INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 10th and 11th, 2018 of St. John Vianney Center 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, St. John Vianney Center 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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709.123(a)(2)(iii) LICENSURE Consent to treatment
709.123. Treatment and rehabilitation.
(a) Intake and admission.
(2) Intake procedures shall include documentation of:
(iii) Consent to treatment.
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Observations
The consent to treatment in seven of seven client records reviewed was not compliant with Drug and Alcohol treatment regulations.Each record contained a form labeled " CONSENT FOR VOLUNTARY INPATIENT TREATMENT " , which listed the following two requirements: A parent/ Guardian signature is required for minors. A notice of 72 hours is required if leaving treatment without completing as evidenced by the statement contained on the form " I understand that in order to leave before I am discharged, I must give (up to 72) hours advanced notice in writing to those in charge of my treatment "In Pennsylvania, a minor is considered to have reached the age of majority. 42 CFR Minor Patients, 71 P. S. 1690.112. Substance Abuse Treatment is voluntary; therefore, a facility may not require 72 hour notice to leave treatment.
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Plan of Correction
The Consent for Voluntary Inpatient Treatment (MH 781) is a Pennsylvania DPW form which cannot be revised. Those receiving drug and alcohol services will be provided an addendum to this form at the start of treatment to clarify the following:
1)The request for Parent or Guardian signature is not applicable to them.
2)Their participation in substance abuse treatment is voluntary.
3)They are not required to provide 72-hour notice if they desire to leave treatment.
Residents currently participating in drug and alcohol services will receive the addendum to review and sign. A facility representative will also sign the form. The completed form will be placed in the resident's record. |
709.123(c) LICENSURE Client records
709.123. Treatment and rehabilitation.
(c) Client records. 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:
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Observations
Client records shall include, but not be limited to: (1) Consent forms. (2) Record of services provided. (3) Individualized drug and alcohol treatment and rehabilitation plan. (4) Drug and alcohol aftercare plan, if applicable. (5) Follow-up information. Based on a review of three discharged clients' records, the facility failed to document a followup in one of three records reviewed and an aftercare plan in one of three records reviewed. .Client #7 was admitted on December 13, 2017 and discharged on June 15, 2018. There was no documentation of a follow-up communication after discharge. Client # 4 was admitted on February 23, 2018 and discharged on April 11, 2018. There was documentation of an aftercare plan in the client's record.
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Plan of Correction
The Clinical Director will facilitate a training for the Continuing Care Coordinators to review regulations around completion of Aftercare Plans and follow-up.
The Manager of Continuing Care Services (or designee) will review the charts of those nearing discharge to ensure an aftercare plan is present. Discharged charts will also be audited for documentation of resident follow-up. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
A review of the July 2017 through June 2018 fire drill logs was conducted during the onsite inspection. The facility failed to set off a fire alarm or smoke detector during the sleeping hours drill conducted on October 4, 2017. Staff conducted what was noted as a "silent" drill where clients were not awakened and did not participate. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Facilities will ensure the facility conducts all fire drills by setting off a fire alarm or smoke detector. This will be monitored with monthly auditing until 6 months of consecutive compliance is achieved, then quarterly thereafter.
"Silent Drills" will no longer be utilized for fire safety exercises. Staff and residents will be notified of this change by The Director of Facilities. |
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
Based on a review of seven client records, and an interview with facility staff, the facility failed to ensure the confidentiality of clients in seven of seven records reviewed and the adherence with 28 Pa. Code 709.28, 28 Pa. Code 705.4, 42 CFR Part 2 and 4 Pa. Code 255.5.Client record #'s 1, 2, 3, 4, 5, 6, and 7 contained a form (The Patient Information and Consent Form for telehealth Case Management form) to permit the use of interactive video conferencing. When the Licensing Specialist asked wha the form was for, the facility staff provided the following explanation:Clients may have a sponsor that they have participate in their treatment sessions who by virtue of their location, is not able to be at the facility. The facility then teleconferences them in and conducts the treatment sessions and/or review via the telehealth system. Because there is no means to ensure that the sessions cannot be seen or heard by others, this would not be compliant with 42 CFR Part 2, 28 Pa. Code 709.28 or 28 Pa. Code 705.4.Client record #'s 1, 2, 3, 4, 5, 6, and 7 contained consent to release information forms to the Church/Diocese where they were employed that exceeded what is permissible under 4 Pa. Code The consents allowed for the release of information from the clients record such as, but not limited to, progress notes, psychosocial evaluations, treatment plans and other treatment documents. An interview with facility staff confirmed that the facility had been releasing the information. 