INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the May 27, 2010 licensure renewal inspection. The follow-up inspection was conducted on January 21, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Gaudenzia West Shore 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 February 20, 2010.
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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
Based on observation, and an interview with the facility director, the facility failed to maintain the confidentiality of the client 's identity.
Findings:
The licensing specialist entered the facility at 9:15 a.m. on July 21, 2010. The client sign-in sheet, in the reception area, was observed to contain the first and last names of clients who signed in for Intensive Outpatient Treatment Services.
The program supervisor confirmed the practice of having all client's sign the sign-in sheet upon arrival.
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Plan of Correction
Group sign-in sheet will be handled by the group counselor to obtain client signatures as they arrive in the group room. Sign-in sheet will not be set out at the front desk. Program Supervisor and Administrative Coordinator will implement and monitor the group sign-in sheet process. Division Director and Program Supervisor will take corrective action if the plan is not followed. Plan was already started as of 1/22/10 when staff was addressed in staff meeting regarding this issue.
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709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client for the disclosure of information contained in the client record in six of seven client records reviewed.
Findings:
Seven client records were reviewed on January 21, 2010. An informed and voluntary consent was required in seven client records. The facility failed to document what specifically was being released to the entity in client records #1, 2, 3, 4, 6 and 7.
A consent in client record #1 dated 10/20/2009 to a Managed Care Organization, to secure funding, failed to address the specific information that would be released to the entity stating the information to be disclosed was " funding information and requested information."
A consent in client record #2 dated 10/3/2009 to a Single County Authority, failed to address the specific information that would be released, stating only "funding information and requested information", which is not the specific information required.
Two consents in client record #3 both dated 11/17/2009 to a third party payor and a Managed Care Organization, failed to address the specific information that would be released, stating only "funding information and requested information", which is not the specific information required.
A consent in client record #4 dated 11/10/2009 to a Managed Care Organization, failed to address the specific information that would be released, stating only "funding information and requested information", which is not the specific information required.
A consent in client record #6 dated 10/3/2009 to a Managed Care Organization, failed to address the specific information that would be released, stating only "funding information and requested information", which is not the specific information required.
A consent in client record #7 dated 9/17/2009 to a Managed Care Organization, failed to address the specific information that would be released, stating only "funding information and requested information", which is not the specific information required.
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Plan of Correction
All funding release have been corrected to state only the big 5 releasable criteria as follows: diagnosis/prognosis, relapse, presence in tx, nature of the project, and progress for the purpose of securing authorization and funding. Administrative Coordinator and Program Supervisor will monitor releases being used by staff for any old forms that may surface. Staff were informed in staff meeting 1/29 and will subject to corrective action for use of any form other than the approved release form. Plan was implemented on 2/16/10. |
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
Based on a review of client records and an interview with the Program Supervisor, the facility failed to document a progress note after each significant client contact in two of seven client records reviewed.
Findings:
Seven client records were reviewed on January 21, 2010. A progress note after each significant client contact was required in seven client records. The program supervisor confirmed that notes could not be located. The facility failed to document a progress note after each significant client contact in client records #2 and 6.
In client record #2, the record of service documented group sessions on 12/28/2009, 12/14/2009, 1/4/2010, and 1/11/2010; however, group progress note was documented for these dates.
In client record #6, the record of service documented group sessions on 11/23/2009, 12/24/2009, 12/28/2009, 12/30/2009, 12/31/2009, 1/4/2010, 1/8/2010, 1/13/2010, 1/15/2010, 1/20/2010; however, no group progress note was documented for these dates. Additionally, individual sessions were documented on 12/18/2009 and 11/22/2009, and individual notes were documented for these dates.
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Plan of Correction
Progress notes will be documented within 72 hours of date of service as per policy. Program Supervisor is responsible for monitoring the completion of progress notes. This monitoring process is audited through our current QI/UR process. Failure to complete these notes in timely manner will result in corrective action. Plan has been implemented as of 2/5/10 as staff were informed during staff meeting 1/29.
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