INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 23, 2007 through October 24, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Self Help Movement, 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 November 23, 2007.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of training records, the facility failed to document HIV/AIDS and TB/STD training in seven of fourteen records reviewed, #6, 9, 10, 11, 12, 13 and 14. Employees #6, 10, 11, 12 and 13 have not received HIV/AIDS and TB/STD training. Employees #9 and 14 did not receive HIV/AIDS training.
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Plan of Correction
The clinical supervisor, CEO and director of administration are contacting training sites to register for trainings for the first available spots for employees who have not received ST/TB and or HIV/AIDS training.
The clinical supervisor and the director of administration and human services will check each file and make sure that each employee has TB/STD and HIV/Aids training within the first year of hire. The director of administration will ensure that each employee will either be signed up for a training at an approved training site or have a training set up onsite.
All new employees will be set up within the first year of hire for the above trainings. |
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 a review of client's records, the facility failed to obtain an informed consent to release information form in three of six records reviewed, #1, 5 and 6. Information released to CBH exceeded that allowed by 4 Pa. Code 255.5 in two records, #1 and 6. A statement was documented regarding information released to a client's grandmother and a consent to release information for the grandmother was not obtained in one record reviewed, #5.
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Plan of Correction
A counselor meeting was conducted by the director of treatment on 10/26/07. All staff have been informed of the limitations of sharing confidential information with CBH and other funding sources during reviews. Reinforcemnt to all counselors was made during counselor meeting of the necessity to have individual release forms signed by the client with identification of the individual relationship to the client. The clinical supervisor also met with the indicated counselor rgarding information that should not have been released.
The clinical supervisor will review all of the counselor's clinical charts upon the client's admittance to ensure that the consent for release forms are completed indicating the limitations of disclosure of information to CBH and other third party agencies. The intake coordinator will review all intake consent forms and hold staff accountable for the completion of required consent to release forms and limits of information shared with funding sources.
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709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document a complete personal history in six of six records reviewed, #1, 2, 3, 4, 5 and 6. Information regarding the clients's family history and sexual history was missing.
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Plan of Correction
Intake personnel have been informed by the director of treatment on 10/26/07 and reinforced to all counselors the mandates regarding complete information in the bio-psychosocial regarding the client's coping mechanisms, age of first sexual experience and detailed information regarding the client's support systems and the client's attitude towards treatment which must be contained in the bio-psychosocial.
The director of treatment will review all clinical documentation of family and sexual history in the clinical files. We have included this in a revised biopsychosocial report that indicated the client's sexual history, age of first use, abuse history, etc. The biopsychosocial will be reviewed within 72 hours. Deficient bios will be given back to the counselor for completion and reviewed by the director of treatment until compliance is achieved.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a complete psychosocial evaluation in six of six records reviewed, #1, 2, 3, 4, 5 and 6. Coping mechanisms were not documented in five records, #1, 2, 4, 5 and 6. Support systems were missing in three records, #1, 3 and 5 and not evaluated in three records, #2, 4 and 6. The client's attitude towards treatment was not addressed in five records reviewed, #1, 2, 3, 4 and 5.
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Plan of Correction
Intake personnel have been informed by the director of treatmnet on 10/26/07 and reinforced to all counselors the mandates regarding complete information in the bio-psychosocial regarding the client's coping mchanisms, age of first sexual experience and detailed information regarding the client's support systems and the client's attitude towards treatment which must be contained in the bio-psychosocial. The director of treatment will review all bios within a 72 hour period to ensure that all information is comprenhensive. If any information is missing, the file will be returned to the counselor with notes on what needs to be completed. The file will then be given back to the director of treatment to ensure compliance. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations in three of four records reviewed, #1, 5 and 6.
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Plan of Correction
Case consultations will be conducted between the individual counselors and director of treatment on a monthly basis to discuss the progress, specific client needs or concerns, use of interventions and treatment progress. The assigned counselor will be responsible for completing a consultation note reflecting the discussion in a DAP (Data, Assessment and Plan) format. Any client sanctions due to noncompliance of Self Help Movement rules will also be contained in the consultation notes and reveiwed by the director of treatment during the monthly clinical reviews.
This was reinforced at the counselor's meeting held on 10/26/07. A case consultation note will be completed by the counselor regarding these consultations in DAP form and placed in the clinical file. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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Observations
Based on a review of client's records, the facility failed to document the date the discharge summary was completed in three of three records reviewed, #4, 5 and 6. The facility's policy and procedure indicated that all discharge summaries were to be completed within 7 days after discharge. The date that the discharge summary was completed was not documented.
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Plan of Correction
It was discussed in the counselor meeting held on 10/26/07 that all discharge summaries will include the date that the discharge summary was completed and will adhere to completion with 7 days of the client's discharge. The director of treatment will review. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 document follow-up information in three of three records reviewed, #4, 5 and 6.
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Plan of Correction
A plan of action has been in effect and there are checks and blances to assure a discharge follow-up form is provided on each discharged client. The director of treatment will ensure this is followed through.
The director of treatment will review all discharge summaries and ensure that all aftercare follow-up infomation such as the client's status is documented eg. working, attending outpatient, etc. Both the director of treatment and administrative staff will review forms on a monthly basis to ensure that all contact information is recorded on follow-up forms and filed in all clinical files of client's who have completed treatment or have been discharged from the program. A staff member will be assised effective 10/26/07 to follow-up on the client's status by phone or mail communication and record the present status information on the forms. |