4 Pa. Code limits the release of information to the employer or prospective employer whether the client has or is receiving treatment with the project.The facility Policies and Procedures, the Care Policies manual "Rights, Responsibilities, Ethics Policy No. 2" August 2015, and forms contained in the client records such as, but not limited to the "Notice of Privacy Practices, and "AUTHORIZATION FOR RELEASE OF INFORMATION -GENERAL-" contained information that conflicted and did not comply with 42 CFR Part 2, 28 Pa. Code 709.28 and/or 4 Pa. Code 255.5.The documents indicated that the facility may release Protected Health Information (PHI) also referred to as "Medical information" in the "NOTICE OF PRIVACY PRACTICES" (without clearly defining "Medical information") without client consent to obtain payment to Medicaid, a private insurance plan, or a state office to get paid for services delivered to the client. Additionally, there is no mention of the restrictions imposed by 4 Pa. code 255.5(b).The "NOTICE OF PRIVACY PRACTICES" page 2, states; "Once signed , authorization can be revoked in writing at any time...in reliance upon your authorization." A client has the right to revoke a consent verbally. 42 CFR (a)(6).Based on the review of client records, the facility failed to protect the client against redisclosure of information in the Authorization for Release of Information form. The form states "Information disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and may no longer be protected under federal law". PA Code 709.28 does not permit re-disclosure of client information. Client records 1, 2, 3, 4, 5, 6 and 7 were reviewed with all containing forms with incorrect wording.Client records number one through seven, inclusive contained a form labeled Authorization for Release of Information. The release form stated: "I understand that this authorization, except for actions already taken, may be revoked by me at any time by communicating with the Medical Records Department in writing or verbally". While this form does allow for the revocation to be verbal, it required the client to make the revocation to specific individuals, which would not comply with 42 CFR (a)(6).The facility "NOTICE OF PRIVACY PRACTICES" indicated that information could be released with out client consent about suspected abuse, neglect or domestic violence, or relating to suspected criminal activity, to collect information about disease or injury, to report vital statistics to the public health authority, to an accrediting organization or another agency responsible for monitoring the healthcare system for such purposes as reporting or investigation of unusual incidents, to avert threat to health or safety to law enforcement or other persons who can reasonably prevent or lessen the threat of harm, to correctional facilities, government programs relating to the eligibility and enrollment, and for national security reasons, such as protection of the President. Most of these are not permissible to be released without client consent, and information released with the clients consent would be restricted to what is permissible under 42 CFR Part 2 and 4 Pa. Code 255.5.The facility released client information to a laboratory for urine drug screens without there being a consent to release from the clients in their records and without a signed Qualified Service Organization Agreement in place.
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Plan of Correction
Telehealth Use:
St. John Vianney is currently working with the Department of Drug and Alcohol Programs regarding this citation. Projected corrective action date is November 30, 2018.
PHI Disclosed with Church/Diocese/Religious Community:
St. John Vianney does not agree with this citation and is currently working with the Department of Drug and Alcohol Programs (DDAP) regarding it. The legal issues are being discussed by counsel for St. John Vianney and DDAP attorneys, and hopefully a resolution can be reached by November 30, 2018.
Release of Information:
As of 9/5/2018, the Release of Information forms utilized by the facility have been revised by the Director of MIS, Quality & Regulatory Compliance with the following changes:
-The statement "Information disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and may no longer be protected under federal law" now includes the notation that, for those receiving drug & alcohol treatment, whether information is subject to re-disclosure is governed by controlling federal and state law.
-All Release of Information forms were revised to confirm consent may be revoked at any time by communicating with any facility staff member verbally or in writing.
Notice of Privacy Practices:
The Notice of Privacy Practices form has been revised by the Director of MIS, Quality & Regulatory Compliance to include a notation that information for drug and alcohol treatment participants will only be disclosed in the cases permissible under 42 CFR Part 2, 4 Pa. Code 255.5, or other applicable law. Corrective action date is 9/5/2018.
Qualified Service Organization Agreement:
A signed release of information form for Health Network Laboratories will be obtained for those currently utilizing services before completion of the agreement. This release will be placed in the resident's record as of 9/5/2018.
The Director of Nursing has completed negotiations with Health Network Laboratories and the finalized service agreement is on-file at the facility as of 9/14/2018.
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to ensure that there was appropriate documentation of the client's rights against discrimination. The facility failed to list discrimination against marital status and sexual orientation in client record # ' s 1, 2, 3, 4, 5, 6, and 7.
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Plan of Correction
The Director of MIS, Quality & Regulatory Compliance has revised the Civil Rights Resident Letter to note the facility will not discriminate in the provision of services on the basis of marital status or sexual orientation.
This revised Civil Rights Resident Letter will be provided to all admitted residents and posted on all nursing units. |