INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 18, 2015 through November 19, 2015 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Harbor Counseling 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 client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in one of eleven records reviewed. Additionally, the facility also failed to ensure that an informed and voluntary consent to release information was obtained in one of eleven client records reviewedThe findings included:4 Pa. Code states:Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.(1) Whether the client is or is not in treatment.(2) Client's prognosis.(3) The nature of the project.(4) A brief description of the client's progress.(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.Eleven client records requiring proper releases of information were reviewed on November 18, 2015 through November 19, 2015. The facility failed to stay within the limits imposed by 4 Pa. Code 255.5 (b) in client record # 6. Additionally, the facility failed to obtain a signed consent to release form from the client prior to the disclosure of information in client record #10.Client #6 was admitted into treatment on July 10, 2015 and was discharged on October 9, 2015. A release of information to a government agency was signed on 08/10/2015 and allowed for the disclosure of the psychosocial evaluation, the treatment plan, the discharge plan, and the aftercare plan, which exceeded 255.5. Client #10 was admitted into treatment on December 9, 2014 and was discharged on July 15, 2015. There was a facsimile documented in the client chart, dated 03/24/15, to a government agency; however, as of the date of this inspection and prior to the disclosure of the client's information, there was no signed consent to release information form documented in the client's chart.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We have recently made a full transition to Electronic Medical Records (EMR) and had our system and process designed to eliminate oversights such as the two identified in this citation. The program automatically identifies any current releases of information, so that disclosures are not given without the presence of a current release. Releases allowing disclosure to a government agency are set up to automatically stay within the limits imposed by 4 Pa. Code 255.5. Additionally, all staff are required to attend necessary Confidentiality trainings. The Program Director will review this regulatory standard, this citation, and the new process/system with all staff at a regular general staff meeting on January 5, 2016. Clinical Supervisor will monitor records to ensure ongoing 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 a review of client records, the facility failed to document treatment plan updates within the 60-day regulatory period as required by Chapter 709 in four of eleven client records reviewed.The findings include:Eleven client records requiring documentation of treatment plan updates within the regulatory timeframe were reviewed on November 18, 2015 through November 19, 2015. The facility failed to document 60-day treatment plan updates in client records, #4, 7, 8, and 11.Client #4 was admitted into treatment on March 5, 2015 and was still an active client as of the date of the on-site inspection. The last documented treatment plan update was completed on 09/15/2015. A treatment plan update was due to be completed no later than 11/15/2015; however, there wasn't one documented in the client record at the time of the inspection.Client #7 was admitted into treatment on December 15, 2014 and was discharged on April 15, 2015. The master treatment and rehabilitation plan was completed on 12/29/2015 and the treatment plan update was completed on 03/18/2015, which was outside of the 60-day timeframe required in Chapter 709.Client #8 was admitted into treatment on April 6, 2015 and was discharged on July 30, 2015. The master treatment and rehabilitation plan was completed on 04/27/2015 and a treatment plan update was due to be completed no later than 06/27/2015; however, there wasn't one documented in the client chart at the time of the inspection.Client #11 was admitted into treatment on December 10, 2015 and was discharged on July 17, 2015. A treatment plan update was completed on 05/11/2015; therefore, another update needed to be completed no later than 07/11/2015. A treatment plan update was completed on 07/13/2015, which was outside of the 60-day timeframe required in Chapter 709.