INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 6 - 7, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Family A.C.T.S. Incorporated 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.
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Plan of Correction
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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 records and an interview with the facility director, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in two of five clients records.
The findings included:
Five client records were reviewed on June 7, 2011. Per regulation, the project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. Five client records required an informed and voluntary consent from the client. The facility failed to obtain an informed and voluntary consent for the disclosure of client information to a residential treatment program and the funding entity in client record # 1. The facility failed to obtain an informed and voluntary consent for family therapy sessions in client record # 2.
Client # 1 was admitted into treatment on October 12, 2010. Information was released to the funding entity without an informed and voluntary consent from the client. A progress report was released to a residential treatment program in October of 2010, without an informed and voluntary consent from the client. The consents to release information were not documented in client record # 1, at the time of the review, on June 7, 2011.
Client # 2 was admitted into treatment on December 30, 2010. Family therapy sessions are conducted on a weekly basis. An informed and voluntary consent was not obtained from the client prior to conducting family sessions. The consent to release information was not documented in client record # 2, at the time of the review, on June 7, 2011.
On June 7, 2011, at approximately 1:30 PM the Facility Director was interviewed and confirmed these client records did not include the required consents to release information.
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Plan of Correction
The facility director will ensure that informed and voluntary consent from clients for the disclosure of information contained in the client record is obtained. The facility director will ensure that an informed and voluntary consent will be obtained prior to conducting family sessions. Facility Director has retrained staff during 6/15/11 weekly staff supervision on the completion of consents to release information. Facility Director will complete monthly client chart audits to ensure staff are documenting consents to release information. |
709.91(b)(6) LICENSURE Intake and admission
709.91. 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 and an interview with the facility director, the facility failed to document psychosocial evaluations that provide a composite picture of the individual including client assets, strengths or other factors that can contribute to the resolution of identified problems of the client in five of five client records. The facility failed to document psychosocial evaluations that provide a composite picture of the individual including the coping mechanisms of the client in four of five client records.
The findings include:
Five client records were reviewed on June 7, 2011. Five client records required the completion of psychosocial evaluations that provide a composite picture of the individual including client assets, strengths and coping mechanisms. The facility failed to document psychosocial evaluations that provide a composite picture of the individual including client assets and strengths in client records # 1, 2, 3, 4 and 5. The facility failed to document psychosocial evaluations that provide a composite picture of the individual including client coping mechanisms in client records # 1, 3, 4 and 5.
Client # 1 was admitted into treatment on October 12, 2010. The psychosocial evaluation was completed on October 12, 2010. The psychosocial evaluation did not provide a composite picture of the individual and did not include the client assets, strengths or coping mechanisms.
Client # 2 was admitted into treatment on December 30, 2010. The psychosocial evaluation was completed on December 30, 2010 The psychosocial evaluation did not provide a composite picture of the individual and did not include the client assets and strengths.
Client # 3 was admitted into treatment on January 18, 2011. The psychosocial evaluation was completed on January 25, 2011. The psychosocial evaluation did not provide a composite picture of the individual and did not include the client assets, strengths or coping mechanisms.
Client # 4 was admitted into treatment on September 7, 2010 and discharged on October 25, 2010. The psychosocial evaluation was completed on September 7, 2010. The psychosocial evaluation did not provide a composite picture of the individual and did not include the client assets, strengths or coping mechanisms.
Client # 5 was admitted into treatment on September 2, 2010 and discharged on December 20, 2010. The psychosocial evaluation was completed on September 2, 2010. The psychosocial evaluation did not provide a composite picture of the individual and did not include the client assets, strengths or coping mechanisms.
The facility director was interviewed on June 7, 2011 at approximately 1:30 PM. The facility director reviewed these psychosocial evaluations and agreed with the findings. On June 7, 2011, the facility director revised the evaluation form to include a category for client assets and strengths.
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Plan of Correction
The facility director will ensure that psychosocial evaluations provide a composite picture including assets, strengths or other factors. This will be acomplished through the addition of question regarding assets, strengths or other factors on the psychological evaluations. Facility Director will retrain staff on the completion of psychosocials during next weekly supervision to be held on 06/22/2011. Facility Director will complete monthly client chart audits to ensure Psychological evaluations are completed appropriately. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document follow-up attempts within 60 days of discharge, as per facility policy, in two of two client records.
The findings include:
Five client records were reviewed on June 7, 2011. Two client records were closed and required documentation of a follow-up attempt. Per agency policy, a follow-up phone call will be conducted within 60 days of discharge. The facility failed to document a follow-up attempt within 60 days in client records # 4 and 5.
Client # 4 was admitted into treatment on September 7, 2010 and discharged on October 25, 2010. A follow-up attempt was due to be completed no later than December 25, 2010. A follow-up attempt was not completed until February 23, 2011.
Client # 5 was admitted into treatment on September 2, 2010 and discharged on December 20, 2010. A follow-up attempt was due to be completed no later than February 20, 2011. There was no documentation of a follow-up attempt in client record # 5 at the time of the review on June 7, 2011.
The facility director was interviewed on June 7, 2011 at approximately 1:30 PM. The facility director confirmed that the follow-up was late for client # 4 and not completed for client # 5.
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Plan of Correction
The facility director will ensure that follow-up attempts are made within 60 days as per the facility policy. Staff will be retrained by the facility director during the 06/22/11 weekly staff supervision to ensure that follow-ups are completed on all discharges within 60 days of the discharge date as per facility policy. Facility director will complete monthly client chart audits to ensure that follow-ups are being completed within the stated time frames. |