INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on May 4, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, STR Addiction Counseling, LLC. 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) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in two of fourteen client records reviewed.
Client #1 was admitted on January 16, 2021 and was an active client at the time of the inspection. A release of information form to a governmental agency, signed and dated by the client on March 5, 2021, allowed for the release of medical records, clinical notes, discharge summary and the medication list, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #4 was admitted on March 10, 2020 and was discharged on August 4, 2020. A release of information form for a laboratory, signed and dated by the client on March 10, 2020, did not document the specific information to be disclosed.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Director of Quality Assurance and Executive Director create a release for government agencies, specifically highlighting the areas of 255.5. Staff will be trained on the proper use of consents and the guidelines of 255.5 on 5/26/21. This training will be conducted on a bi-annual basis to ensure compliance.
Director of Quality Assurance will weekly auditing client consents to ensure compliance.
Client #1 is still in services, the release was revoked and the proper release was signed.
Client #4 is no longer in services. |
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 must 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 project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that documented the purpose of disclosure in one of fourteen client records reviewed.
Client #4 was admitted on March 10, 2020 and was discharged on August 4, 2020. A release of information form for a laboratory, signed and dated by the client on March 10, 2020, did not document the purpose of disclosure.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Director of Quality Assurance and Executive Director will conduct a training with staff on 5/26/21. During this time, they will be trained on consents. This training will be conducted bi-annually to ensure compliance.
Director of Quality Assurance will conduct weekly audits of consents to ensure compliance.
Client #4 is no longer in services. |