records requiring documentation of informed consent forms were reviewed on February 15, 2012. Ten of ten records, specifically record #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, and 11, contained consent forms that failed to include the name of the person, agency or organization to whom disclosure was to be made.
Client # 1 was admitted on October 19, 2011. Record # 1 contained a consent form, signed and dated October 19, 2011. The consent form identified the recipient of the information as, "my primary care physician (as identified in my chart)." The consent form failed to include the actual name of the person, agency or organization to whom disclosure was to be made.
Client # 2 was admitted on October 17, 2011. Record # 2 contained two consent forms, signed and dated October 17, 2011. One consent form identified the recipient of the information as, "probation / parole (for the county/state identified in my chart)" and the other consent identified the recipient as, "my primary care physician (as identified in my chart)." Both consent forms failed to include the actual name of the person, agency or organization to whom disclosure was to be made.
Client # 3 was admitted on October 5, 2011. Record # 3 contained a consent form, signed and dated October 5, 2011. The consent form identified the recipient of the information as, "my primary care physician (as identified in my chart)." The consent form failed to include the actual name of the person, agency or organization to whom disclosure was to be made.
Client # 4 was admitted on November 17, 2011. Record # 4 contained two consent forms, signed and dated November 17, 2011. One consent form identified the recipient of the information as, "probation / parole (for the county/state identified in my chart)" and the other consent identified the recipient as, "my primary care physician (as identified in my chart)." Both consent forms failed to include the actual name of the person, agency or organization to whom disclosure was to be made.
Client # 5 was admitted on October 27, 2011. Record # 5 contained two consent forms, signed and dated October 27, 2011. One consent form identified the recipient of the information as, "probation / parole (for the county/state identified in my chart)" and the other consent identified the recipient as, "my primary care physician (as identified in my chart)." Both consent forms failed to include the actual name of the person, agency or organization to whom disclosure was to be made.
Client # 6 was admitted on November 23, 2011. Record # 6 contained two consent forms, signed and dated November 23, 2011. One consent form identified the recipient of the information as, "probation / parole (for the county/state identified in my chart)" and the other consent identified the recipient as, "my primary care physician (as identified in my chart)." Both consent forms failed to include the actual name of the person, agency or organization to whom disclosure was to be made.
Client # 7 was admitted on September 1, 2011 and discharged on December 13, 2011. Record # 7 contained a consent form, signed and dated September 1, 2011. The consent form identified the recipient of the information as, "probation / parole (for the county/state identified in my chart)." The consent form failed to include the actual name of the person, agency or organization to whom disclosure was to be made.
Client # 8 was admitted on July 25, 2011 and discharged on September 20, 2011. Record #8 contained two consent forms, signed and dated July 25, 2011. One consent form identified the recipient of the information as, "probation / parole (for the county/state identified in my chart)" and the other consent identified the recipient as, "my primary care physician (as identified in my chart)." Both consent forms failed to include the actual name of the person, agency or organization to whom disclosure was to be made.
Client # 9 was admitted on April 13, 2011 and discharged on June 27, 2011. Record # 9 contained a consent form, signed and dated April 13, 2011. The consent form identified the recipient of the information as, "probation / parole (for the county/state identified in my chart)" Another consent form was signed but undated and identified the recipient as, "my primary care physician (as identified in my chart)." Both consent forms failed to include the actual name of the person, agency or organization to whom disclosure was to be made.
Client # 11 was admitted on January 20, 2011 and discharged on April 18, 2011. Record # 11 contained two consent forms, signed and dated January 20, 2011. One consent form identified the recipient of the information as, "probation / parole (for the county/state identified in my chart)" and the other consent identified the recipient as, "my primary care physician (as identified in my chart)." Both consent forms failed to include the actual name of the person, agency or organization to whom disclosure was to be made.
The findings were confirmed by the Vice President of Quality Improvement during the exit interview.
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Plan of Correction
The Project Director will oversee that the consent forms are revised to include a prompt to specify the name of the primary care facility or physician and to include a prompt to specify the probation or parole office. The Facility Director or designee will ensure that all staff are re-educated to complete the new releases thoroughly, incorporating the specific names/agencies. Staff will also be directed to get new release forms completed for all active clients which include the actual name of the person, agency or organization to which disclosure was to be made for those forms that originally did not include the information. The Quality Improvement Department will ensure ongoing compliance via random chart reviews. |
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 upon a review of client records, the facility failed to document an individualized treatment plan that was developed with the client in accordance with the facility's policies and procedures.
The findings include:
In reference to the treatment plans, the facility's policy states:
Treatment plans are to be completed within 30 days of admission.
Ten client records requiring documentation of an individualized treatment plan were reviewed on February 15, 2012. Five of ten records, specifically record #'s 2, 4, 6, 7, and 11 contained treatment plans that were not developed with the client.
Client # 2 was admitted on October 17, 2011. The comprehensive treatment plan was signed on November 17, 2011 by the therapist and was unsigned by the client. A review of progress notes contained no mention of the treatment plan or working on the treatment plan with the client.
Client # 4 was admitted on November 17, 2011. The comprehensive treatment plan was signed on December 17, 2011 by the therapist and was unsigned by the client. A review of the progress notes, contained no mention of the treatment plan or working on the treatment plan with the client.
Client # 6 was admitted on November 23, 2011. The comprehensive treatment plan was due on December 23, 2011 and had not been signed by the client until February 1, 2012. A review of the progress notes, contained no mention of the treatment plan or working on the treatment plan with the client prior to February 1, 2012.
Client # 7 was admitted on September 1, 2011 and discharged on December 13, 2011. The comprehensive treatment plan was due by October 3, 2011. The treatment plan was signed by the therapist on November 30, 2011. A review of the progress notes, contained no mention of the treatment plan or working on the treatment plan with the client prior to November 30, 2011.
Client # 11 was admitted on January 20, 2011 and discharged on April 18, 2011. The comprehensive treatment plan was signed on February 8, 2011, by the therapist and was not signed by the client until April 18, 2011. A review of the progress notes, contained no mention of the treatment plan or working on the treatment plan with the client prior to April 18, 2011.
The findings were confirmed by the Vice President of Quality Improvement during the exit interview.
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Plan of Correction
The Facility Director or designee will oversee that all staff are re-educated via staff meeting to develop the Comprehensive Treatment Plan with the client within 30 days of admission. Staff will be reminded that they must obtain the client signature when the Comprehensive Treatment Plan is developed. The Quality Improvement Department will ensure ongoing compliance via random chart reviews and will further re-educate therapists as needed. |