INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 29, 2015 by staff from the Division of Drug and Alcohol Program Licensure. 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) 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 adhere to the limitations imposed under 4 Pa. Code 255.5 in one of twelve records reviewed and/or allowed for the release of information without a signed consent to release information form from the client..
The findings include:
4 Pa. Code states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following:
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Twelve client records were reviewed on December 29, 2015. The facility released information that exceeded the limitations imposed under 4 Pa. Code 255.5 in client record #5.
Client #5 was admitted on June 4, 2015 and discharged on August 27, 2015 - A progress report dated August 27, 2015 to the client's probation officer, a government agency, referenced the discharge of the client. The report included the specific name of the drug that the client relapsed on, which exceeds 4 PA Code 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To prevent exceeding the allowances of Confidentiality regulation 709.28(c)(3), a separate discharge form was developed in 2011 restricting information released to parole/probation officers. This form which complied with 4 Pa. code 255.5 will be reviewed with clinical staff by the Clinical Supervisor during the staff meeting scheduled for Monday January 25th,2016. Regulation 709.28(c)(e) will also be discussed to retrain staff on the limitations and allowances of this code. The Clinical Director shall review each summary and sign each summary to ensure the limitations of the regulation is not breached. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 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 30 days in five of twelve client records reviewed.
The findings include:
Twelve client records requiring documentation of a treatment plan update were reviewed during the renewal inspection on December 29, 2015. The facility failed to document a treatment plan update at least every 30 days in client records #1, 3, 4, 5 and 10.
Client # 1 was admitted on 10/6/2015 and is still an active client. A master treatment plan was completed 10/15/2015. Treatment plan updates were due 11/15/2015 and 12/15/2015 and the chart was missing both updates as of the date of the licensing inspection.
Client # 3 was admitted on 5/21/2015 and discharged on 11/18/2015. A treatment plan update was due no later than 10/30/2015 however, it was not done until 11/17/2015.
Client # 4 was admitted on 7/17/2015 and discharged on 10/12/2015. A treatment plan update was due no later than 9/11/2015 however, it was not done until 9/25/2015.
Client # 5 was admitted on 6/4/2015 and discharged 8/27/2015. A treatment plan update was due no later than 8/15/2015. The chart was missing the update as of the date of the licensing inspection.
Client #10 was admitted on 8/28/2015 and discharged 12/7/2015. A master treatment plan was completed 8/31/2015. A treatment plan update was due no later than 10/1/2015 and it was missing in the chart. The only treatment update in the chart was dated 11/5/2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Five records failed to contain a Treatment Plan update at least every 30 days which violates standard 709.52(b). The following will occur during the staff meeting scheduled for Monday January 25th 2016. The Clinical Supervisor will review the Treatment Pan update policy and standard with staff. Clinical Supervisor will introduce staff to the new tracking grid which highlights which Treatment Plans are due. Charts will be audited weekly by the clinical supervisor and/or director beginning 2/2/2016. |