INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 3-4, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Counseling Center of Mercer County 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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709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the annual report, the facility failed to make available to the public an annual report that included a financial statement of income and expenses.
The findings include:
The annual report for the 2012/2013 fiscal year was reviewed on December 4, 2013. The annual report did not include a financial statement of income and expenses.
The Project Director was interviewed on December 4, 2013 and confirmed the findings.
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Plan of Correction
Upon completion of the Audit, a copy of the budget for the D/A Program which includes the income and expenses will be attached to the Annual report. This is already presented to the board during the review of the Annual audit. The attachment would be available for the public.
The Facility Director will be responsible to monitor compliance with this regulation.
Target Date for completion is January 31,2014.
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709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of client records and the client handbook, the facility failed to provide documentation that clients were informed of their rights in ten of ten client records.
The findings include:
Ten client records and the client handbook were reviewed on December 3-4, 2013. Ten client records required documentation that the client was informed of their rights. The facility failed to document in client records # 1, 2, 3, 4, 5 , 6, 7, 8, 9 and 10 that the clients were informed that they had the following rights:
(3) The right to inspect his own records. That the project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.
(4) The client has the right to appeal a decision limiting access to his records to the project director.
(5) The client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records.
(6) The client has the right to submit rebuttal data or memoranda to his own records
The Compliance Officer was interviewed on December 4, 2013 and confirmed the findings.
This is a repeat citation.
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Plan of Correction
The following rights will be added to the Client Rights and Responsibilities information packet that each client receives:
- To never be discriminated against based on age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
- To inspect your own records and know who else has accessed them. Portions of the records may be temporarily removed prior to the inspection if it is determined that the information may be detrimental if presented to you.Reasons for removing sections shall be documented and kept on file.
- To appeal a decision limiting access to your records.
- To request the correction of inaccurate, irrelevant, outdated or incomplete information from your records.
- To submit rebuttal data or memoranda to your own records.
Compliance Officer added the changes to the packet on 12/4/13 for immediate release to clients.
It will be the responsibility of the fiscal technition to review the packet with the client at the time of registration. The client will sign off on the EMR form indicating receipt of the packet. |
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 the review of client records, the facility failed to document a complete client record that included case consultation notes and/or aftercare plans in five of six client records.
The findings include:
Ten client records were reviewed on December 3-4, 2013. Six client records were reviewed for documentation of case consultation notes and/or aftercare plans. The facility failed to document case consultation notes in client records # 1, 2, 3 and 4. The facility failed to document an aftercare plan in client record # 6.
Client # 1 was admitted on March 28, 2013. Case consultation notes were due to be completed by June 30 and September 30, 2013. There were no case consultation notes documented as of December 4, 2013.
Client # 2 was admitted on May 22, 2013. The record included case consultation notes that were signed and dated by the counselor on July 25 and November 20, 2013. The facility failed to document that clinical/facility staff had participated in the case consultations. The case consultations were co-signed by a staff member but not until July 29 and December 2, 2013 respectively.
Client # 3 was admitted on June 25, 2013. The record included a case consultation note was signed and dated by the counselor September 16, 2013. The facility failed to document that clinical/facility staff had participated in the case consultation. The case consultation was co-signed by a staff member but not until September 18, 2013.
Client # 4 was admitted on March 17, 2013. Case consultation notes were due to be completed by June 30 and September 30, 2013. There were no case consultation notes documented as of December 4, 2013.
Client #6 was admitted on March 28, 2013 and successfully discharged on May 29, 2013. The aftercare plan, signed by the client on May 29, 2013, did not include a contact person or the reentry process.
The Project Director, Clinical Supervisor and the Compliance Officer were interviewed on December 4, 2013 and did not dispute the findings.
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Plan of Correction
Beginning January 1,2014, the electronic form will be adapted to include the names of all participants in order to document inclusion of their input to the consult. The clinicians will no longer be required to sign the form. The assigned clinician will sign the document after review at the weekly treatment team.
The quarterly audit will review this area and assure that the consults are completed and timely. The Clinical Supervisor will be responsible for assuring that this change is implimented consistantly.
A training will be held by January 31,2014 to review aftercare planning and appropriate documentation. Special emphasis will be placed on completing the portion of the current form which addresses the readmission process, including name of the Intake worker and admission process.
The Clinical Supervisor will be responsible for providing training and reviewing aftercare plans. The quarterly audit will also review for completion.All charts should be in compliance by 2/1/14. |