This report is a result of an on-site licensure renewal inspection, and an inspection conducted for the approval to use a narcotic agent, specifically Buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on July 21, 2015 through July 23, 2015, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Marworth 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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Observations
Based on a review of client records and a review of Marworth's "Authorization for Release of Information" form, the facility failed to provide clients with an informed and voluntary consent to release which adhered to 42 CFR and State Law - 71 P.S. subsection 1690.112.
The findings include:
Nineteen electronic client records were reviewed on July 21, 2015 through July 23, 2015. Based on a review of these records, Marworth's "Authorization for Release of Information" form was observed to be out of compliance with 42 CFR and State Law - 71 P.S. subsection 1690.112.
The "Authorization for Release of Information" form did not contain documentation of the client's right to verbally revoke a signed consent for the release of information. The facility ' s " Authorization for Release of Information" form documented, "This authorization is subject to revocation, in writing, at any time except to the extent that action has been taken in reliance thereon."
In addition, the "Authorization for Release of Information" form documents "Note: If patient is under 14 years of age and is not an emancipated minor, the parent or guardian must sign." Although the facility is not counseling substance abusing minors, Marworth's "Authorization for Release of Information" form is misinforming clients of the rights of minors in drug and alcohol treatment.
Lastly, Marworth failed to demonstrate that a copy of client consent was offered to the client and a copy maintained in the client record. Marworth's "Authorization for Release of Information" form contained the statement: "Copy of completed authorization form must be given to patient." However, upon interview with Quality Assurance it was disclosed that not all clients are given a copy of the "Authorization for Release of Information" form.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Marworth's Vice President will have posted in each admissions office a statement: "a patient has the right to a copy of any and all authorizations for the release of information from the medical record. A copy of the authorization is also maintained in the medical record." This posting will be in place by 9/4/2015.
The authorization to release information will be amended to delete the sentence "if patient is under the age of 14 and is not an emnacipated minor, the parent or guardian must sign." This is the responsibility of the Vice President of Marworth and will be effective 9/30/2015 with the printing of revised authorization.
The citation for verbal revocation will be addressed as follows:The following statement will be added to authorization "This consent is subject to revocation at any time except to the extent that the program or person which is to make the disclosure has already acted in reliance on it.Acting in reliance includes the provision of treatment services in reliance on a valid consent to disclose information to a third party payer."This statement addition will be completed under the direction of Marworth Vice President effective 9/30/2015.
The POC for all three deficiencies will not recurr since a new form will be developed with the appropreiate revisions and the old forms will be destroyed. |