INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 25, 2021 through May 26, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Horsham 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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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
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information form for the disclosure of information in three of fourteen records reviewed.
Client #2 was admitted into the detox level of care on May 20, 2021 and was active at the time of inspection. There was documentation of billing to the funding source; however, there was no consent form on file prior to the disclosure of information.
Client #7 was admitted into the detox level of care February 10, 2021 and was discharged February 15, 2021. There was documentation of billing to the funding source; however, there was no consent form on file prior to the disclosure of information.
Client #13 was admitted into the residential level of care February 15, 2021 and was discharged March 3, 2021. There was documentation of billing to the funding source; however, there was no consent form on file prior to the disclosure of information.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Beginning 7/12/2021, the Medical Records Director will retrain all
All Admissions and Social Work staff in Horsham Policy: Confidentiality and Release of Information, Drug and Alcohol Records. This policy requires that informed and voluntary consent for the release of information must be obtained in writing and must include:
(1) Name of the person, agency or organization to whom disclosure is made.
(2) Specific information disclosed.
(3) Purpose of disclosure.
(4) Dated signature of client or guardian.
(5) Dated signature of witness.
(6) Date on which the consent will expire.
The policy also states that a copy of a client consent shall be offered to the client and a copy maintained in the client record.
Beginning 8/2/2021 Horsham Medical Records will review 20% of admissions each month to verify that consent forms are completed according to policy and will report findings to the Program Supervisor, Admissions Director and PI Director.
The Program Supervisor and Admissions Director will address any areas of non-compliance and ensure staff are reminded of responsibility for adhering to policy. The Program Supervisor and Admissions Director will report actions they have taken to ensure completion of consents at monthly PI meetings.
The audit results and actions taken will be reviewed at the PI meeting to verify that the deficiency is corrected and consent forms are completed according to policy. This review will be documented in the meeting minutes.
The Director of Clinical Services is responsible for oversight and completion of this Plan. |
709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organizaton to whom a disclosure was to be made to on informed and voluntary consent forms in three of fourteen client records reviewed.
Client #2 was admitted into the detox level of care on May 20, 2021 and was active at the time of the inspection. A release of information form was signed and dated by the client with a purpose of physician on May 20, 2021; however, the consent form did not include the specific name of the person, agency or organization to whom the disclosure was to be made.
Client #4 was admitted into the detox level of care on May 15, 2021 and was discharged May 19, 2021. A release of information form was signed and dated by the client with a purpose of recovery house on May 15, 2021; however, the consent form did not include the specific name of the person, agency or organization to whom the disclosure was to be made.
Client #8 was admitted into the residential level of care on May 19, 2021 and was active at the time of inspection. A release of information form was signed and dated by the client with a purpose of recovery house on May 15, 2021; however, the consent form did not include the specific name of the person, agency or organization to whom the disclosure was to be made.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Beginning 7/12/2021, the Medical Records Director will retrain all
All Admissions and Social Work staff in Horsham Policy: Confidentiality and Release of Information, Drug and Alcohol Records. This policy requires that informed and voluntary consent for the release of information must be obtained in writing and must include:
(1) Name of the person, agency or organization to whom disclosure is made.
(2) Specific information disclosed.
(3) Purpose of disclosure.
(4) Dated signature of client or guardian.
(5) Dated signature of witness.
(6) Date on which the consent will expire.
The policy also states that a copy of a client consent shall be offered to the client and a copy maintained in the client record.
Beginning 8/2/2021 Horsham Medical Records will review 20% of admissions each month to verify that consent forms are completed according to policy and will report findings to the Program Supervisor, Admissions Director and PI Director.
The Program Supervisor and Admissions Director will address any areas of non-compliance and ensure staff are reminded of responsibility for adhering to policy. The Program Supervisor and Admissions Director will report actions they have taken to ensure completion of consents at monthly PI meetings.
