INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on 8/11/2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Spring-Ford Counseling Services, Inc. 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) 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 an informed and voluntary consent that includes all of the required content required by regulation for the disclosure of information contained in five of nine client records reviewed.
The findings include:
Limitations imposed at 4 Pa. Code, states the following: The project may disclose information as set forth in with the consent of a client, in writing, the information to an insurance company, health, or hospital plan or facsimile thereof, which has contracted with the client to provide or will provide medical, hospital, disability or similar benefits.
Nine client records requiring informed and voluntary consent to release information forms were reviewed on 8/11/2015. The facility failed to obtain a written informed and voluntary consent to release information to the funding source in client records # 1, 3, 5, 6 and 7.
Client # 1 was admitted on 6/17/2015 and was still an active client at the time of the inspection. The facility failed to obtain a written informed and voluntary consent to release information to the client's funding source. The facility billed the client's insurance company for services rendered on 8/5/2015, 7/22/2015 and 7/15/2015.
Client # 3 was admitted on 6/18/2015 and was still an active client at the time of the inspection. The facility failed to obtain a written informed and voluntary consent to release information to the client's funding source. The facility billed the client's insurance company for services rendered on 8/6/2015, 7/23/2015 and 7/9/2015.
Client # 5 was admitted on 12/23/2014 and was discharged on 3/19/2015. The facility failed to obtain a written informed and voluntary consent to release information to the client's funding source. The facility billed the client's insurance company for services rendered on 3/19/2015, 2/19/2015 and 2/5/2015.
Client # 6 was admitted on 2/17/2015 and was discharged on 5/15/2015. The facility failed to obtain a written informed and voluntary consent to release information to the client's funding source. The facility billed the client's insurance company for services rendered on 3/17/2015, 3/10/2015 and 2/3/2015.
Client # 7 was admitted on 9/29/2014 and was discharged on 1/29/2015. The facility failed to obtain a written informed and voluntary consent to release information to the client's funding source. The facility billed the client's insurance company for services rendered on 1/29/2015, 1/13/2015 and 1/7/2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.28 (c)
As of 9/18/2015, the Clinical Coordinator, has developed a release of information form that allows the agency to provide the following information to funding source: whether the client is or is not in treatment, the prognosis of the client, the nature of the project, the progress of the client, and whether the client has relapsed into drug or alcohol abuse and the frequency of this relapse. The Clinical Coordinator will inspect files immediately following the initial session to ensure consents forms have been signed and dated. Files will be reviewed by Clinical Coordinator on monthly basis. Client # 1 was discharged on 8/19 and signed a consent at that time allowing us to provide information to his insurance company so that the agency may bill for services. Client # 3 was discharged on 9/10 and did not sign a consent due to agency error. The Clinical Coordinator has addressed this with the Office Administrator and assigned Therapist.
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709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to document a consent to treatment upon intake in two of nine client records reviewed.
The findings include:
Nine client records requiring documentation of consent to treatment upon intake were reviewed on 8/11/2015. The facility failed to document a consent to treatment upon intake in client records # 2 and 6.
Client # 2 was admitted on 5/20/2015 and discharged on 7/1/2015. A documented consent to treatment was not obtained from the client.
Client # 6 was admitted on 2/17/2015 and discharged on 5/15/2015. A documented consent to treatment was not obtained from the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.91 (b) (4)
By 9/30/15, the Clinical Coordinator will inform all treatment providers that they are expected to review the forms that must be signed and dated and kept in the treatment files. The Clinical Coordinator will inspect files immediately following the initial session to ensure that all necessary forms have been signed and dated. In the event that a form is missing from a file at the time of the initial session, reserve copies will be available to treatment providers.
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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 maintain documentation that individual treatment and rehabilitation plans were developed with the client in three of nine client records reviewed.
The findings include:
Nine client records requiring documentation that individual treatment and rehabilitation plans were developed with the client were reviewed on 8/11/2015. There was no documentation that individual treatment plans were developed with the client in client records # 3, 5 and 7.
Client # 3 was admitted to treatment on 6/18/2015. There was no documentation that the client's individual treatment and rehabilitation plan dated 8/7/2015 was completed with the client.
Client # 5 was admitted to treatment on 12/23/2014. There was no documentation that the client's individual treatment and rehabilitation plan dated 2/5/2015 was completed with the client.
