INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 12, 2023 through April 13, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Council of Southeast Pennsylvania, 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:
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Plan of Correction
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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 must be in writing and 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 on a review of client records, the facility failed to document the name of the person, agency, or organization to whom disclosure is made on consent to release information forms in two of fourteen client records reviewed.
Client #10 was admitted on March 30, 2023 and was active at the time of inspection. A release of information form to a primary care physician was signed and dated by the client on November 23, 2022; however, the consent form did not include the specific name of the person, agency, or organization to whom the disclosure was to be made.
Client #11 was admitted on February 2, 2023 and was discharged on March 29, 2023. A release of information form to a primary care physician was signed and dated by the client on October 7, 2022; however, the consent form did not include the specific name of the person, agency, or organization to whom the disclosure was to be made.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 4/17/23, this citation was discussed in Group Supervision. Action steps include staff double checking for forms that have been left blank when client returns Intake packet. Staff will document the reason why the client did not complete consents for their PCP or any other party, after checking with client to see if they missed filling in information in error.
Identified charts and all other charts will have the consents listed removed by 5/10/2023.
Director of Intervention Services, will be responsible for the implementation of the Action Plan, auditing and ensuring that Active and Discharged client charts do not contain incomplete consents. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on an administrative review, the facility failed to maintain a data collection and recordkeeping system that allows for the efficient retrieval of data needed to measure the project's performance in relation to its stated goals and objectives.
During the first day of inspection, the facility failed to provide full access to the electronic record system. Client file access was requested at 9:15 am and full access to the system was not granted until 11:45am, two and a half hours after the initial request.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A request for more efficient auditor access has been made to the EHR management company. In addition, we will develop a report with the EHR support team to ensure that access to the required data in PA Code 709.31, including the Program, Admission Date, Discharge Date, and Discharge Reason for a specific time period. The estimated length of time for Lauris, the EHR management company, to complete system adjustments is 3-4 weeks. The target date for completion would be June 10, 2023.
The Director of Intervention Services is responsible for ensuring that the adjustments are completed and that the report has been developed. |
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
Based on a review of client records, the facility failed to maintain a complete client record on an individual, which is to include follow-up information, in three of three applicable client records reviewed.
Client #12 was admitted on December 15, 2022 and discharged on February 8, 2023. The client record did not include documentation of follow-up information.
Client #13 was admitted on June 30, 2022 and discharged on August 11, 2022. The client record did not include documentation of follow-up information.
Client #14 was admitted on January 12, 2023 and discharged on March 2, 2023. The client record did not include documentation of follow-up information.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On April 17, 2023 this citation was discussed in Group Supervision. Department staff will be provided with a report of 30 Day Follow-ups due for the month. The Director of Intervention Services will be notified upon successful completion of the 30 day Follow-up, or after 3 unsuccessful attempts. |