INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 21, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Northern Tier Counseling, 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.
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Observations
Based on the review of 10 client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 4 records reviewed. Additionally, there were 3 client records that had consent to release forms that did not identify the specific information that would be released.
Client #1 was admitted on 07/06/17 and was still active at the time of the inspection. There was a consent to release information form to the funding source dated 8/10/17; however, the release form did not indicate what specific information would be released.
Client #2 was admitted on 03/20/17 and was still active at the time of the inspection. There was a letter sent to the client's physician dated 5/1/17; however, there was no client-signed consent to release information form in the record prior to the disclosure of information.
Client #4 was admitted on 07/11/17 and was still active at the time of the inspection. There was a consent to release information form to the funding source dated 711/17; however, the release form did not indicate what specific information would be released.
Client #5 was admitted on 10/29/15 and was discharged on 06/26/17. There was documentation that contact was made with the funding source over the course of the client's treatment episode; however, there was no client-signed consent to release information form in the record prior to the disclosure of information.
Client #6 was admitted on 09/28/16 and was discharged on 01/13/17. There was a letter sent to the client's physician dated 5/1/17; however, there was no client-signed consent to release information form in the record prior to the disclosure of information. Additionally, there were sessions conducted on 11/15/16 and 11/29/16 where the client's spouse attended, but there was no client-signed consent to release information form in the record prior to both sessions.
Client #7 was admitted on 03/13/17 and was discharged on 09/06/17. There were consent to release information forms to two different funding sources both dated 3/13/17; however, neither of the release forms indicated what specific information would be released.
Client #9 was admitted on 06/23/16 and was discharged on 06/21/17. There was a letter sent to the client's employer dated 9/14/16; however, the client did not sign a consent to release information form for the employer until 12/1/16.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Northern Tier Counseling
Plan of Correction
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.
Observations: #276
On 10/12/17 a staff meeting will be held with both Administrative Staff and Drug and Alcohol Staff. The release of Information form will be reviewed. Regulation 255.5 will be printed and disseminated to all those present for the staff meeting. Any relevant staffs that are absent will be met with 1:1 as soon as possible following this meeting. All newly hired staff from the date of 10/12/17 will have specific orientation to 255.5 and the Release of Information form.
With respect to the citation noted for client's #7, #4, and #1; all staff and supervisors will be trained as to why reasons must be noted on the release of information as to what information may be released. The protocol explaining this process will be reviewed and updated to reflect that a reason must be checked for the release to be considered complete and appropriate.
With respect to the citation noted for clients #9, #6, #5, and #2; effective immediately following inspection on 9/21/17- all documentation requested by a third party or the client is reviewed and co-signed by the Program manager. No information will be permitted to leave the agency without first being reviewed by the Program Manager or CEO to ensure all aspects of that client's confidentiality are maintained. During the staff meeting on 10/12/17 additional training will be completed with all clinical and administrative staff to again review 255.5 regulations, the purpose of the release, all aspects of said release that need to be completed to make that release authentic. Furthermore; training and education as well as disciplinary action have been reviewed with members of the Administrative and Clinical team.
It should also be noted that effective 10/16/17 supervisory responsibilities within the Drug and Alcohol program are being re- assigned to a different member of management. The new Program Manager will have more time to devote to daily supervision. A renewed focus on monthly compliance checks will also be in effect immediately. Each month- during the staff meeting held bi-monthly- charts will be pulled at random and reviewed by the Program Manager to ensure compliance.
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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 10 client records, the facility failed to provide a complete client record, which is to include complete record of services, case consultation notes, aftercare plans, and follow-up information in 5 records reviewed.
Client #1 was admitted on 07/06/2017 and was active at the time of the inspection. There was a 8/10/17 individual session progress note in the record; however, there was no entry in the record of service.
Client #5 was admitted on 10/29/2015 and was discharged on 06/26/2017. The record did not contain documentation of an aftercare plan and any follow-up information.
Client #6 was admitted on 09/28/2016 and was discharged on 01/13/2017. The record did not contain documentation of any case consultation notes.
Client #9 was admitted on 06/23/2016 and was discharged on 06/21/2017. The record did not contain documentation of any follow-up information.
Client #10 was admitted on 04/13/2017 and was discharged on 09/07/2017. The record did not contain documentation of an aftercare plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Observation#1889
Effective 10/12/17 a review of the Drug and Alcohol regulations for Outpatient Level of Care will begin. All Administrative and Clinical staff will begin to review each section of regulations related to their clinical documentation and charting expectations. Forms will be reviewed section by section with assigned regulations attached.
A renewed focus on weekly staff supervision will take place starting on Monday 10/16/17. Monthly compliance checks will occur within scheduled staff meetings to review current/open charts within the program. Supervisory/education notes will be taken by the Program Manager during weekly supervisions to ensure the staff are able to voice questions or lack of understanding they may have relating to any process/protocol within the department. Disciplinary action will be reviewed if improvement is not noted within 90 days.
Client #1- chart was returned to therapist of record to review and correct. Record of service was corrected and completed and returned to supervisor for review by 10/13/17.
Client #5 & #10- Both charts lacked an after care plan. Both charts are discharged at this point and therapist of record was unable to reach the client post inspection to attempt to work on after care plan with the client. After care plans were completed by the therapist of record by 10/13/17 based on therapists recommendations.
Client #6- Case consultation was completed with out client participation and reviewed at the staff meeting on 10/12/17.
Client #9- Follow up protocol has been reviewed with staff during the 10/12/17 staff meeting. A follow up attempt was made to this client the week of 10/2/17. To date- no response has been received from the client.
It should also be noted that effective 10/16/17 supervisory responsibilities within the Drug and Alcohol program are being re- assigned to a different member of management. The new Program Manager will have more time to devote to daily supervision.
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