INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the April 19, 2011 licensure renewal inspection. The follow-up inspection was conducted on November 23, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Clear Concepts Counseling 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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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on the review of staffing information provided on the staffing self report form and the caseload lists, the facility failed to ensure that each caseload remained within 35:1. The findings included:An unannounced Plan Of Correction follow up inspection was conducted on November 23, 2011. During the inspection, Division staff reviewed caseload lists and clinical hours for each counselor and computed the caseload for each counselor. The caseloads and clinical hours for eleven clinical staff were reviewed. One counselor ( # 3 ) had a client to counselor caseload of 37:1 based on the hours worked and the assigned caseload. An interview was conducted withe the Project Director on 11/26/11 and she agreed that the numbers provided to Division staff were accurate. The findings were not disputed. This issue was previously cited during the April 21, 2011 licensing inspection. A plan of correction was approved on May 2, 2011 which indicated that the Clinical Supervisor would review caseloads on a regular basis during individual supervision to ensure that the caseloads were in compliance.
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Plan of Correction
Our facility will be in full compliance with this regulation by 12/23/2011. The number of clients assigned to counselor #3 will be reduced in order to achieve the 35:1 client to counselor ratio. The Clinical Supervisor will review this counselor's caseload on a regular basis during individual supervision to ensure this doesn't happen again in the future. |
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, the facility failed to document informed and voluntary consents for releases of information in two of five client records. The findings included: Five client records were reviewed during the unannounced onsite Plan of Correction follow up inspection conducted on November 23, 2011. Two of the five client records reviewed failed to include documentation of a consent to release information form that was executed prior to the release of client identifying information.Client record # 1- The client was admitted on 8/9/11. Documents in the record indicated that client identifying information had been faxed to an insurance entity. The faxes were not dated A fax was sent to the Single County Authority (SCA) on 9/9/11. There was no documentation of a consent to release information form for the releases of information made to the SCA. No release of information was signed by the client prior to these releases of information.Client record # 2- This client was admitted on 6/16/11. This record contained a general consent to release information to an attorney that was dated 9/21/11. This form contained no witness signature and specified that , " All records and other information.." could be released to the attorney. This consent to release information was not an informed consent and was not a valid consent to release information relative to drug and alcohol treatment information. The findings were reviewed by the Project Director and were not disputed.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy were reviewed at our 12/8/2011 staff meeting. The proper completion of consents and disclosure of client information will begin immediately. To ensure correct completion of consents forms the Quality Assurance manager will verify completion during quarterly reviews. |
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 informed and voluntary consents which included the specific information to be released in four of five client records. The findings included: Five client records were reviewed during the unannounced Plan of Correction follow up inspection conducted on November 23, 2011. Four of the five client records reviewed failed to include documentation of the specific information to be released and/or exceeded the limits of information that the client agreed to on the signed consent. Client record # 1- The client was admitted on 8/9/11. Releases of information to various entities were signed at the time of intake on 8/9/2011. The consent to release information to the client's probation officer, executed on 8/9/11, limited the release of information to the client's attendance at the program . A release of information documented in the record on 10/14/2011 released information to the probation officer summarizing the client's progress in treatment. Client record # 3- The client was admitted on 1/27/11, discharged on 3/21/11 and readmitted on 4/25/2011. At the time of the 1/27/11 intake, various consents for the release of information were signed. One release form was for contact with a family member in the event of an emergency. This consent to release information form was signed at the time of the first intake on 1/27/11 and did not specify what information would be released in the event of an emergency. At the time of the readmission on 4/25/11 the consents to release information were not updated.Client record # 4- This client was admitted on 6/6/2011. At the time of intake a release of information form was executed for the purpose of informing family members of scheduling and emergency contact information. This release form did not specify what specific information would be released in these instances. Client record #5- The client was admitted on 12/30/10, discharged on 6/30/11 and readmitted on 9/1/11. The consent to release information dated 11/3/11, to the insurer, did not specify what information would be released but was signed by both the client and a witness ( the counselor). A consent to release information to the employer was documented on 11/30/10 and failed to document the specific information to be released. A consent to release information to a significant other and family members was documented on 12/28/10 and failed to document the specific information to be released. At the time of the 9/1/11 readmission, the consents to release information were not renewed.The findings were reviewed by the Project Director and were not disputed.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy were reviewed at our 12/8/11 staff meeting. The proper completion of consents and disclosure of client information will begin immediately. This standard and policy will also be reviewed with all therapists by the Clinical Supervisor in individual supervision. The Quality Assurance manager will also verify completion during quarterly reviews. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of the facility policy and procedure manual and client records, the facility failed to adhere to the 55 Pa. Code Part III requirement to have the physician sign off on all treatment plans and updates within 15 days of formulation in two of two client records. The findings included: Five client records were reviewed during the onsite Plan of Correction follow up inspection of 11/23/2011. Two of these records were funded by Medical Assistance. Written facility policy stated that "treatment plans for medical assistance recipients must be dated by their supervisory physician before their start date or services may not be billed to Medical Assistance". Policy indicated elsewhere that the physician must review and sign off on treatment plans and updates within 15 days. Treatment plans and /or updates in two of two records were not signed by the physician or were signed later than required in the facility policy and procedure. Client record # 1 - Admitted on 8/9/11 and last treated on 11/2/11. The treatment plan was formulated on 9/911 and updated on 11/9/11. At the time of the record review on 11/23/11, the physician had not signed off on the update. Client record # 2 - The client was admitted on 6/16/11 and last treated on 11/14/11. The preliminary treatment plan was formulated on 6/16/11 and not signed by the physician until 7/14/11. The comprehensive treatment plan was formulated on 7/17/11 and signed by the physician on 8/11/11. The findings were reviewed with the Project Director and were not disputed.
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Plan of Correction
Our facility will be in full compliance with this standard and our agency policy immediately. This standard and our agency policy were reviewed at staff meeting on 12/8/2011. The proper timeframe for our Medical Director to co-sign completed treatment plans of clients funded by Medical Assistance/Healthchoices will begin immediately. The Director of Clinical Services reviewed this standard with our Medical Director at staff meeting on 12/8/2011. The Director of Clinical Services will also do random reviews to ensure the proper timeframe of co-sign is being completed by the Medical Director. |