This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on July 8, 2015 through July 9, 2015 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, RHD Montgomery County Methadone Clinic 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 the review of client records, the facility failed to ensure that a completed informed and voluntary consent to release information was obtained in three of sixteen client records reviewed.
The findings included:
Sixteen client records requiring complete informed and voluntary consent to release information forms were reviewed on July 8, 2015 through July 9, 2015. The facility failed to ensure that a completed informed and voluntary consent to release information form was obtained in client records, #4, 7, and 12.
Client #4 was admitted into methadone maintenance treatment on July 22, 1998 and was still an active client at the time of the inspection. A release of information to a hospital was signed and dated on 7/18/2014; however; the release of information did not include the specific information to be released and the purpose of the disclosure at the time of the inspection.
Client #7 was admitted into methadone maintenance treatment on April 8, 2015 and was still an active client at time of the inspection. A release of information to a family member was signed and dated on 4/8/2015; however; the release of information did not include the purpose of the disclosure at the time of the inspection.
Client #12 was admitted into methadone maintenance treatment on February 2, 2009 and was discharged on February 18, 2015. A release of information to an emergency contact was signed and dated on 10/27/2014; however, the name of the emergency contact identified was the narcotic treatment program instead of the client's family member as was identified by the relationship portion of the consent. Additionally, a release of information was signed and dated on 10/27/2014; however; the release of information did not include the name of the person or organization to whom the disclosure was made to, the specific information to be released and the purpose of the disclosure at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Clinical Meeting was held on 7/21/15 by the Clinical Supervisor with the MCMC staff to address a Plan of Correction for the Confidentiality citation received. Voluntary and informed consent was addressed regarding the client and client record. This consent shall be in writing and include complete information that is to be released as well as to whom this information is released and the purpose of this release. Additionally, it shall be documented as to whether the client was offered a copy of this release of information. The Clinical Supervisor will monitor the compliance of this via chart audits and the Program Director will oversee this compliance.
Corrections made:
Patient #4 had an incomplete release to her Doctor. She states she no longer sees this Doctor and no further release is needed. Patient #7 had an incomplete release for her husband. A new release was completed and signed by patient on 7/23/15. Patient #12 is discharged and no new release is warranted. CS and PD will monitor that this citation does not occur again via chart audits. |