INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 14, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Independent Family Services, 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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of the client records, the facility failed to document a consent to release information form prior to the disclosure of information in one of three client records.
The findings include:
Three client records were reviewed on November 14, 2013. Consent to release information forms were required in three client records. Record #2 failed to document a consent to release information form.
Client # 2 was admitted to treatment on October 7, 2013. A fax confirmation form on 11-4-2013 documented information was faxed to a funding source, but a consent to release information form for the funding source was not signed.
The findings were reviewed with the project director and were not disputed.
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Plan of Correction
The Facility Director met with the counselor involved on 11/15/13 and reviewed the consent policy and procedure. The Facility Director met with Client #2 on 11/18/13, reviewed the program's policy on the consent to release confidential information and obtained the client's signed consent to release specific information relevant to the needs of the SCA's office. During the AOD staff meeting of 11/21/13, the Facility Director reviewed the consent policy and procedures. The IFS Compliance Officer was present during the 11/21/13 staff meeting to ensure that the issue will be reviewed via the CQI checklist during medical record reviews. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of the client records, the facility failed to demonstrate the clients are informed of their rights in three of three client records.
The findings include:
Three client records were reviewed on November 14, 2013. Three of the three client records did not include documentation the clients were informed of all of their rights. The client rights form signed by the client did not include all of the clients rights. The client rights form failed to include civil rights, the project director temporarily removing portions of records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file. The right to appeal a decision limiting access, the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from the record, and the right to submit rebuttal data or memoranda to the record.
The findings were reviewed with the project director and were not disputed.
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Plan of Correction
The Facility Director modified the "Client Rights & Responsibilities" form, signed upon intake, to include the statement reflected in 709.30(3) pertaining to the Project Director's ability to remove portions of the client record prior to inspection. The public notice of "Client Rights" posted in the lobby was also modified according to the regulation and replaced by the Facility Director. During the AOD staff meeting of 11/21/13, the Facility Director reviewed the regulation and policy modification. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to provide a complete client record on each individual in one of three client records.
The findings include:
Three client records were reviewed on November 14, 2013. One of the three client records did not provide a complete client record for an individual in records #3.
Client record #3 was admitted to outpatient treatment on April 24, 2013 and discharged on July 15, 2013. Documentation of a follow up was to be completed once a month for six months post discharge. Follow-up was not documented as of November 14, 2013.
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
The Facility Director reviewed the follow-up policy and procedures with the AOD staff during the 11/21/13 staff meeting, including forms to be used, length and frequency of the follow-up, information to be gathered and the nature of the follow-up regarding clients that were terminated from treatment due to non-compliance issues as well as those successfully discharged. The AOD Casemanager will review all discharged client records over the past 6 months and follow-up with a phone call to any terminated or discharged clients that did not receive follow-up according to program policy, including Client record #3. The IFS Compliance Officer was present for the 11/21/13 AOD staff meeting to ensure that the issue will be reviewed via the CQI checklist during medical record reviews. |