INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 3, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, WPIC Narcotic Addiction Treatment Program 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 May 12, 2008.
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Plan of Correction
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711.92(c)(1) LICENSURE TX Plan Goals
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment, as formulated by both staff and client.
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Observations
Based on a review of client records on April 3, 2008, the facility failed to document individualized short and long-term goals in the treatment and rehabilitation plan in six of nine records reviewed, #4, 5, 6, 7, 10 and 11. The short and long-term goals were not measurable and did not include individual issues identified in the psychosocial evaluation.
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Plan of Correction
Plan of Correction:
Compliance to developing individualized treatment plans in a timely fashion will be evidenced by periodic quality reviews by the Clinical Administrator combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Particular attention will be paid to the development of realistic and measurable short and long-term goals. Training about the regulations and completion of treatment plans will occur during individual supervisory sessions conducted by the Clinical Supervisor. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Supervisor beginning no later than 5/15/08 and continuing through the course of the licensing review period.
All staff will be trained by 6/15/08
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711.92(c)(3) LICENSURE Support Service
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records on April 3, 2008, the facility failed to document proposed support services on the individual treatment and rehabilitation plan in seven of nine records reviewed, #4, 6, 7, 8, 10, 11 and 12.
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Plan of Correction
Plan of Correction:
Compliance to developing individualized treatment plans in a timely fashion will be evidenced by periodic quality reviews by the Clinical Supervisor combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Training about the regulations and completion of treatment plans will occur in individual supervisory sessions conducted by the Clinical Supervisor. Particular focus shall be placed upon including the patient's participation in appropriate support services, including 12-step fellowships among other activities as part of the plan of recovery.
Program leadership will develop a resource manual that contains community resources and will be geared specifically to the issues experienced by individuals participating in the program. The manual will be available for staff use by 7/1/08. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Supervisor beginning no later that 5/15/08 and continuing through the course of the licensing review period. All staff will be trained by 6/15/08
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711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) 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 on April 3, 2008, the facility failed to document a complete treatment and rehabilitation plan update at least every 60 days in three of nine records, #7, 9 and 16. In client records #7 and 9, the assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan was missing. Treatment plan updates only stated "resolved" or "unresolved." The last treatment plan update was missing in client record #16 . The last update was completed on December 18, 2007 .
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Plan of Correction
Plan of Correction:
Compliance to developing individualized treatment plan updates in a timely fashion will be evidenced by periodic quality reviews by the Clinical Supervisor combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Training about the regulations and completion of treatment plan updates will occur in individual supervisory sessions conducted by the Clinical Supervisor. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Clinical Supervisor beginning no later than 5/15/08 and continuing through the course of the licensing review period.
All staff will be trained by 6/15/08
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711.93(c)(1)(ii) LICENSURE Confidentiality-Staff Access to Records
711.93. Client records.
(c) Confidentiality.
(1) A written procedure shall be developed by the project director which complies with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(ii) Staff access to client records.
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Observations
Based on a review of the facility's policies and procedures on April 3, 2008, the facility failed to identify the staff that would have access to client records and provide for a system that ensures security of drug and alcohol treatment records in accordance with state law and federal regulations (71 P.S. and 42 CFR part 2 Subpart C Subsection 2.32).
The facility's policy did not identify which staff would have access to client records. WPIC staff not involved in provision of substance abuse services had the ability to identify clients as participants in substance abuse services without written consent by accessing the electronic data base.
This is a repeat deficiency from the October 2007 inspection.
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Plan of Correction
WPIC submits this plan of correction related to the licensing citations discussed and clarified in the meeting of Friday (2/29/08) in Harrisburg.
The plan focuses on the following key points:
- Access to medical records maintained on patients participating in WPIC Addiction Medicine Services (AMS) treatment programs which are licensed by the DAPL, by individuals who are concurrently treating those same patients in programs of WPIC which are not licensed by DAPL; and,
- The WPIC AMS operations manual describing such access as required by Pennsylvania State licensing standards; and,
- Plans regarding alterations and modifications to the Psych Consult system to address DAPL's stated concerns specific to that system.
