INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 12, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Anthony Pater 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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709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of administrative materials, the governing body failed to make available to the public an annual report for the fiscal year ended June 30, 2012.
The findings include:
Administrative materials were reviewed on September 12, 2013. The facility is publicly funded. An annual report was completed for the fiscal year ended June 30, 2012 but was not made available to the public as of September 12, 2013. The project/facility director confirmed the findings.
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Plan of Correction
The project director has submitted a legal notice to the Altoona Mirror letting the public know of the availability of the annual report for 2012. Documentation of this is kept on file. To avoid missing this in future years, a reminder of the need for publication will be placed at the bottom to the annual report template. The annual report will be made available to the public every year. |
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 obtain a written, informed and voluntary consent from the client prior to the release of information contained in the client record in one of five client records. In addition, the facility exceeded the limitations imposed at 4 Pa. Code 255.5 when disclosing client information in one of five client records.
The findings include:
Eight client records were reviewed on September 12, 2013. Five client records were reviewed for informed and voluntary consents from the client. The facility failed to obtain a written, informed and voluntary consent from the client prior to the release of information in client record # 4. The facility exceeded the limitations imposed at 4 Pa. Code 255.5 when releasing information to a judge in client record # 4.
Client # 4 was admitted into treatment on December 19, 2012. Client record # 4 included a letter to a judge dated February 25, 2013. A consent to release information to the judge was not obtained from client # 4 prior to the release of information contained in the client record. The letter to the judge indicated the client had tested positive for marijuana which exceeded the limitations imposed at 4 Pa. Code 255.5.
The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
To avoid any future oversights of obtaining a release of information to a judge or exceeding the limitations of 4 Pa. Code 255.5, a copy of deficiency #0277 shall be highlighted and kept with blank copies of the agency's releases of information and the company letterhead. The Project Director will be responsible for this task.
Additionally, the Project Director will place a copy of the limitations imposed at 4 Pa. Code 255.5 in with blank copies of the agency's releases of information and the company letterhead. The Project Director will then conduct monthly chart reviews to ensure the correct consents to release information have been completed. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to develop with the client an individualized treatment and rehabilitation plan in four of five client records.
The findings included:
Eight client records were reviewed on September 12, 2013. Five client records were reviewed for individual treatment and rehabilitation plans. The facility failed to document an individualized treatment and rehabilitation plan was developed with the client in client records # 1, 2, 3 and 5.
Client # 1 was admitted into treatment on March 7, 2013. An individual treatment plan was completed on March 19, 2013. The treatment plan did not include the client's signature. A review of the progress notes for client # 1 failed to document the treatment plan was developed with the client.
Client # 2 was admitted into treatment on February 20, 2013. An individual treatment plan was completed on March 1, 2013. The treatment plan did not include the client's signature. A review of the progress notes for client # 2 failed to document the treatment plan was developed with the client.
Client # 3 was admitted into treatment on March 11, 2013. An individual treatment plan was completed on March 28, 2013. The treatment plan did not include the client's signature. A review of the progress notes for client # 3 failed to document the treatment plan was developed with the client.
Client # 5 was admitted into treatment on April 19, 2013 and discharged on July 9, 2013. An individual treatment plan was completed on April 26, 2013. The treatment plan did not include the client's signature. A review of the progress notes for client # 5 failed to document the treatment plan was developed with the client.
The project/facility director was interviewed throughout the inspection and confirmed the findings.
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Plan of Correction
The Project Director shall develop a individualized treatment and rehabilitation plan which includes a place for the client's signature and counselor's signature. The new individualized treatment and rehabilitation plan will be developed by 10/1/13 and will be utilized for each client that receives a plan on or after 10/1/13. The Project Director will conduct monthly chart audits to ensure that said plans are signed by the client. |
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 quarterly case consultations in four of four client records. In addition, the facility failed to document a discharge summary within one week of discharge in four of four client records.
The findings include:
Eight client records were reviewed on September 12, 2013. Four client records required quarterly case consultations. Four client records were closed and required the completion of a discharge summary. The facility failed to document quarterly case consultations in client records # 1, 2, 3 and 4. The facility failed to document a discharge summary within one week of discharge in client records # 5, 6, 7 and 8.
Client # 1 was admitted into treatment March 7, 2013. A case consultation was due to be completed no later than June 30, 2013. There was no documentation of any case consultations in client record # 1.
Client # 2 was admitted into treatment February 20, 2013. A case consultation was due to be completed no later than June 30, 2013. There was no documentation of any case consultations in client record # 2.
Client # 3 was admitted into treatment March 11, 2013. A case consultation was due to be completed no later than June 30, 2013. There was no documentation of any case consultations in client record # 3.
Client # 4 was admitted into treatment December 19, 2012. Case consultations were due to be completed no later than March 31 and June 30, 2013. There was no documentation of any case consultations in client record # 4.
Client # 5 was admitted into treatment April 19, 2013 and discharged on July 9, 2013. A discharge summary was due to be completed no later than July 16, 2013. The discharge summary completed for client # 5 was not dated. The facility failed to document the discharge summary within one week of discharge.
Client # 6 was admitted into treatment February 11, 2013 and discharged on April 9, 2013. A discharge summary was due to be completed no later than April 16, 2013. The discharge summary completed for client # 6 was not dated. The facility failed to document the discharge summary within one week of discharge.
Client # 7 was admitted into treatment January 14, 2013 and discharged on April 2, 2013. A discharge summary was due to be completed no later than April 9, 2013. The discharge summary completed for client # 7 was not dated. The facility failed to document the discharge summary within one week of discharge.
Client # 8 was admitted into treatment March 14, 2013 and discharged on June 20, 2013. A discharge summary was due to be completed no later than June 27, 2013. The discharge summary completed for client # 8 was not dated. The facility failed to document the discharge summary within one week of discharge.
The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The Project Director shall develop a quarterly case consultation form by 10/1/13. The Project Director shall add "case consultation" to the Chart Order to help assure all clients admitted on or after 10/1/13 will receive a timely consult. The Project Director will also review all charts open as of 10/1/13 that require a consult and will complete said form by 10/1/13. The Project Director will conduct random chart audits to ensure that compliance with case consultations has occurred.
The Project Director shall add a place for the Counselor to sign and date the discharge summary which includes a reminder that summaries must be completed within seven days of discharge. The Project Director will then conduct random audits of discharged cases to assure summaries have been completed within the appropriate time frame. |