INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 18, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services Carlisle 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 April 14, 2008.
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Plan of Correction
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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 a review of the facility's policies and procedures, the facility failed to have a written procedure that complied with 4 Pa. Code 255.5. The facility's written procedures for the confidentiality of client identity and records contained a document entitled "Confidentiality Regulations and the Drug and Alcohol Treatment Programs". This procedure included the wording that allowed for the release of client information "with or without the client's consent" to judges and probation/parole.
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Plan of Correction
The Director of Quality Improvement has revised the "Confidentiality Regulations and the Drug and Alcohol Treatment Programs" procedure to state that client information can only be released with the client's consent to judges and probation/parole. |
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 obtain an informed an voluntary consent and comply with the limitations imposed by 4 Pa. Code 255.5 in two of three records reviewed, #2 and 3. Documentation on the Pennsylvania Client Placement Criteria that was sent to the funding source included family information and family addiction information.
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Plan of Correction
The Facility Director will oversee that staff are re-educated through staff meeting regarding the limitations imposed by 4 Pa. Code 255.5 and how these limitations include information documented on the Pennsylvania Client Placement Criteria which is routinely sent to the funding source. The Quality Improvement Department will monitor ongoing compliance with the limitations of 4 Pa. Code 255.5 through chart audits. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document a complete treatment plan in two of four records reviewed, #2 and 4. Treatment plan goals were not stated in terms of measurable criteria. Treatment plans were also illegible.
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Plan of Correction
The Facility Director will oversee that staff are re-trained in staff meeting to complete the treatment plan to include goals that are stated in terms of measurable criteria. Staff will be reminded that documentation must be legible and will also be reminded that they do have the option to type so that legibility concerns can be avoided. The Quality Improvement Department will monitor the content and legibility of the treatment plan through ongoing chart audits. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document complete treatment plan updates in three of four records reviewed, #1, 2 and 4. Treatment plan updates did not include an assessment of the client's progress in relationship to the stated goals of the treatment plan in two records, #1 and 2. A treatment plan update was not documented in client record #4.
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Plan of Correction
The Facility Director will remind staff in staff meeting to complete all treatment plan updates in a timely manner. Staff will also be re-educated to include an assessment of the client's progress in relationship to the goals stated on the comprehensive treatment plan. The Project Director and Quality Improvement Department will also oversee an ongoing internal monitoring system by the office administration to ensure the timely completion of treatment plan updates. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to document complete progress notes in four of four records review, #1, 2, 3 and 4. Progress notes were illegible and were missing the assessment portion of the progress note.
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Plan of Correction
The Facility Director will oversee that staff are re-educated through staff meeting to complete progress notes thoroughly and legibly. Staff will be reminded to include their assessment in each note and will be offered the opportunity to type their notes to avoid legibility issues. The Quality Improvement Department will oversee an internal monitoring system by office administration to ensure that progress notes are legible. The Quality Improvement Department will also monitor the content of the progress notes to ensure thorough completion through ongoing chart audits. |