1. At no time either currently, or historically, has access to confidential treatment information generated by WPIC AMS programs licensed by DAPL been permitted by anyone outside of WPIC. This includes the medical components of the University of Pittsburgh Medical Center (UPMC). WPIC will only permit access to those medical records created in its Psych Consult system and generated by its AMS programs to those individuals who are specifically permitted to have such access by the following strictures:
a. These individuals are "members" of the AMS treatment programs and are maintained on DAPL's licensing grid as such. Further, WPIC AMS ensures that these individuals have had specific training in the confidentiality of drug and alcohol treatment records as outlined in the state (4 PA Code 255.5) and federal (42 CFR part 2) laws.
b. Informed and voluntary consent from the WPIC AMS patient is obtained prior to the release of such protected health information.
2. WPIC AMS will adapt its written operations manual to better reflect the intent of the licensing standards regarding the Electronic Medical Record as per DOH Licensing Alert 1-05. This operations manual containing the policy and procedure regarding electronic medical records will be maintained by each licensed ambulatory program using the electronic medical records system. This operations manual description will:
a. Identify by position and job title, the specific WPIC staff who will access the database; the access restrictions assigned to each position, and a listing of staff with administrative privileges.
b. Describe the security system protecting the database including how access restrictions will be implemented, firewall protections, password protocols, and how and to whom temporary access would be afforded for evaluation procedures.
c. Describe the maintenance procedures addressing the location of the server, schedule for backing up the data, staff responsible for maintenance, location of back-up storage mediums, and timeframes for deletion.
3. WPIC Administration will ensure that modifications are made to the Psych Consult database as it currently exists. These modifications will include the documentation of system "user awareness," and the implementation of specific audit activities designed to monitor and address both appropriate and improper access of protected health information generated by the WPIC AMS programs licensed by DAPL. WPIC shall ensure through its Information Security Officer, the implementation and collaborative oversight with WPIC AMS leadership (in particular the facility directors of all WPIC AMS programs licensed by DAPL) of such activities involving the following steps:
a. Documentation of User Awareness.
i. A document will be presented to each user who works with patients who have protected health information generated by the WPIC AMS programs licensed by DAPL.
ii. The document will inform the user of the potential to access this information and the special confidentiality afforded to this information.
iii. The user will acknowledge that the appropriate training has been provided and that the purpose of reviewing the information is to deliver high quality integrated behavioral health care.
iv. The user will sign the document.
v. The completed document will be retained in the patient record. The signed document will expire after one year and will be re-evaluated and re-issued, as appropriate, at expiration.
b. Audit of Access and completion.
i. User access to patient records is recorded on a per-instance basis. This produces an audit trail. This audit trail will be conducted by Information Services Staff designated by the WPIC Information Security Officer, and monitored jointly by the WPIC Information Security Officer and the Clinical Administrator of Addiction Medicine Services.
ii. The audit trail will be compared to the patients who are and/or have been assigned to a WPIC program licensed by DAPL and to the documentation of user preparation and awareness of requirements for handling protected health information generated by WPIC AMS programs licensed by DAPL.
iii. The status of the document and the user access of patient information will be reviewed for completeness and appropriateness.
iv. All inconsistencies will be investigated and resolved through either corrective action or progressive disciplinary procedures.
v. The audit trails will be conducted a minimum of every third day to ensure compliance.
4. WPIC asserts that the Psych Consult electronic medical records system is compliant with the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Documentation to this effect will be sent in hardcopy form to DAPL through the mail.
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711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) 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 client records reviewed on April 3, 2008, the facility failed to ensure that an informed and voluntary consent to release information was obtained in eleven of eleven records, #1, 3, 4, 5, 6, 7, 8, 10, 11 and 12. It was possible for WPIC staff not involved in the provision of substance abuse services to identify patients as participants in those services without written consent by accessing the electronic record keeping system which contained such information.
This is a repeat deficiency from the October 2007 inspection.
