INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 12-15, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, White Deer Run, 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 May 12, 2010.
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Plan of Correction
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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 the review of client records, a discussion with the clinical director and a review of sample documents provided by supervisory staff, the facility failed to ensure that releases of information adhered to the limitations imposed at 4 Pa. Code subsection 255.5(a)(10) & (b), where required, .
The findings include:
During the course of reviewing client records, Division staff noted that there was no documentation of disclosures made to funding entities to request authorization for treatment at the facility.
The clinical director was interviewed on 4/14/2010 about the procedures for documenting disclosures to funding entities for authorization to provide services. As explained by the director, the procedure is that the clinical staff prepare a document based on the Pennsylvania Client Placement Criteria (PCPC) dimensions. The document is then submitted to the Utilization Review staff who verbally disclose information to the funding entity. The clinical director stated that the Utilization Review staff only release information which is compliant with the limitations established at 4 Pa. Code subsection 255.5(b).
Sample documentation was presented by the director . Upon review of the documentation provided, Division staff determined that the information in the document prepared by clinical staff allowed for the release of information that exceeded the limitations imposed at 4 Pa. Code subsection 255.5(b). Comments in the document discussed family relationships, shame and guilt experienced by the client, mood and affect of the client, emotional and physical abuse the client experienced, clients employment and specifics of treatment plan goals and objectives. When the director was asked whether documentation of the information actually released by the Utilization review staff was available to make a determination about how much of the information in the document prepared by the clinical staff was redacted to comply with the requirement, the director indicated that typically the UR staff does not keep documentation of what they actually release [as required at 4 Pa.. Code 255.5 subsection(a)(10)] . The director explained that UR staff are well versed in the requirements at 4 Pa. Code 255.5(b) and that they do not release anything that is not permitted. While Division staff are not in any way challenging the veracity of this assertion, the only documentation presented at the time of the inspection included information that exceeded the limitations imposed at 4 Pa. Code subsection 255.5(b) and is, therefore, not in compliance with the regulation.
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Plan of Correction
On or before May 10, 2010 all Utilization Review staff will implement the use of funder specific forms for the managed Medicaid MCO and continue with the previously utilized commercial funding review forms. As agreed upon with the surveyor, Utilization Review staff will strike out what is not reported or disclosed in the course of all review calls. These funder specific forms will continue to be kept in the Utilization Review department while the patient is actively involved in treatment. These forms will be available for review prior to the discharge of the patient. Upon discharge of each patient, the funder specific forms will be consolidated in the misc. section of each patient's medical record. Medical Records will monitor 10% of discharge charts for the following 6 months to evaluate compliance. |
709.53(a)(7) LICENSURE correspondence
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:
(7) Client-related correspondence.
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Observations
Based on the review of client records and an interview with the clinical director on April 14, 2010, the facility failed to document all client related correspondence in 18 of 18 client records.
The findings include:
The client records reviewed from April 13 to 15, 2010 included documentation of consents to release information to funding sources, but that no documentation of correspondence with those funding sources to procure payment in those client records.
During an interview with the clinical director it was determined that Utilization Review staff are not documenting the content of the verbal disclosures made to funding sources in each client record as required at 4 Pa. Code subsection (a)(10). Documentation of these contacts must be included in the documentation in the client record. No such documentation was filed in the sample of records reviewed during the licensing inspection. Twenty client records were reviewed during the onsite inspection. Eighteen client records were required to include documentation of this correspondence.
Client record # 1 - There was no documentation of verbal disclosures to the funding source.
Client record # 2 - There was no documentation of verbal disclosures to the funding source.
Client record # 3 - There was no documentation of verbal disclosures to the funding source.
Client record #4 - There was no documentation of verbal disclosures to the funding source.
Client record # 5 - There was no documentation of verbal disclosures to the funding source.
Client record # 6 - There was no documentation of verbal disclosures to the funding source.
Client record #7 - There was no documentation of verbal disclosures to the funding source.
Client record # 8 - There was no documentation of verbal disclosures to the funding source.
Client record # 9 - There was no documentation of verbal disclosures to the funding source.
Client record # 10 - There was no documentation of verbal disclosures to the funding source.
Client record # 11 - There was no documentation of verbal disclosures to the funding source.
Client record # 12- There was no documentation of verbal disclosures to the funding source.
Client record # 13 - There was no documentation of verbal disclosures to the funding source.
Client record # 14 - There was no documentation of verbal disclosures to the funding source.
Client record # 15 - There was no documentation of verbal disclosures to the funding source.
Client record # 16 - There was no documentation of verbal disclosures to the funding source.
Client record # 17 - There was no documentation of verbal disclosures to the funding source.
Client record #18 - There was no documentation of verbal disclosures to the funding source.
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Plan of Correction
On or before May 10, 2010 all Utilization Review staff will implement the use of funder specific forms for the managed Medicaid MCO and continue with the previously utilized commercial funding review forms. As agreed upon with the surveyor, Utilization Review staff will strike out what is not reported or disclosed in the course of all review calls. These funder specific forms will continue to be kept in the Utilization Review department while the patient is actively involved in treatment. These forms will be available for review prior to the discharge of the patient. Upon discharge of each patient, the funder specific forms will be consolidated in the misc. section of each patient's medical record. Medical Records will monitor 10% of discharge charts for the following 6 months to evaluate compliance. |
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 the review of client records during the onsite inspection, the facility failed to document client follow up contact in accordance with stated agency policy.
The findings included:
Twenty client records were reviewed during the inspection . Four of these client records were required to include documentation of an attempt to follow up on the clients. Two of the four client records failed to include documentation of attempts to follow up on clients in accordance with the timeframes stated in facility policy.
Client record # 13 - admitted 2/17/10 and discharged 2/20/10. The client record did not include documentation of an attempt to follow up on the client within seven days of the client's referral to another level of care. There was no such documentation as of 4/15/10.
Client record #19 - admitted 1/29/10 and discharged 2/21/10. The client record did not include documentation of an attempt to follow up on the client within seven days of the client's referral to another level of care. There was no such documentation as of 4/15/10.
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Plan of Correction
The Continuing Care Coordinator will provide training prior to May 15, 2010 for the continuing care staff responsible to complete follow up contacts. This will include a review of the White Deer Run policy on defined time frames for calls to be completed. The Medical Records Department will monitor 10% of all discharged charts for the next six months for compliance with the agency policy and report findings to the Regional Administrator. |