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We have recently made a full transition to Electronic Medical Records (EMR) and had our system and process designed to eliminate oversights such as the one identified in this citation. The program automatically identifies and flags any upcoming required treatment plan updates for each client, and also identifies the date any treatment plan update is due. Through the EMR program each clinician receives daily notification of any upcoming treatment plan updates they are responsible for, and the Clinical Supervisor receives daily notification for required documentation for all clinicians. The Program Director will review this regulatory standard, this citation, and the new process/system with all staff at a regular general staff meeting on January 5, 2016. Clinical Supervisor will monitor records to ensure ongoing compliance. Client #4's chart now includes an updated treatment plan provided by the clinician. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in four of eleven client records reviewed.The findings included:Eleven client records requiring the documentation of the provision of services in accordance with those specified in the treatment plan were reviewed on November 18, 2015 through November 19, 2015. The facility failed to provide counseling services as stated in the treatment and rehabilitation plan in client record #'s 1, 4, 5, and 7.Client #1 was admitted into treatment on December 8, 2014 and was still an active client at time of the inspection. An individual treatment and rehabilitation plan was developed with the client on 01/02/2015 and the plan stated that the client would be provided individual sessions 4 times per month. During the months of February, March, May, and October 2015, the client received three individual therapy sessions per month. During the months of June, July, August, and September 2015, the client received two individual therapy sessions per month. There was no additional documentation reflecting the client/counselor no-showed or cancelled any sessions during those months in the client chart at the time of the inspection.Client #4 was admitted into treatment on March 5, 2015 and was still an active client at time of the inspection. An individual treatment and rehabilitation plan was developed on 04/01/2015 and the plan stated that the client would be provided individual sessions 4 times per month. During the months of May and September 2015, the client received zero individual therapy sessions per month. During the months of July and August 2015, the client received one individual therapy session per month. During the month of June 2015, the client received two individual therapy sessions. There was no additional documentation reflecting the client/counselor no-showed or cancelled any sessions during those months in the client chart at the time of the inspection.Client #5 was admitted into treatment on May 21, 2015 and was still an active client at time of the inspection. An individual treatment and rehabilitation plan was developed with the client on 08/20/2015 and the plan stated that the client would be provided individual sessions 2 times per month. During the months of September and October 2015, the client received one individual therapy session per month. There was no additional documentation reflecting the client/counselor no-showed or cancelled any sessions during those months in the client chart at the time of the inspection.Client #7 was admitted into treatment on December 15, 2015 and was discharged on April 15, 2015. An individual treatment and rehabilitation plan was developed with the client on 12/29/2014 and the plan stated that the client would be provided individual sessions 4 times per month. During the months of January and March 2015, the client received three individual therapy sessions per month. During the month of April 2015, the client received one individual therapy session. There was no additional documentation reflecting the client/counselor no-showed or cancelled any sessions during those months in the client chart at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We have recently made a full transition to Electronic Medical Records (EMR) and had our system and process designed to eliminate oversights such as the one identified in this citation. The program requires the entry of documentation reflecting cause for any missed or cancelled sessions. This system and process also allows the clinicians and the Clinical Supervisor to identify the need to review and adjust any treatment plans to reflect present actual client need and participation. The Program Director will review this regulatory standard, this citation, and the new process/system with all staff at a regular general staff meeting on January 5, 2016. Clinical Supervisor will monitor records to ensure ongoing compliance. As of 12/15/15 the records involving the services provided to clients #1, #4, and #5 have been reviewed by the Clinical Supervisor and the appropriate clinicans/clients as necessary, and the records have been updated providing explanation or clarification regarding the discrepancies between the treatment plans and the record of services. Client #7 is a discharged client, but wherever past records provided explanation to determine cause for the discrepancies, the record was updated appropriately.
