INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 20-21, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Jefferson Outreach Drug And Alcohol Program Central 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 16, 2010.
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Plan of Correction
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711.92(c)(3) LICENSURE Support Service
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to document treatment plans to include proposed type of supportive services in three of six client records.
The findings include:
Six client records were reviewed on January 20-21, 2010. All six records required a treatment plan with supportive services. The facility did not document a treatment plan to include proposed types of supportive services in client records # 4, 5 and 6.
The facility ' s policy titled " Proposed type of supportive services " states:
Each treatment plan should contain a statement of the type of supportive services provided or arranged for the patient, based upon the patients ' unique set of needs as well as an indication of the steps to be taken by the patient and/or program to obtain those services.
In record # 4, the treatment plan documented on 3/10/09 did not contain a statement of the type of supportive services provided or arranged for the patient.
In record # 5, the treatment plan documented on 4/24/09 did not contain a statement of the type of supportive services provided or arranged for the patient.
In record # 6, the treatment plan documented on 5/21/09 did not contain a statement of the type of supportive services provided or arranged for the patient.
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Plan of Correction
In an effort to have the patient's needs for and use of supportive services take a more primary role, we are first going to revise our method of assessing patient supports. This past week our Division has devised a form that will ask each patient at intake about current supports they have in their lives: personal, educational, and professional. They are then asked for input about the types of services or supports they think they might improve their ability to achieve sobriety and other recovery goals. This information is then used in the formulation of a treatment plan. To be sure that our therapist appropriately uses this information and then continues to monitor patient supports, she will receive training by the Coordinator of Treatment and Training on the inclusion of support services in treatment and documentation on 2/1/10.
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711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the review of client records, the facility failed to document a treatment plan update at least every 60 days as per facility policy in four of six client records.
The findings include:
Six client records were reviewed on January 20-21, 2010. All six records required documentation of a treatment plan update. The facility did not document a treatment plan update at least every 60 days as stated in the project ' s policy manual in client records # 2, 3, 4 and 5.
The facility ' s policy titled " Treatment Plans " states:
Treatment plans should be updated every 60 days following the completion of the Comprehensive plan.
Client # 2 was admitted to the program on 8/20/09; the comprehensive treatment plan was dated 9/18/09, but a treatment plan update was dated 12/1/09.
Client # 3 was admitted to the program on 4/22/09; the comprehensive treatment plan was dated 5/20/09, but the treatment plan updates were dated 8/3/09, 10/27/09 and 12/29/09.
Client # 4 was admitted to the program on 2/10/09; the comprehensive treatment plan was dated 3/10/09, but the treatment plan updates were dated 5/5/09 and 8/11/09.
Client # 5 was admitted to the program on 3/27/09; the comprehensive treatment plan was dated 4/24/09, but the treatment plan updates were dated 6/26/09 and 9/11/09.
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Plan of Correction
The facility director investigated the issue and determined that the Outreach counselor was documenting via progress notes that these patients were non-compliant with treatment and she was unable to engage them, but she was unable to discharge these patients due to medication issues (they are being medicated by the staff psychiatrist). The counselor will be trained to complete a treatment plan (either comprehensive or update) that is to be completed in the absence of the patient, which will establish a plan of action for how the counselor will make attempts to re-engage the non-compliant patient. This training will be carried out by the facility director on 2/8/10. The facility director will also work with the staff psychiatrist to develop a plan to more effectively ensure that all patients receiving medication at Outreach are attending therapy sessions as prescribed by their treatment plans. This meeting will take place by 2/8/10 at the latest. |
711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document follow-up information within sixty days from the date of discharge as per facility policy in one of one client records.
The findings include:
Six client records were reviewed on January 20-21, 2010. Of those six records, follow-up information was required in one. The facility did not document follow-up information within sixty days from the date of discharge as stated in the project ' s policy manual in client record # 5.
The facility ' s policy titled " Follow-up Information " states:
It is the policy that patients who are discharged from the program because of any reason other than being transferred or referred (e.g. treatment completion, AWOL) receive follow-up contact. Follow-up information is typically collected 60 days after discharge by means of a two page follow-up form.
Client # 5 admission date was 3/27/09, the discharge date was 10/30/09, but follow-up was not documented at the time of review on 1/21/10.
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Plan of Correction
The facility director will retrain the new employee in the proper follow-up procedure of clients who leave the Outreach program. This training will occur by 2/8/10. The identified problem is that the counselor in charge of contacting this discharged patient was not aware that even failed attempts to contact the employee should be documented. The form will be altered so that there is a space to document failed attempts to contact the patient via phone calls. This form revision will occur by 2/5/10. The facility director will regularly monitor this counselor's paperwork in weekly administrative supervision. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) 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 the review of client records, the facility failed to document informed and voluntary consent from the client for the disclosure of information contained in six of six client records.
The Findings include:
Six client records were reviewed on January 21-22, 2010. All six records required documentation of informed and voluntary consent. The facility did not document informed and voluntary consent for the release of information in client records # 1, 2, 3, 4, 5 and 6.
Client records # 1, 2, 3, 4, 5 and 6 did not document the client ' s right to verbally revoke a signed consent for the release of information to a government agency. The facility documented the clients must revoke this consent in writing.
Additionally, client record # 2 documented a signed consent to release " evaluations ' to a government agency. This exceeds what is permissible to release under 4 Pa. Code
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Plan of Correction
Upon inspection, the facility director found that the front desks where patients first register at intake had older versions of consents currently being used. All older versions will be located and destroyed. The most recent consent forms, which permit verbal revocation, will be given to every Outreach employee by the Facility Director by 2/5/2010. Patients newly admitted to the facility will have their charts reviewed and any incorrect releases will be replaced with the appropriate forms. The facility director will oversee paperwork to ensure the correct consent is being used.
Outreach clinical staff will be trained by the division director in the limits of confidentiality when communicating with outside sources 2/5/2010. This training will stress the importance of: 1) not providing more information than is permitted by 4 Pa. Code 255.5, 2) communicating the limits of disclosure to the patient, and 3) using Outreach's informed and voluntary consent forms. The facility director will oversee paperwork to ensure this communication with a government agency does not happen again. |