The audit results and actions taken will be reviewed at the PI meeting to verify that the deficiency is corrected and consent forms are completed according to policy. This review will be documented in the meeting minutes.
The Director of Clinical Services is responsible for oversight and completion of this Plan.
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709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to keep consent to release information forms within the limits established by 4 Pa. Code 255.5 (b) for releases of information in six of fourteen client records reviewed.
Client #1 was admitted into the detox level of care on May 20, 2021 and was active at the time of inspection. There was a consent to release information form to the funding source, signed and dated by the client, that allowed for the release of "All past and present drug and alcohol treatment and records", which exceeds the limits established by 4 Pa. Code 255.5.
Client #2 was admitted into the detox level of care on May 20, 2021 and was active at the time of inspection. There was a consent to release information form to a primary care physician, signed and dated by the client, that allowed for the release of "Other" information and did not provide specifics as to what other is, which exceeds the limits established by 4 Pa. Code 255.5.
Client #6 was admitted into the detox level of care on May 3, 2021 and was discharged May 8, 2021. There was a consent to release information form to the funding source, signed and dated by the client, that allowed for the release of "All past and present drug and alcohol treatment and records", which exceeds the limits established by 4 Pa. Code 255.5.
Client #10 was admitted into the residential of care on May 2, 2021 and was active at the time of inspection. There was a consent to release information form to the funding source, signed and dated by the client, that allowed for "All past and present drug and alcohol treatment and records", which exceeds the limits established by 4 Pa. Code 255.5.
Client #11 was admitted into the residential of care on May 8, 2021 and was discharged May 13, 2021. There was a consent to release information form to the funding source, signed and dated by the client, that allowed for "All past and present drug and alcohol treatment and records", which exceeds the limits established by 4 Pa. Code 255.5.
Client #12 was admitted into the residential of care on January 6, 2021 and was discharged May 27, 2021. There was a consent to release information form to the funding source, signed and dated by the client, that allowed for "All past and present drug and alcohol treatment and records", which exceeds the limits established by 4 Pa. Code 255.5.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Beginning 7/12/2021, the Medical Records Director will retrain all
All Admissions and Social Work staff in Horsham Policy: Confidentiality and Release of Information, Drug and Alcohol Records. This policy requires that informed and voluntary consent for the release of information must be obtained in writing and must include:
(1) Name of the person, agency or organization to whom disclosure is made.
(2) Specific information disclosed.
(3) Purpose of disclosure.
(4) Dated signature of client or guardian.
(5) Dated signature of witness.
(6) Date on which the consent will expire.
The policy also states that a copy of a client consent shall be offered to the client and a copy maintained in the client record.
The training will address requirements to be included in consent forms per Horsham policy including the requirement for specific information to be disclosed. The training will clarify that statements such as "All past and present drug and alcohol treatment and records" are not sufficiently specific, do not meet policy and are not acceptable.
Beginning 8/2/2021 Horsham Medical Records will review 20% of admissions each month to verify that consent forms are completed according to policy and will report findings to the Program Supervisor, Admissions Director and PI Director.
The Program Supervisor and Admissions Director will address any areas of non-compliance and ensure staff are reminded of responsibility for adhering to policy. The Program Supervisor and Admissions Director will report actions they have taken to ensure completion of consents at monthly PI meetings.
The audit results and actions taken will be reviewed at the PI meeting to verify that the deficiency is corrected and consent forms are completed according to policy. This review will be documented in the meeting minutes.
The Director of Clinical Services is responsible for oversight and completion of this plan.
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709.28 (c) (5) 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 must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document a dated witness signature on an informed and voluntary consent to release information form in five of fourteen client records reviewed.
Client #1 was admitted into the detox level of care on May 20, 2021 and was active at the time of inspection. There was a consent to release information form to the funding source, signed and dated by the client on May 20, 2021; however, the consent form did not include a dated signature of a witness.
