Observations
Based on a review of client records on March 21, 2017, the facility failed to obtain a valid consent to release information in client records #1 & 7.
Client #1 was admitted on 11/4/16 and was an active client at the time of the licensing inspection. A consent to release to a person dated 11/4/16 did not specify the person or agency to whom information was to be disclosed. Additionally, there was no valid consent for the client's funding source.
Client #7 was admitted on 8/4/16 and was discharged on 12/2/16. A facsimile transmission sheet dated 9/26/16 indicated that identifying information was released to a government agency, however no consent to release to this agency was documented in the record.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will meet with clinician on April 10th, 2017 at 3pm to review the chart. Clinician will meet with the identified client on Monday April 10, 2017 at 6pm to review and sign all identified consents that need to be corrected. consents.Clinical Supervisor will conduct a training on April 12, 2017 with all Rehab After Work staff on confidentiality reviewing state code Pa 255.5 and explaining the 5 main aspects that can be disclosed. Clinical Supervisor will also focus on the needs for all Rehab After Work client to provide written consent to disclose ANY of the following allotted information:
1-Whether the client is or is not in treatment.
2-The prognosis of the client.
3-The nature of the project.
4-A brief description of the progress of the client.
5-A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such.
To ensure ongoing compliance with confidentiality, the clinical supervisor will conduct monthly random chart audits to ensure all consent forms are appropriately documented within the chart. |
Observations
Based on a review of client records on March 21, 2017, the facility failed to update the treatment plan every 60 days in client records, #3, 6 & 7.
Client #3 was admitted on 7/20/16 and was an active client at the time of the licensing inspection. A treatment plan update was documented on 10/5/16. A treatment plan update was due by 12/5/16, but was not documented until 1/19/17.
Client #6 was admitted on 3/14/16 and was discharged on 12/2/16. A treatment plan update was documented on 7/1/16. A treatment plan update was due by 9/1/16 but was not documented until 9/9/16. Additionally, a treatment plan update was due by 11/9/16 but was not documented at the time of the licensing inspection.
Client #7 was admitted on 8/4/16 and was discharged on 12/2/16. A treatment plan update was documented on 9/16/16. A treatment plan update was due by 11/16/16 but was not documented at the time of the licensing inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will discuss this regulation to update every 60 days in staff meetings with all clinical staff.
Clinical supervisor will conduct chart audits monthly to ensure that treatment plans are being updated every 60 days in accordance with state regulations.
Clinical supervisor will review this regulation during weekly clinical supervision with all clinical staff in an attempt to remain in compliance.
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Observations
Based on a review of client records on March 21, 2017, the facility failed to provide treatment according to the client's individualized treatment plan in client records, #1, 3, 4, 6 & 7.
Client #1 was admitted on 11/4/16 and was an active client at the time of the licensing inspection. Two treatment plan updates dated 12/19/16 and 2/3/17 indicated IOP group counseling, 4 times per week, however the record of service indicated that group was provided on the following dates:
12/28, 12/30, 1/9, 1/13, 1/16, 1/20, 1/25, 1/30, 2/3 and 2/17/17; there is no documentation of services provided to the client since 2/17/17.
Client #3 was admitted on 7/20/16 and was an active client at the time of the licensing inspection. A treatment plan update dated 10/5/16 indicated IOP group counseling, 4 times per week, however the record of service indicated group was provided on the following dates:
10/6, 10/10, 10/ 17, 10/19, 10/26, 11/1, 11/7, 11/9, 11/10, 11/14, 11/28/16 and no documentation of services provided to the client until 1/19/17.
Client #4 was admitted on 8/30/16 and was discharged on 11/23/16. The comprehensive treatment plan dated 8/30/16 and a treatment plan update dated 10/30/16 indicated IOP group counseling, 4 times per week, however the record of service indicated group was provided on the following dates:
8/31, 9/5, 9/8, 9/14, 9/15, 9/21, 9/22, 10/6, 10/10, 10/12, 10/13, 10/17, 10/19, 10/20, 10/26, 10/27, 11/2, 11/7, 11/16, 11/21, 11/22/16.
Client #6 was admitted on 3/14/16 and was discharged on 12/2/16. A treatment plan update dated 9/9/16 indicates group counseling 1 time per week however the record of service contains periods where there is no documentation of services provided to the client; specifically from 9/23/16 to 10/19/16 and also from 10/19/16 to 12/2/16. The facility did not document in the chart to explain why the client was not attending treatment during these timeframes.
Client #7 was admitted on 8/4/16 and was discharged on 12/2/16. A treatment plan update dated 9/16/16 indicates group counseling 2 times per week however, there is no documentation of services provided to the client from 11/2/16 to 12/2/16. The facility did not document in the chart to explain why the client was not attending treatment during this timeframe.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will conduct monthly chart audits with all clinical staff.
Clinical Supervisor will discuss the importance of documenting consistency of treatment, if there is a break in treatment,( case consultation notes, progress notes, and record of service) in weekly staff meetings.
Clinical Supervisor will review this regulation in weekly clinical supervision sessions with all clinical staff as part of remaining in compliance. |