INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 29-30, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Conewago - Pottsville 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 and a plan of correction is due on August 3, 2010.
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Plan of Correction
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records and an interview with medical staff, the facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in two of twelve client records.
The findings include:
Twelve client records were reviewed on June 30, 2010. All of the client records were required to include an informed and voluntary consent from the client prior to the disclosure of information. Records, #6 and 10, had documented instances where information had been disclosed about the client but there was no documentation of a consent form signed by the clients.
Client #6 was admitted on April 16, 2010. Lab work had been completed for the client and returned to the facility on April 13, 2010. There was not a consent form allowing for the disclosure of information to the Laboratory.
Client #10 was admitted on June 28, 2010. Lab work had been completed for the client and returned to the facility on June 29, 2010. There was not a consent form allowing for the disclosure of information to the Laboratory.
On June 30, 2010 at 3:47pm the inspector inquired if it was standard practice to get client consent before releasing information to the laboratory. Medical staff verified that they have never had consent forms completed for laboratory work.
The facility could not provide verification of a Quality Service Organization Agreement for the referenced laboratory.
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Plan of Correction
On June 30, 2010, prior to the Department of Health Licesing Specialist completing the inspection, the facility developed and implemented a specific consent to release form for the laboratory which referenced Federal Regulation 42 CFR, part 2 (Confidentiality of drug and alcohol abuse patient records). The Facility Director and the Corporate Compliance Office will continue to review patient records to ensure continued compliance in this area. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
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Observations
Based on the review of the program's policies and procedures and client records, the facility failed to document follow-up information in one of two closed client records reviewed.
The findings include:
Five detox client records were reviewed on June 29, 2010. Follow-up information was required in two closed client records, specifically client records # 11 and 12. Per the facilities policy and procedure, follow-ups will be documented within 7 days after discharge when the client is referred for additional treatment and within 30 days when not referred for additional treatment.
Client record #12 was discharged on May 22, 2010 as of June 29, 2010 there was no documentation of an attempt to follow-up on the client.
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Plan of Correction
On July 1, 2010 a training was provided to individuals assigned to the task of completing follow-ups with specific emphasis on ensuring that follow-ups is completed and documented on all clients completing treatment at the specified intervals as outlined by the facility's policy and procedures manual. The Facility Director and Corporate Compliance Officer will continue to monitor client files to ensure continued compliance of the facility's follow-up policy and procedures. |