INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 9-11, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, JF Kennedy Community MH/MR Center 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 March 16, 2010.
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to document an informed and voluntary consent from the client for the disclosure of information contained in six of twelve client records.
The Findings include:
Twelve client records were reviewed on February 9-11, 2010. All twelve records required documentation of informed and voluntary consent. The facility did not document informed and voluntary consent for the release of information in client records # 1, 4, 5, 6, 7 and 12.
Client records # 1, 4, 5 and 12 did not contain documentation of the client ' s right to verbally revoke a signed consent for the release of information to a referring treatment provider. The facility documented the clients must revoke the consent in writing.
Client records # 6 and 7 did not contain documentation of the client ' s right to verbally revoke a signed consent for the release of information to a family member. The facility documented the clients must revoke the consent in writing.
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Plan of Correction
Our informed and voluntary consent form was revised several years ago. During this inspection, we noted that some old forms were being used by some staff. By 3/1/2010, all old forms stating the clients must revoke their consent in writing were discarded by the Division Director. The Unit Director will be responsible for reviewing client records during weekly chart reviews to ensure on-going compliance. |
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 the review of client records, the facility failed to document a treatment plan update at least every 60 days as per facility policy in five of twelve client records.
The findings include:
Twelve client records were reviewed on February 9-11, 2010. All twelve records required documentation of a treatment plan update. The facility did not document a treatment plan update at least every 60 days as stated in the project ' s policy manual in client records # 4, 6, 7, 8 and 12.
The facility ' s policy titled " Treatment/Treatment Rehabilitation Services " states:
Treatment Plan Updates will be completed by the therapist at least 60 days. Each treatment plan update will include an assessment of the client ' s progress in relationship to the stated goals of the comprehensive treatment plan.
Client # 4 was admitted to the program on 7/7/09; the comprehensive treatment plan was dated 7/17/09, but the only treatment plan update was documented on 11/9/09.
Client # 6 was admitted to the program on 7/23/09; the comprehensive treatment plan was dated 7/30/09, but the treatment plan updates were only documented on 9/9/09 and 11/30/09.
Client # 7 was admitted to the program on 6/10/09; the comprehensive treatment plan was dated 6/23/09, but the treatment plan updates were only documented on 8/24/09 and 12/14/09.
Client # 8 was admitted to the program on 4/27/09; the comprehensive treatment plan was dated 4/27/09, but the treatment plan updates were only documented on 6/23/09, 8/24/09 and 11/30/09.
Client # 12 was admitted to the program on 6/4/09 and discharged on 11/13/09; the comprehensive treatment plan was dated 6/15/09, but the treatment plan updates were only documented on 7/15/09 and 10/04/09.
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Plan of Correction
The Division Director will conduct two trainings to assist staff to improve their time management in order to achieve timely documentation of treatment plan updates. These trainings will be conducted on Apirl 7th and April 14, 2010 by the Division Director. The Unit Director will be responsible for monitoring charts on a weekly basis and during individual staff supervision to ensure compliance. |
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 the review of client records, the facility failed to document a case consultation at least every 90 days as per facility policy in three of twelve client records.
The findings include:
Twelve client records were reviewed on February 9-11, 2010. All twelve records required documentation of a case consultation. The facility did not document a case consultation at least every 90 days as stated in the project ' s policy manual in client records # 1, 6 and 8.
The facility ' s policy titled " Client Records " states:
Case consultation notes will be completed by the therapist at least every 90 days for the initial year of treatment and at least bi-annually thereafter.
Client # 1 was admitted to the program on 9/30/09, but a case consultation was not documented at the time of review on 2/9/10.
Client # 6 was admitted to the program on 7/23/09, but the only case consultation was documented on 10/3/09.
Client # 8 was admitted to the program on 4/27/09, but the only case consultation was documented on 7/27/09.
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Plan of Correction
The Division Director will conduct two trainings to assist staff to improve their timely documentation of case consultations. These trainings will be held on April 7th and April 14, 2010. The Unit Director is responsible for monitoring records weekly and in individual staff supervision to ensure compliance. |