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 6, 2010 licensure renewal inspection. The follow-up inspection was conducted on August 26, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, House of Meadville, 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 September 24, 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, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in four of six client records. The findings include:Seven client records were reviewed on August 26, 2010. Six were reviewed for compliance with the project obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record. There was no documentation of the specific information to be released on the consent to release information forms in client records # 2, 3, 5 and 6. In client record # 2, a release of information consent signed by the client listed the specific information to be released as "communication with wife". This does not identify the specific information to be released. In client record # 3, the client and staff signed and dated two blank releases of information consent forms, both dated June 1, 2010. In client record # 5, a release of information consent signed by the client for the adult probation department listed specific information to be released that exceeded the limitations imposed at 4 Pa. Code, Subsection 255.5(b). The specific information to be released included progress notes. In client record # 6, a release of information consent signed by the client listed the specific information to be released as " other-continuity of care". This does not identify the specific information to be released.
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Plan of Correction
Facility director redesigned voluntary consent forms for probation and parole release of information that will reflect only specific information that can be released at 4 Pa code, subsection 255(b).
General voluntary consent forms were redesigned that reflect lines for specific information to be released. Staff was trained on Sept 2 on the proper use of both forms and how to determine specificity of what is to be released. Along with regular chart review, clinical supervisor will be responsible to see that consents are done appropriately. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records, the facility failed to document goals with timeframes in the aftercare plan in one of one client record. The findings include:Seven client records were reviewed on August 26, 2010. An aftercare plan was required in one client record. The facility did not document the timeframes for the completion of goals in the client's aftercare plan in client record # 5.
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Plan of Correction
Staff training was held on September 2, 2010 concerning how to appropriately document time frames for goal completions in the aftercare plan. Clinical supervisor will be responsible to oversee chart review of after care plans. |