INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the January 28, 2009 licensure renewal inspection. The follow-up inspection was conducted on June 16, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Drug and Alcohol Treatment Services, Scranton 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 July 21, 2009.
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Plan of Correction
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709.82(e)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(1) Medical/dental.
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Observations
Based on the review of the client records and the letter of agreement file during the unannounced onsite licensing inspection of June 16, 2009, the facility failed to ensure the ability to assist clients in obtaining dental support services.
The findings included :
Four client records and the letter of agreement file were reviewed during the onsite licensing inspection. Documentation did not appear in any of the records reviewed to support the facility's ability to assist the client in obtaining dental support services. The letter of agreement file was also reviewed and there was no documentation of a signed letter of agreement with a dentist.
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Plan of Correction
The Agency has finally found a local Dentist who is willing to enter into an agreement to provide said services to clients. The agreement will be drawn up early next week and sent for appropriate signatures |
709.83(a)(8) LICENSURE Client records
709.83. 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) Record of services provided.
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Observations
Based on the review of the client records and interviews with agency personnel, the facility failed to document accurate and current records of service in four of five client records.
The findings included:
Four client records were reviewed during the onsite unannounced licensing inspection of June 16, 2009. Four client records were reviewed for compliance with this regulation. Client records # 1, 2, and 4 documented treatment sessions in progress notes which were not documented on the records of services. The records of services were not current or complete.
Record # 1 had only two of fifteen total treatment sessions documented on the services record.
Record # 2 did not include documentation of sessions on the record of services which were documented in progress notes on June 1, 2, 3, 5, 8 and 9, 2009.
Record # 4- Notes were documented for sessions held on June 3, 4 and 11, 2009 but no corresponding entry was documented on the record of services.
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Plan of Correction
Historically there has been a problem at certain times of the year with computer generated records of service. A decision will have to made soon to either return to a manual system or purchase a new billing system that is quicker. Part of the problem is related to BDAPS inability to decide on a vendor for a CIS/Billing system. We have been trying to avoid purchasing a new system and have an announcement made soon after that a vendor has been selected.
In addition the Clinical Staff has been instructed to complete and forward each group roster to the Billing Dept. at the end of each work day. The Billing department has been instructed to enter all data from the previous day the following morning.It will be the responsibility of the Clinical Director and the Billing Office Manager to monitor this process daily. |
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 the review of the agency policy and procedure manual during the unannounced onsite licensing inspection of June 16, 2009, the facility failed to document a policy and procedure which adhered to the requirements specified at 4 Pa. Code subsection 255.5 and 42 CFR part II, subpart B , subsection 2.12(c)(5)(ii).
The findings included:
The agency confidentiality policy was reviewed onsite. The manual contained the following statement on page 41:
" In the event that an individual who is active with the Agency's services, or has been active with the Agency in the past, perpetrates a criminal act against the agency or one of its staff, the Center will release client records, without consent, to proper legal authorities for the purpose of bringing prosecution to the offender. The Executive Director must be consulted before any information is disclosed , and a summary of the consultation as well as documentation of the release of information without consent will be fully documented in the client record."
This section is a violation of state law at 71 P. S. Subsection 1690.108(b), 4 Pa. Code Subsection 255.5(b) and federal regulations at 42 CFR part II, subpart B , subsection 2.12(c)(5)(ii).
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Plan of Correction
The change has been made and reviewed by the Licensing Specialist. The policy manual change was approved in the June 17th Board Meeting. |
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 the review of client record during the unannounced onsite licensing inspection of June 16, 2009, the facility failed to document disclosures of client identifying information which adhere to the requirements stated at 4 Pa. Code subsection 255.5(b).
The findings included :
Four client records were reviewed during the inspection on June 16, 2009. Each of the records was required to comply with limitations on releases of client identifying information specified at 4 Pa. Code subsection 255.5(b). One client record (#2) would have permitted release of information to employers which were not permitted. Specifically , a consent to release information documented for release to an employer would have permitted the release of the five areas specified at subsection (b). Employers are permitted to have only information related to the client's presence in treatment.
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Plan of Correction
The Clinical Director along with all supervisors will hold an in-house training on July 23, 2009 with all clinical staff. Confidentiality will be the only topic discussed. The particular citation will be addressed at that time along with an overall review of confidentiality regulations.
It will be the responsibility of each clinical supervisor and the Clinical Director to monitor these changes thru monthly chart reviews. |