Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client for disclosure of information that indicated the purpose of disclosure in three of six client records.The findings included:Six client records requiring an informed and voluntary consent from the client to include the purpose of disclosure were reviewed on June 25, 2015. The facility failed to obtain an informed and voluntary consent from the client that included the purpose of disclosure in client records #3, 4, and 5.Client # 3 was admitted into treatment on March 31, 2015 and discharged on May 20, 2015. A consent to release information to a treatment provider, signed and dated March 31, 2015, did not include the purpose of disclosure. A consent to release information to a primary care physician, signed and dated March 31, 2015, did not include the purpose of disclosure. A consent to release information to a pharmacy, signed and dated March 31, 2015, did not include the purpose of disclosure. A consent to release information to a health center, signed and dated March 31, 2015, did not include the purpose of disclosure. A consent to release information to the client's mother, signed and dated March 31, 2015, did not include the purpose of disclosure. A consent to release information to the client's father, signed and dated March 31, 2015, did not include the purpose of disclosure. A consent to release information to the client's mother, signed and dated March 31, 2015, did not include the purpose of disclosure. Client #4 was admitted into treatment on May 13, 2015 and discharged on May 20, 2015. A consent to release information to a treatment provider, signed and dated May 13, 2015, did not include the purpose of disclosure. A consent to release information to a primary care physician, signed and dated May 13, 2015, did not include the purpose of disclosure. A consent to release information to a pharmacy, signed and dated May 13, 2015, did not include the purpose of disclosure. A consent to release information to a health center, signed and dated May 13, 2015, did not include the purpose of disclosure. A consent to release information to a funding source, signed and dated May 13, 2015, did not include the purpose of disclosure. A consent to release information to the Lebanon County Public Defender, signed and dated May 13, 2015, did not include the purpose of disclosure. A consent to release information to the client's mother, signed and dated May 13, 2015, did not include the purpose of disclosure. Client #5 was admitted into treatment on January 13, 2015 and discharged on May 20, 2015. A consent to release information to a treatment provider, signed and dated May 13, 2015, did not include the purpose of disclosure. A consent to release information to a primary care physician, signed and dated May 13, 2015, did not include the purpose of disclosure. A consent to release information to a pharmacy, signed and dated May 13, 2015, did not include the purpose of disclosure. A consent to release information to a health center, signed and dated May 13, 2015, did not include the purpose of disclosure. These findings were reviewed with facility staff during the complaint investigation.
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Plan of Correction
On 6/25/15, upon completion of the onsite survey, the Executive Director, met will all staff who are involved with completing consents that disclose information. Staff was informed that they must document a purpose for the consent. The facility is also in the process of developing new consent forms that will have a pre-filled purpose. However in the event of needing a blank consent staff has been education to the importance and requirement of a purpose for said consent. After a staff training on 7/16/15 on consents and confidentiality, the new consents will be introduced on 7/20/15. There will be a monthly and a quarterly chart review conducted by the Clinical Supervisor to ensure compliance. The Executive Director will ensure overall compliance of consents and confidentiality.
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Observations
Based on the review of client records, the facility failed to document short and long-term goals as formulated by both staff and client in six out of six client records.The findings include:Six client records requiring documentation of short and long-term goals in the individual treatment and rehabilitation plan were reviewed on June 25, 2015. The facility failed to document short and long-term goals as formulated by both staff client in records #1, 2, 3, 4, 5, and 6. In all six client records, the first four goals (Sobriety, Spirituality, Life Skills and Employment)were not individualized as they were the same for each client. These findings were reviewed with facility staff during the complaint investigation.
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Plan of Correction
In order to resolve the issues of individualized long-term and short-term goals based on client participation, a new treatment plan was developed to reflect individualized, long-term and short term goals with measurable objectives. Upon completion of a staff training on treatment planning, to be held on 7/16/15, the new treatment plan will be implemented on 7/20/15. There will be a monthly and a quarterly chart review conducted by the Clinical Supervisor to ensure compliance. The Executive Director will ensure overall compliance of the treatment planning process.
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