INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 12, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services Gettysburg Psychiatric 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 18, 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. |
709.92(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 a complete treatment plan updates in six of six client records reviewed, #1, 3, 4, 5, 7 and 8. Treatment plan updates did not include an assessment of the client's progress in relationship to the stated goals of the treatment plan in four records, #1, 4, 5, and 8. Treatment plan updates were not documented in two records, #3 and 7.
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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 the review of the client records, the facility failed to document complete progress notes in five of twelve records reviewed, #1, 2, 4, 6 and 11. Group progress notes were missing data pertaining to client's participation in group and many notes were illegible.
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Plan of Correction
The Facility Director will oversee that all staff are re-educated in staff meeting to legibly complete all progress notes and to include data pertaining to the client's participation in group. The Quality Improvement Department will monitor the quality of the group progress notes through random chart audits. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations in four of eight records reviewed, #2, 4, 5 and 9. Case consultations were late in two records, #2 and 4. Case consultations were missing in two records, #5 and 9.
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Plan of Correction
The Facility Director will oversee that all staff are reminded in staff meeting to complete case consultations in a timely manner. The Quality Improvment Department will oversee an internal monitoring system by office administration to ensure the timely completion of case consultations. |
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 a review of client records, the facility failed to document complete aftercare plans in three of three client records reviewed, #7, 8 and 9. There were no goals with time frames documented or support services offered in all client records reviewed.
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Plan of Correction
The Facility Director will oversee that staff are re-educated through staff meeting to complete Aftercare plans that include individualized goals with specific time frames and support services that the client should access. The content quality of the Aftercare plan will be monitored through ongoing chart audits by office administration and through random audits by the Quality Improvment Department. |