INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 24-25, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Outside In Pathway to Recovery Outpatient Services 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 December 24, 2008.
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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 the client records, the facility failed to document an informed client consent of the release forms in two of seven client records. The findings include:Seven client records were reviewed on November 24-25, 2008. Informed consent to release information forms were required in seven client records. The facility did not document an informed consent in client records #1 and 4. The Value Behavioral Health standardized release forms did not include a relevant purpose for the disclosure of the information. The Value Behavioral Health standardized release forms did not include the specific information to be released, but the information released exceeded the limitations imposed at 4 Pa. Code Subsection 255.5(b).
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Plan of Correction
Pathway to Recovery Clinical Supervisors will review outcome of site visit and confidentiality standards with the addiction counselors during a staff training/meeting on December 9, 2008 from 9:00 - 11:00 AM. Any client after December 9, 2008 implementation date will reflect compliance with regulation. The Clinical Supervisor will follow up and monitor to ensure ongoing compliance with regulations. The Facility Director and Clinical Supervisor will revise release form to reflect compliance. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to document the type and frequency of treatment on the treatment plans in five of seven records. The findings include:Seven client records were reviewed on November 24 - 25, 2008. Type and frequency of treatment on the treatment plans were required in six records. The facility did not document type and frequency of treatment in client records # 1, 3, 4, 5, and 6. Groups and family sessions are not documented on the treatment plans. The frequency of treatment was not specific but gave a range of 1 - 3 times per week.
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Plan of Correction
Pathway to Recovery Clinical Supervisors will review outcome of site visit and documentation standards with the addiction counselors during a staff training/meeting on December 9, 2008 from 9:00 - 11:00 AM. Any client after December 9, 2008 implementation date will reflect compliance with regulation. The Clinical Supervisor will follow up and monitor to ensure ongoing compliance with regulations. The Facility Director and Clinical Supervisor will revise the first page of the treatment plan to reflect the frequency of service group and family sessions. |
709.93(a)(2) 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:
(2) Medication records.
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Observations
Based on the review of client records, the facility failed to document medication records in seven of seven records. The findings include:Seven records were reviewed on November 24-25, 2008. The medication records were required in all seven records. All of the records did not include the frequency of use of the medication. Client records #1 and 5 did not include documentation of any medications and were blank. Client record #3 did not have the dose. Client record #4 included documentation of a list of medications on the medication records that was different from the medications listed in the psychosocial evaluation.
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Plan of Correction
Pathway to Recovery Clinical Supervisors will review outcome of site visit and documentation standards with the addiction counselors during a staff training/meeting on December 9, 2008 from 9:00 - 11:00 AM. Any client after December 9, 2008 implementation date will reflect compliance with regulation. The Clinical Supervisor will follow up and monitor to ensure ongoing compliance with regulations. The Facility Director and Clinical Supervisor will revise the psychosocial to reflect the frequency of use of the medication. |