Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent in records, #1, 4, 5, 6, 7, 8 and 12.
4 Pa. Code states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Client #1 - It was documented in the client chart that the facility released the client 's medication dosage to the funding source on April 29, 2016 which exceeded 4 PA Code 255.5.
Client #4 - It was documented in the client chart that the facility released the client 's medication dosages and intimate details of past trauma to the funding source on March 8, 2016, April 7, 2016 and May 2, 2016 which exceeded 4 PA Code 255.5.
Client #5 - It was documented in the client chart that the facility released the client 's medication to the funding source on April 29, 2016 which exceeded 4 PA Code 255.5. In addition, the facility failed to get the client 's signature with the date on two consent to releases dated March 10, 2016.
Client #6 - It was documented in the client chart that the facility released the client 's medication to the funding source on May 3, 2016 which exceeded 4 PA Code 255.5. In addition, the facility failed to get the client 's signature with the date on the consent to release dated April 26, 2016.
Client #7 - It was documented in the client chart that the facility released the client 's medication dosages, HIV information and intimate details of past trauma to the funding source on October 13, 2015, November 24, 2015, December 18, 2015 and May 3, 2015.
Client #8 - It was documented in the client chart that the facility released the client 's medication dosages and intimate details of past trauma to the funding source on December 9, 2015 and January 9, 2016 which exceeded 4 PA Code 255.5. In addition, the facility failed to get the client 's signature with the date on two consent to releases dated November 17, 2015.
Client #10- The facility failed to document the name of the person, agency or organization to whom disclosure is being made in a consent to release from dated December 15, 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The People With Hope (PWH)/Short Term Program will obtain an informed and voluntary consent from the client per 4 Pa. Code and DDAP Policy 709.28(c)(1)for the disclosure of specific information disclosed in the following charts,#1, #4, #5, #6, #7, #8 and #12 along with the current active charts.
On June 13, 2016 a Record-Keeping training will be facilitated to review 4 Pa. Code 255.5 and the Confidentiality Request to Release Information Form and DOH Policy 709.28 (c)(1).
All Consent to Release Information Forms will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director
PWH/Short Term Program Director
PWH/Short Term Supervisor
Timeframe for Completion: June 13, 2016
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Observations
The facility failed to document a record of service which included the date of service, type of service and the specific services provided to the individual client in five of twelve client records reviewed during the course of the annual licensing inspection on May 16 through May 17, 2016.
Client #1 was admitted to treatment on April 22, 2016 and was still an active client at the time of inspection. The facility failed to completely document the client 's record of service for April and May not including the date and time of individual sessions.
Client # 3 was admitted to treatment on February 22, 2016 and was still an active client at the time of inspection. The facility failed to document the client's record of service for February 2016 and March 2016.
Client # 4 was admitted to treatment on February 23, 2016 and was still an active client at the time of inspection. The facility failed to document the client's record of service for May 2016 except for one session on 5/6/2016.
Client #7 was admitted to treatment on October 13, 2015 and discharged on January 12, 2016. The facility failed to document individual sessions on the client's record of service for November 2015 and December 2015.
Client #11 was admitted January 4, 2016 and discharged on February 3, 2016. The facility faciled to document the dates of the individual sessions on the record of service.
These findings were reviewed with facilty staff during the licensing process.
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Plan of Correction
The People With Hope (PWH)/Short Term Program will document a record of service to include the date of service, type of service and the specific services provided to the individual client in client chart's #1, #3, #4, #7, and #11 along with the remaining active client charts.
On June 13, 2016. there will be a training based on completing the Record of Service per DDAP Policy 709.53(a)(3). The training will review documenting a record of service to include the date of service, type of service and the specific services provided to the individual client.
Persons Responsible:
Division Director
PWH/Short Term Program Director
PWH/Short Term Supervisor
Timeframe for Completion: June 13, 2016
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