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Plan of Correction
WPIC submits this plan of correction related to the licensing citations discussed and clarified in the meeting of Friday (2/29/08) in Harrisburg.
The plan focuses on the following key points:
- Access to medical records maintained on patients participating in WPIC Addiction Medicine Services (AMS) treatment programs which are licensed by the DAPL, by individuals who are concurrently treating those same patients in programs of WPIC which are not licensed by DAPL; and,
- The WPIC AMS operations manual describing such access as required by Pennsylvania State licensing standards; and,
- Plans regarding alterations and modifications to the Psych Consult system to address DAPL's stated concerns specific to that system.
1. At no time either currently, or historically, has access to confidential treatment information generated by WPIC AMS programs licensed by DAPL been permitted by anyone outside of WPIC. This includes the medical components of the University of Pittsburgh Medical Center (UPMC). WPIC will only permit access to those medical records created in its Psych Consult system and generated by its AMS programs to those individuals who are specifically permitted to have such access by the following strictures:
a. These individuals are "members" of the AMS treatment programs and are maintained on DAPL's licensing grid as such. Further, WPIC AMS ensures that these individuals have had specific training in the confidentiality of drug and alcohol treatment records as outlined in the state (4 PA Code 255.5) and federal (42 CFR part 2) laws.
b. Informed and voluntary consent from the WPIC AMS patient is obtained prior to the release of such protected health information.
2. WPIC AMS will adapt its written operations manual to better reflect the intent of the licensing standards regarding the Electronic Medical Record as per DOH Licensing Alert 1-05. This operations manual containing the policy and procedure regarding electronic medical records will be maintained by each licensed ambulatory program using the electronic medical records system. This operations manual description will:
a. Identify by position and job title, the specific WPIC staff who will access the database; the access restrictions assigned to each position, and a listing of staff with administrative privileges.
b. Describe the security system protecting the database including how access restrictions will be implemented, firewall protections, password protocols, and how and to whom temporary access would be afforded for evaluation procedures.
c. Describe the maintenance procedures addressing the location of the server, schedule for backing up the data, staff responsible for maintenance, location of back-up storage mediums, and timeframes for deletion.
3. WPIC Administration will ensure that modifications are made to the Psych Consult database as it currently exists. These modifications will include the documentation of system "user awareness," and the implementation of specific audit activities designed to monitor and address both appropriate and improper access of protected health information generated by the WPIC AMS programs licensed by DAPL. WPIC shall ensure through its Information Security Officer, the implementation and collaborative oversight with WPIC AMS leadership (in particular the facility directors of all WPIC AMS programs licensed by DAPL) of such activities involving the following steps:
a. Documentation of User Awareness.
i. A document will be presented to each user who works with patients who have protected health information generated by the WPIC AMS programs licensed by DAPL.
ii. The document will inform the user of the potential to access this information and the special confidentiality afforded to this information.
iii. The user will acknowledge that the appropriate training has been provided and that the purpose of reviewing the information is to deliver high quality integrated behavioral health care.
iv. The user will sign the document.
v. The completed document will be retained in the patient record. The signed document will expire after one year and will be re-evaluated and re-issued, as appropriate, at expiration.
b. Audit of Access and completion.
i. User access to patient records is recorded on a per-instance basis. This produces an audit trail. This audit trail will be conducted by Information Services Staff designated by the WPIC Information Security Officer, and monitored jointly by the WPIC Information Security Officer and the Clinical Administrator of Addiction Medicine Services.
ii. The audit trail will be compared to the patients who are and/or have been assigned to a WPIC program licensed by DAPL and to the documentation of user preparation and awareness of requirements for handling protected health information generated by WPIC AMS programs licensed by DAPL.
iii. The status of the document and the user access of patient information will be reviewed for completeness and appropriateness.
iv. All inconsistencies will be investigated and resolved through either corrective action or progressive disciplinary procedures.
v. The audit trails will be conducted a minimum of every third day to ensure compliance.
4. WPIC asserts that the Psych Consult electronic medical records system is compliant with the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Documentation to this effect will be sent in hardcopy form to DAPL through the mail.
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