INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 22nd and 23rd, 2019 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
Based on a review of seven client records, the facility failed to document an addendum to the "CONSENT FOR VOLUNTARY INPATIENT TREATMENT" form , which would inform drug and alcohol clients that they are not required to provide 72-hour notice if they desire to leave treatment in two of seven records reviewed..
The " CONSENT FOR VOLUNTARY INPATIENT TREATMENT " form stipulated that 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 "
Client #1 was admitted on September 19, 2018 and discharged on February 16, 2019. There was no documentation of the addendum in the client record.
Client #4 was admitted on September 9, 2018 and discharged on March 14, 2019. There was no documentation of the addendum in the client record.
Substance Abuse Treatment is voluntary; therefore, a facility may not require 72 hour notice to leave treatment.
This is a repeat citation. The facility was previously cited for noncompliance with this standard during the July 11, 2018 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. The facility will continue to utilize the Consent for Voluntary Inpatient Treatment Drug & Alcohol Services Addendum to inform service recipients they are not required to provide 72-hour notice should they desire to leave treatment. On 5/28/2019, an audit was conducted for all active residents receiving services. The addendum was present for all current residents.
2. This form will be pre-loaded in the medical record and reviewed at the time of admission to ensure this information is communicated to all residents.
3. The Director of MIS, Quality & Regulatory Compliance (or designee) will audit the medical record of service recipients within 5 days from the start of drug & alcohol treatment services. This will serve as an additional check to confirm the resident has received the addendum and the form is properly filed. Auditing will continue until six consecutive months of 90% or better compliance rate is achieved.
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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 interviews 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 and 4 Pa. Code 255.5.
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 255.5(a)(6). The consents allowed for the release of information from the client's 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.
This is a repeat citation. The facility was previously cited for noncompliance with this standard during the July 11, 2018 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will provide only the Contact Person (Health Care Coordinator) with clinical reports that exceed the information noted in 4 Pa. Code 255.5(b). Written consent will be obtained prior to any release of information.
- SJVC will not execute consent forms for the release of information that exceeds the information noted in 4 Pa. Code 255.5(b) to representatives of a Religious Community or Diocese other than a Health Care Coordinator. For these persons, releases of information will be restricted to describing the nature of the program, confirmation of treatment participation, prognosis, brief description of the resident progress, current relapse status and the frequency of such relapse.
- The Director of Quality & Regulatory Compliance will facilitate a training with all Medical Records staff and Continuing Care Coordinators by 10/31/2020. This training will review the stated process change, execution of consent forms and monitoring for compliance.
- The Director of Quality & Regulatory Compliance or designee will review a sample of active charts for compliance monthly. The results will be reported to the facility's Performance Improvement Committee to provide on-going monitoring. Chart reviews will continue until six consecutive months of 100% compliance is achieved.
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