INITIAL COMMENTS
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This report is a result of a complaint investigation conducted on June 10 through July 21, 2020, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the investigation, Avenues Recovery Center of Bucks 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 investigation and a plan of correction is required.
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Plan of Correction
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709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
The facility failed to limit correspondence to the employer of client #1 to what is permitted by 4 Pa. Code 255.5 (a) 6.
On January 8, 2019 the facility submitted a facsimile to the employer of client #1. This document contained a description of the client ' s specific addiction issues, the diagnosis, and the presence of positive urine screens.
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Plan of Correction
The Quality Assurance Liaison will be responsible for ensuring that the staff only uses the approved PA Code 255.5 (Projects and coordinating bodies: disclosure of client-oriented information) Release of Confidential Information form to limit correspondence to employers to ensure that what is released is specific to what the code allows to be sent/communicated on the patient's behalf to ensure protection of client confidentiality. The Quality Assurance Liaison along with the Facility Director will retrain staff on the 004 PA 255.5 Code with all staff to be sure that all are educated on the policy that Avenues has put in place. |
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
The facility failed to obtain a valid consent to release information prior to the release of information to the employer of client #1.
Client #1 was admitted on 12/17/2018 and discharged on 2/8/2019. It was determined that the facility released client identifying information to the employer of client #1 without obtaining the client ' s written consent. A facsimile transmission, dated January 8, 2019, was discovered which was sent by the facility to the employer however no consent to release information was found for the employer.
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Plan of Correction
The Quality Assurance Liaison is responsible for ensuring that all clients have proper signed Releases of Confidential Information on patient's behalf before staff submits/corresponds with any person the client asks. Although verbal consent was given, staff was made aware this is not enough to fulfill requests when the request is going to a third party. The Quality Assurance Liaison along with the Facility Director will retrain staff on the 004 PA Code 255.5 (Projects and coordinating bodies: disclosure of client-oriented information) with all staff to be sure that all are educated on the policy that Avenues has put in place and reiterate that verbal consents must not be accepted and that they must also be in writing. |
709.83(a)(3) LICENSURE Client records
709.83. 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:
(3) Client-related correspondence.
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Observations
The facility failed to include all client-related correspondence in the client record.
On January 8, 2019 the facility submitted a facsimile to the employer of client #1, which was confirmed during the investigation. On July 16, 2020 a request was made by DDAP staff for the facility to submit all information released from the client record. Documentation of this correspondence was not submitted with the record and was not presented upon further direct request for all information the facility released regarding the client.
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Plan of Correction
In the EMR used, there is a tab for 'correspondence' for staff to log all interactions with persons listed on clients' releases. During the education and training on 004 PA Code 255.5 (Projects and coordinating bodies: disclosure of client-oriented information) and the need for Releases to be on file, the Quality Assurance Liaison and Facility Director will also incorporate this into their meeting. The correspondence form in the EMR is spelled out to ask the type of communication (fax, email, phone, etc.), whom the communication was to, what the communication was regarding, the assessment/plan of the communication, and also has a spot to upload any attachment if anything was submitted on the client's behalf.The retrain will incorporate all of the importance of gathering this information to document in the client's record. |