Client # 7 was admitted to treatment on 9/29/2014. There was no documentation that the client's individual treatment and rehabilitation plan dated 1/24/2015 was completed with the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.92 (a)As of this date 9/14/15, the Clinical Coordinator has informed all treatment providers that they are expected to review treatment planning procedures, specifically the importance of developing plans and updates with the clients. Clinical Coordinator has developed an treatment plan update form that includes a client signature and date line. This form is included in any new clients packet. Clinical Coordinator will inspect files on a monthly basis. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) 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, the facility failed to document a treatment plan update at least every 60 days in two of four client records reviewed.
The findings include:
Four client records requiring documentation of a treatment plan update were reviewed during the renewal inspection on 8/11/2015. The facility failed to document a treatment plan update at least every 60 days in client records # 4 and 7.
Client # 4 was admitted on 5/21/2015 and was still an active client at the time of the inspection. The client's last treatment plan was completed on 5/21/2015.
Client # 7 was admitted on 9/29/2014 and discharged on 1/29/2015. The client's last two treatment plans were completed on 1/29/2015 and 9/24/2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.92 (b)
As of this date 9/14/15, the Clinical Coordinator has informed all treatment providers of the importance of treatment plan updates as well as review the procedure for utilization of the update forms. The Clinical Coordinator will inspect files on monthly basis and remind treatment providers when updates are due at time of chart review. Clinical Coordinator has also listed timeframes and due dates for DAT clients and given to therapists, however Clinical Coordinator will continue to chart review and remind therapist when needed.
Client #4 was discharged on 8/13/15, 2 days after inspection. At that point Aftercare plan was developed. Therapist did not update treatment plan due to his discharge.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the project failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in four of ten client records reviewed.
The findings include:
Ten client records were reviewed for counseling services on 8/11/2015. The project failed to ensure that clients received counseling services according to the client's individual treatment and rehabilitation plan in client records # 3, 4, 5 and 9.
Client record # 3 contained a treatment plan dated 6/18/2015 that identified the counseling services to be provided as individual therapy sessions 1 time per week. The only individual therapy sessions scheduled for the client the weeks of 6/28/2015 - 8/1/2015 were on 7/9/2015 and 7/23/2015.
Client record # 4 contained a treatment plan dated 5/21/2015 that identified the counseling services to be provided as individual therapy sessions 1 time per week. The only individual therapy sessions scheduled for the client the weeks of 6/28/2015 - 8/1/2015 were on 7/2/2015 and 7/30/2015.
Client record # 5 contained a treatment plan dated 12/9/2015 that identified the counseling services to be provided as individual therapy sessions 1 time per week. The only individual therapy sessions scheduled for the client the weeks of 12/28/2014 - 1/31/2015 were on 1/8/2015 and 1/22/2015.
Client record # 9 contained a treatment plan dated 11/19/2014 that identified the counseling services to be provided as individual therapy sessions 1 time per week. The only individual therapy sessions scheduled for the client the weeks 11/30/2014 - 1/3/2015 were on 12/17/2014 and 12/31/2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.92 (c)
As of 9/14/15, the Clinical Coordinator has informed all treatment providers of the importance of developing a treatment plan update with the client anytime the client's services change and no longer reflect the goals, objectives and strategies included in the initial treatment plan. The Clinical Coordinator will regularly inspect files, 1x per month to ensure that treatment plans and updates are consistent with the client's actual treatment. Client #4 was discharged 8/13/15, 2 days after inspection, updated treatment plan was not developed due to discharge. Client #3 an updated treatment plan was developed by therapist and discussed with client on September 10, 2015, client is now discharged.
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709.17(a)(1) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
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Observations
Based on a review of administrative documentation, the facility failed to comply with the directive issued by the Department requiring the facility to develop and implement policies and procedures for the reporting of unusual incidents.
The findings include:
As per the directive within Chapter 709 Subchapter C enacted on 10/18/2014, the facility was required to develop and implement policies and procedures for the reporting of unusual incidents. The facility's administrative records were reviewed for documentation of policies and procedures for the reporting of unusual incidents on 8/11/2015. As of the date of the inspection, the facility has not developed policies and procedures for the reporting of unusual incidents.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.17 (a) (1)
By 9/30/15, the Director and Clinical Coordinator will develop policies and procedures for the reporting of unusual incidents. The Clinical Coordinator will ensure that all treatment providers are trained on how to report unusual incidents and will oversee that treatment providers sign a form explaining these policies and procedures. A copy will be provided to the treatment provider as well as placed in their employee files.
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