INITIAL COMMENTS
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This report is a result of complaint investigation conducted on October 20, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the allegations made against Treatment Trends, Inc. Keenan House were unsubstantiated. However, based on the findings of the on-site inspection, Treatment Trends, Inc. Keenan House 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)(3) 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:
(3) Purpose of disclosure.
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Observations
Based on the review of client records, the facility failed to document a consent to release that allowed for the disclosure of the discharge summary and exceeded 4 Pa. Code 255.5 in three of three records reviewed.
The findings include:
Eight client records were reviewed on October 20, 2011. Six records reviewed required a consent to release for a probation and parole officer. The facility released a discharge summary to a probation and parole officer that exceeded 4 Pa. code 255.5 in client records # 2, 3, and 6; the facility failed to obtain the client's consent to include the release of the discharge summary in patient records # 2, 3, and 6.
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Plan of Correction
It is the intention of TTI to observe the Confidentiality regulations as specified in 709.28(c)(3) and not exceed 4 Pa. Code 255.5. As of November 1, 2011 the Discharge Summary which was previously sent to probation/parole officers will no longer be sent and a new Parole/Probation "Short Form" will take it's place that is in compliance with 4 Pa. Code 255.5 as specified within 709.28(c)(3). This information will be disseminated through our regular staff meeting on 11/7/2011 thus informing the clinical staff and Unit Secretary of the new "Short Form". The Unit Secretary forwards both documents to the Clinical Director for review and signature prior to mailing them and is responsible for ensuring this deficiency does not reoccur. She is responsible to ensure both documents are addressed correctly (Discharge Summary to the file and the Short Form to the P.O.). During that same meeting time will be utilized to train staff of the allowances and limitations afforded by 4Pa. Code 255.5 to ensure they know about the new form and what is allowed to be released. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation within the required time frame in two of four client records.
The findings include:
Eight client records were reviewed on October 20, 2011. According to the facility's counselor handbook, a biopsychosocial assessment shall be completed within 10 working days of a client's admission to the program. Four client records were reviewed for psychosocial evaluations. Two of the four were not completed within the required 10 working days, specifically, client # 4 and 8.
Client # 4 was admitted on September 19, 2011. A psychosocial evaluation was due by September 29, 2011. The facility completed the psychosocial evaluation on October 13, 2011. This was completed 14 days late.
Client # 8 was admitted on June 28, 2011. A psychosocial evaluation was due by July 8, 2011. The facility completed the psychosocial evaluation on July 11, 2011. This was completed 3 days late.
These findings were reviewed and confirmed with the facility director, clinical supervisor, and the director of vocational services.
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Plan of Correction
Two charts were found to contain Biopsychosocials that were late which is in violation of 709.51(b)(6). To ameliorate this violation the following will occur by November 7, 2011: The Counselor Handbook will be reviewed in staff meeting specifically regarding time allowences for clinical documents such at the Biopsycosocial, Clinical Evaluation, Inital and Updated Treatment Plans, etc.. Moving forward, the additional action will be addoped that the Clinical Director will double check the paperwork after it flows through it's present system which is an inital check by the Clinical Supervisor to ensure staff is keeping to the necessary set dates of completion. |