INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on December 8, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Diakon Child, Family and Community Ministries 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 one of eight client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in client record # 5.
Client # 5 was admitted on June 1, 2020 and was still active at the time of the inspection. Information was released to a funding source without a valid informed and voluntary consent form.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 9, 2019 annual inspection.
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Plan of Correction
Client #5 has a signed release of information on file for the local SCA, who funded his treatment. The release was signed on 7/16/2020 and was witnessed on the same date. A copy of this consent is available if needed.
To avoid future problems in this area, initial session paperwork has been updated as of 12/23/2020 to include a specific consent to release information for Insurance/Funding Source that will be required to be completed at assessment session. Further, staff were educated on 12/16/2020 on 709.28 and the necessity to have documented, voluntary consent.
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709.30 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.
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Observations
Based on one of eight client records reviewed, the facility failed to provide written acknowledgement by clients that they have been notified of their rights in client record # 1.
Client # 1 was admitted on March 13, 2020 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Paperwork for second session (Intake Session) was updated on 12/21/2020 to require an acknowledgment outlining that the client has been provided a copy of their rights. Session paperwork cannot be completed without the acknowledgment being signed off by both the client and the staff.
Random chart audits will take place to monitor for compliance.
Staff were educated on 12/16/2020 on 709.30
Clinical Director will monitor for compliance. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on two buprenorphine client records reviewed, the facility failed to provide documentation of an emergency contact for client # 8.
Client # 8 was admitted on November 23, 2020 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Screening forms were updated on 12/18/2020 to now require intake specialists to obtain a name and contact number for an emergency contact.
Further, initial session paperwork was updated as of 12/23/2020 to include a consent to release information that is specific to an emergency contact.
Staff were educated on 12/16/2020 on 715.9 and the importance of having documented consent to release information in the case of an emergency.
Clinical Director and Compliance Team will be responsible for monitoring for compliance in this area.
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709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) 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:
(8) Case consultation notes.
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Observations
Based on five of eight client records reviewed, the facility failed to provide case consults in accordance with the facility policy and procedure manual. The policy and procedure manual indicates a case consult would occur with a treatment plan update.
Client # 1 was admitted on March 13, 2020 and was still active at the time of the inspection. Treatment plan updates occurred on November 9, September 6, and May 18, 2020. There were no case consultations documented in the client record.
Client # 2 was admitted on May 4, 2020 and was still active at the time of the inspection. Treatment plan updates occurred on June 29, 2020. There were no case consultations documented in the client record.
Client # 4 was admitted on June 29, 2020 and was still active at the time of the inspection. Treatment plan updates occurred on October 26, and August 6, 2020. There were no case consultations documented in the client record.
Client # 5 was admitted on June 1, 2020 and was still active at the time of the inspection. Treatment plan updates occurred on November 12, September 17, and July 16, 2020. There were no case consultations documented in the client record.
Client # 6 was admitted on November 13, 2019 and was discharged May 27, 2020. Treatment plan updates occurred on May 27, April 13, February 17, 2020 and December 24, 2019. There were no case consultations documented in the client record.
This is a repeat citation from the July 9, 2019 annual inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility policy on Treatment Plan Updates and Case Consultations was updated on 12/21/2020 to reflect the following timeline:
Case Consultations should be completed, at minimum, every 90 days for the first year of treatment. Following the first year of treatment, case consultations must be completed, at minimum, on an annual basis.
At clinical staff meeting on 12/16/2020, staff were informed of policy changes.
Clinical Director and Compliance Team will be responsible for monitoring compliance in this particular area. |