Client #6 was admitted into the detox level of care on May 3, 2021 and was discharged May 8, 2021. There was a consent to release information form to the funding source, signed and dated by the client on May 3, 2021; however, the consent form did not include a dated signature of a witness.
Client #10 was admitted into the residential of care on May 2, 2021 and was active at the time of inspection. There was a consent to release information form to the funding source, signed and dated by the client on May 2, 2021; however, the consent form did not include a dated signature of a witness.
Client #11 was admitted into the residential of care on May 8, 2021 and was discharged May 13, 2021. There was a consent to release information form to the funding source, signed and dated by the client on May 8, 2021; however, the consent form did not include a dated signature of a witness.
Client #12 was admitted into the residential of care on January 6, 2021 and was discharged May 27, 2021. There was a consent to release information form to the funding source, signed and dated by the client on January 6, 2021; however, the consent form did not include a dated signature of a witness.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Beginning 7/12/2021, the Medical Records Director will retrain all
All Admissions and Social Work staff in Horsham Policy: Confidentiality and Release of Information, Drug and Alcohol Records. This policy requires that informed and voluntary consent for the release of information must be obtained in writing and must include:
(1) Name of the person, agency or organization to whom disclosure is made.
(2) Specific information disclosed.
(3) Purpose of disclosure.
(4) Dated signature of client or guardian.
(5) Dated signature of witness.
(6) Date on which the consent will expire.
The policy also states that a copy of a client consent shall be offered to the client and a copy maintained in the client record.
Beginning 8/2/2021 Horsham Medical Records will review 20% of admissions each month to verify that consent forms are completed according to policy and will report findings to the Program Supervisor, Admissions Director and PI Director.
The Program Supervisor and Admissions Director will address any areas of non-compliance and ensure staff are reminded of responsibility for adhering to policy. The Program Supervisor and Admissions Director will report actions they have taken to ensure completion of consents at monthly PI meetings.
The audit results and actions taken will be reviewed at the PI meeting to verify that the deficiency is corrected and consent forms are completed according to policy. This review will be documented in the meeting minutes.
The Director of Clinical Services is responsible for oversight and completion of this plan.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of all informed and voluntary consent to release information forms were offered to the client in one of fourteen client records reviewed.
Client #14 was admitted into the residential level of care on January 15, 2021 and was discharged February 3, 2021. Release of information forms to the funding source and the emergency contact, signed and dated by the client on January 15, 2021, failed to document that a copy of the form was offered to the client.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Beginning 7/12/2021, the Medical Records Director will retrain all
All Admissions and Social Work staff in Horsham Policy: Confidentiality and Release of Information, Drug and Alcohol Records. This policy requires that informed and voluntary consent for the release of information must be obtained in writing and must include:
(1) Name of the person, agency or organization to whom disclosure is made.
(2) Specific information disclosed.
(3) Purpose of disclosure.
(4) Dated signature of client or guardian.
(5) Dated signature of witness.
(6) Date on which the consent will expire.
The policy also states that a copy of a client consent shall be offered to the client and a copy maintained in the client record.
The consent form, "Horsham Authorization for Release of Confidential Information" requires documentation that the patient was offered and accepted or declined a copy of the form. This form and requirement will be reviewed in the training.
Beginning 8/2/2021 Horsham Medical Records will review 20% of admissions each month to verify that consent forms are completed according to policy and will report findings to the Program Supervisor, Admissions Director and PI Director.
The Program Supervisor and Admissions Director will address any areas of non-compliance and ensure staff are reminded of responsibility for adhering to policy. The Program Supervisor and Admissions Director will report actions they have taken to ensure completion of consents at monthly PI meetings.
The audit results and actions taken will be reviewed at the PI meeting to verify that the deficiency is corrected and consent forms are completed according to policy. This review will be documented in the meeting minutes.
The Director of Clinical Services is responsible for oversight and completion of this plan.
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