INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 28, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System 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) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document a purpose of disclosure on release of information forms in one of seven client records reviewed.
Client #1 was admitted on August 24, 2021 and was active at the time of inspection. A release of information form to a government agency was signed and dated by the client on August 24, 2021 and the form did not document the purpose of disclosure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
* Participant 1 was discharged , clinical supervisor will attempt to contact via usage of their phone number
*Clinical Supervisor will provide in-service training to counseling staff regarding the proper completion of consents, training will include all aspects of the consent .
*Clinical Supervisors will conduct Random monitor of three (3) charts per clinician per month to validate that consents forms are completed correctly
Responsible Party: Clinical Supervisor Completion Date 10/29/21
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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 signature of a witness on release of information forms in one of seven client records reviewed.
Client #6 was admitted on June 17, 2021 and was discharged on July 15, 2021. There were release of information forms to another treatment facility and a funding source, both signed by the client on June 17, 2021; however, neither form documented the dated signature of a witness.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
*Clinical Supervisor will provide in-service training to counseling staff regarding dating signature of a witness on release of information forms.
*Clinical Supervisors will conduct Random monitor of three (3) charts per clinician per month to validate that consents forms are completed correctly
Responsible Party: Clinical Supervisor Completion Date 10/29/2021
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709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event, or condition upon which a consent to release information form will expire on release of information forms in one of seven client records reviewed.
Client #2 was admitted on September 8, 2021 and was active at the time of inspection. There were release of information forms to another treatment facility and a funding source, both signed by the client on September 8, 2021; however, both consent forms expired September 7, 2021, which was the day prior to the client's dated signature.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
* Participant 1 was discharged , clinical supervisor will attempt to contact via usage of their phone number
*Clinical Supervisor will provide in-service training to counseling staff regarding documenting the date, event, or condition upon which a consent to release information form will expire on release of information forms.
*Clinical Supervisors will conduct Random monitor of three (3) charts per clinician per month to validate that consents forms are completed correctly
Responsible Party: Clinical Supervisor Completion Date 10/29/2021
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