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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 document a complete client record on an individual, which includes complete records of services and case consultation notes in five of eleven client records reviewed.The findings include:Eleven client records requiring a complete client record on an individual were reviewed on November 18, 2015 through November 19, 2015. The facility did not provide complete records of services for clients, #1, 2, and 7. Additionally, the facility did not provide case consultation notes for client #'s client record for clients, #7, 9, and 11.Client #1 was admitted into treatment on December 8, 2014 and was still active at the time of the on-site inspection. The facility failed to include documentation of a complete record of service as there were individual progress notes dated 01/29/15, 04/01/15, 04/01/15, 07/09/15, 07/30/15, 08/27/15, 09/03/15, 09/10/15, and 10/01/15 documented in the chart, however, they were not included on the client's record of service as of the date of the inspection.Client #2 was admitted into treatment on June 16, 2015 and was still active at the time of the on-site inspection. The facility failed to include documentation of a complete record of service as there were group progress notes documented in the client chart - 1 in June, 2015, 8 in July, 2015, 10 in August, 2015, and 14 in September, 2015 - however, they were not included on the client's record of service as of the date of the inspection.Client #7 was admitted into treatment on December 15, 2014 and was discharged on April 15, 2015. The facility failed to include documentation of a complete record of service as there were individual progress notes dated 02/04/15, 02/11/15, 03/04/15, 03/25/15, and 04/01/15 documented in the chart, however, they were not included on the client's record of service as of the date of the inspection. In addition, the facility failed to include documentation of any of the client's case consultation notes as of the date of the inspection. Client #9 was admitted into treatment on May 14, 2015 and was discharged on September 25, 2015. The facility failed to include documentation of any of the client's case consultation notes as of the date of the inspection.Client #11 was admitted into treatment on December 10, 2014 and was discharged on July 17, 2015. The facility failed to include documentation of any of the client's case consultation notes as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We have recently made a full transition to Electronic Medical Records (EMR) and had our system and process designed to eliminate oversights such as the one identified in this citation. The program automatically identifies and flags, both for clinicians and support staff, any required case notes for services in the client record of services, as well as missing entries in the client record of service. Through the EMR program each clinician and support staff receives daily notification of any required case notes or discrepancies between case notes and the client record of service. The Clinical Supervisor also receives daily notification of required documentation for all clinicians. The Program Director will review this regulatory standard, this citation, and the new process/system with all staff at a regular general staff meeting on January 5, 2016. Clinical Supervisor will monitor records to ensure ongoing compliance. The records of clients #1 and #2 were reviewed by the Clinical Supervisor and appropriate clinical and support staff. These client records have been updated reflecting corrected records of service. Clients #7, #9 and #11 are no longer active, but wherever a review of internal records allowed, those records have been updated accordingly. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records, the facility failed to document a physician signature on the individual treatment plans and/or treatment plan updates for medical assistance clients stipulated by the Office of Medical Assistance in two of five MA-identified client records.The findings included:Eleven client records were reviewed on November 18, 2015 through November 19, 2015. Five client records were identified as being medical assistance clients, thus requiring a physician signature on the individual treatment plans and updates. The individual treatment plans and/or treatment plan updates contained in client records # 3 and 8 did not contain a physician signature as stipulated by the Office of Medical Assistance.Client #3 was admitted into treatment on February 13, 2015 and was still an active client at the time of the inspection. The treatment plan and treatment plan updates dated 02/13/15, 04/09/15, 07/13/15, and 09/09/15 did not include a physician's signature.Client #8 was admitted into treatment on April 6, 2015 and was discharged on July 30, 2015. The treatment plan and treatment plan updates dated 04/06/15, 04/27/15, and 06/27/15 did not include a physician's signature.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
We have recently made a full transition to Electronic Medical Records (EMR) and had our system and process designed to eliminate oversights such as the one identified in this citation. The program automatically identifies and flags, both for clinicians and support staff, any medical assistance clients requiring documented physician signature on treatment plans and treatment plan updates, and whether the signatures are present or not. Through the EMR program each clinician and support staff receives daily notification of any required signature of our supervising physician. The Clinical Supervisor also receives daily notification of required documentation for all clinicians. The Program Director will review this regulatory standard, this citation, and the new process/system with all staff at a regular general staff meeting on January 5, 2016. Clinical Supervisor will monitor records to ensure ongoing compliance. Both of these client charts and their treatment plans will be reviewed with our supervision physician at the regularly scheduled clinical staffing with him on January 5, 2016. Wherever legally, ethically and appropriately possible the records will be updated appropriately. Wherever necessary or appropriate, medical assistance funds inappropriately received will be reimbursed or reflected in future billings. |