INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 28, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Rehab Management 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:
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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.
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Observations
Based on the review of 7 client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 2 client records.Client # 4 was admitted into the outpatient level of care on 5/24/17 and was discharged 11/26/17. There was documentation that contact was made with a law enforcement agency during the client's treatment episode; however, there was no proper consent to release information form signed by the client prior to disclosure.Client # 5 was admitted into the outpatient level of care on 8/17/17 and was discharged 11/16/17. There was documentation that contact was made with an attorney and a law enforcement agency prior to the client signing a proper consent to release information form on 11/9/17.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A staff meeting was held on 4/30/18 to discuss Confidentiality Policy 709.28. During the staff meeting, clinicians went over the training instructions for completing releases and were made aware of the violation for contacting legal bodies prior to obtaining a written release form. Clinicians went over each section of the release to ensure that there was no confusion about how to properly fill out the release. Clinician explored when to complete a legal release during the evaluation and decided that it would be appropriate after obtaining releases for urine screens to inquire about legal releases. Supervisor will follow up 1x per month on progress made and address any issues as they arise. |
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 7 client records, 3 client records had treatment plan updates completed after the regulatory timeframe or missing at the time of the inspection.Client #4 was admitted on 11/2/17 and was discharged 11/26/17. A treatment plan update was completed on 5/24/17 and the next update was due no later than 7/24/17. However, the update was not completed as of the date of the inspection.Client #6 was admitted on 8/29/17 and was discharged 12/7/17. The comprehensive treatment plan was completed on 8/29/17 and the next update was due no later than 10/29/17. However, the update was not completed until 11/9/17.Client #7 was admitted on 8/28/17 and was discharged on 12/7/17. The comprehensive treatment plan was completed on 9/4/17 and the next update was due no later than 10/28/17. However, the update was not completed as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A staff meeting was held on 4/30/18 to discuss Licensure issue 709.92. Clinicians received a handout that outlined requirements for treatment plan completion timelines including the need for a treatment plan update to be completed and signed within 60 days from the date the client is evaluated. Clinicians were reminded that if for any reason they are unable to obtain a client signature on a treatment plan update to update and sign the treatment plan by the due date, have the client sign the treatment plan during the next session and to add a memo to chart noting why the signature was unable to be obtained. Clinicians were also given a handout outlining how to create configured alerts in Care Logic to make it easier to keep track of the due date of upcoming treatment plan updates in the documentation system. Supervisor will check in with clients 1x per month on progress with configuring alerts and to offer reminders about treatment plan updates every 60 days in Care Logic. |