INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 11, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on May 15, 2007.
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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
The written procedures for the confidentiality of client identity and records contained a document designed by CODAAP titled "Confidentiality Regulations and the Drug and Alcohol Treatment Programs." This document contained incorrect language regarding disclosure to parents of a minor without the client's consent and wording "with or without the client's consent" to judges and probation/parole. In addition, written procedures stated that "a client may revoke a consent to release information, in writing, to the clinic or project manager. The facility must honor a client's verbal revocation of a consent and the facility must document the verbal revocation in writing.
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Plan of Correction
The Director of Quality Improvement has removed the CODAPP document from the policy and procedure manual. This was replaced with copies of the 255.5 and 42CFR regulations. The Project Director will oversee that the company's confidentiality policy is revised to allow for verbal revocation of consents. The Facility Director will oversee the distribution and review of this revised policy to all staff in staff meeting. |
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
Consent to release information forms indicated that clients must revoke a consent in writing in eight of eight records reviewed, #1, 2, 3, 4, 5, 6, 7 and 8.
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Plan of Correction
The Quality Improvement Department is currently overseeing the revision of our consent forms to allow for written or verbal revocation. The Facility Director will oversee that all staff receive the revised consent forms and are educated on how to document verbal revocation. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
A notice of termination was not documented in one of two records reviewed, #7.
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Plan of Correction
The Facility Director will oversee that all clinical staff are reminded to complete and file a notice of termination in all applicable client files. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
The opportunity to request reconsideration of the decision was not afforded in one of two records reviewed, #7.
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Plan of Correction
The Facility Director will oversee that all clinical staff are reminded to complete and file a copy of the notice of termination. Staff will be reminded that by completing and sending this notice of termination they have also given the client an opportunity to request reconsideration of the decision. Filing this notice documents that this opportunity was provided. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Personal histories failed to address family relations, significant events/problems related to the family history and recreation history in eight of eight client records reviewed, # 1, 2, 3, 4, 5, 6, 7 and 8. In addition, one word answers were indicated without any additional information to clarify these responses from the client.
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Plan of Correction
The Facility Director will oversee that all clinical staff receive training in staff meeting to educate the therapists on gathering more detailed information regarding family relations, significant events/problems related to the family history and recreation history in each client's personal history. Therapists will also be reminded to avoid one word answers and to clarify responses from the clients. |
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
The psychosocial evaluation was historical rather than evaluative and failed to include clinical impressions, client's problems/needs, assets/strengths, support systems and coping mechanisms in eight of eight client records reviewed, specifically # 1, 2, 3, 4, 5, 6, 7 and 8.
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Plan of Correction
The Facility Director will oversee that all clinical staff are reminded in staff meeting to give clinical impressions and opinions regarding client's problems/needs, assets/strengths, support systems and coping mechanisms in each client's psychosocial evaluation. |
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
Treatment plan updates did not include a review of progress on previously stated goals in three of three records reviewed, #1, 2 and 7.
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Plan of Correction
The Facility Director will oversee that all clinical staff receive training in staff meeting to educate staf on completing a thorough treatment plan update which addresses the client's progress in the past 60 days as it relates to the previously stated goals from the individual treatment plan. |
709.93(a)(5) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Progress notes.
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Observations
Progress notes for individual sessions did not include the data and assessment portion of the note in five of eight records reviewed, #1, 2, 3, 6 and 7.
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Plan of Correction
The Facility Director will oversee that all staff are educated in staff meeting to thoroughly complete the data and assessment portions of the progress notes. The Quality Improvement department will oversee that progress notes are monitored for thorough completion. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
The aftercare plan was missing in one client record, # 8. The aftercare plan did not include realistic and measurable goals or support services for the client in one of two client records reviewed, #6.
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Plan of Correction
The Facility Director will oversee that all staff are reminded in staff training of the importance in thoroughly completing the aftercare plan when successfully discharging a client. The aftercare plan has been revised to prompt therapists to give more realistic and measurable goals or support services. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Follow up information was not documented in two of four records reviewed, #7 and 8.
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Plan of Correction
The Facility Director will oversee that follow-up information is sent and documented in each client chart. |