INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 10, 2018 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, Lehigh Valley Drug and Alcohol Intake Unit 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 the review of 10 client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 4 client records.
Client #2 was assessed on 8/24/2017. There was documentation that a telephone conversation occurred between facility staff and the client ' s school on 8/24/17; however, there was no proper consent to release information form signed by the client prior to disclosure.
Client #3 was assessed on 6/23/2017. There was documentation that a telephone conversation occurred between facility staff and another treatment provider on 6/26/17, as well as documentation that a facsimile was sent to a second treatment provider on 6/29/17; however, there were no proper consent to release information forms to either treatment provider signed by the client prior to disclosure.
Client #4 was assessed on 1/02/2018. There was documentation that a facsimile was sent to the county court system on 1/02/18; however, there was no proper consent to release information form signed by the client prior to disclosure.
Client #8 was assessed on 5/17/2017. There was documentation that a facsimile was sent to the county court system on 5/17/17; however, there was no proper consent to release information form signed by the client prior to disclosure.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A staff meeting with all Assessors will be held on May 16, 2018 by the Clinical Director and Executive Director to review the confidentiality regulations.
By June 1, 2018 a case manager will be hired to check all files and case notes from the prior day to assure releases have been completed appropriately for anyone that received information concerning the client. The Case manager will also assure that a release is signed should a change in contact be necessary. The Administrative Assistant will monitor the case managers assuring compliance and report any non-compliance on a quarterly basis to the administrative team. |
709.44(b)(4) LICENSURE Follow-up Information
709.44. Client records.
(b) If applicable, the project shall also include the following items in the client record:
(4) Follow-up information.
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Observations
Based on a review of 10 client records, the facility failed to provide a complete client record, which is to include follow-up information, when applicable, in 3 client records.
Client #1 was assessed on 11/02/2017. Treatment was pending for client at the completion of the intake. The facility failed to provide documentation of an attempt to follow-up with either the client or the referred treatment provider.
Client #6 was assessed on 1/23/2018. Treatment was pending for client at the completion of the intake. The facility failed to provide documentation of an attempt to follow-up with either the client or the referred treatment provider.
Client #7 was assessed on 2/26/2018. Treatment was pending for client at the completion of the intake. The facility failed to provide documentation of an attempt to follow-up with either the client or the referred treatment provider.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A case manager will be begin full time as of June 1, 2018. Part of the duties will be to review all referrals from the previous day. any referred for outpatient or IOP treatment, and an admission date not confirmed will prompt the case manager to contact the client to assist in placement. The case manager will note the follow up contact in the case note. Administrative Assistant will monitor the files on a quarterly basis and review the findings with the administrative team to assure compliance. First review will be August 1, 2018. |