Observations
The facility failed to document the required 25 clock hours of annual training for one counselor personnel record reviewed during the annual licensing inspection conducted on July 7, 2017.
Employee # 3 is a counselor and was hired on October 13, 2003. Only 6 hours of training was documented for the July 1, 2016 - June 30, 2017 training year.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
0083 ? Licensure Training Hours Required for Counselors - §704.11(f)(2)
CADC/Employee #3, who is currently on full workers' comp restriction and unable to work, will schedule and attend a minimum of 12.5 hours of DDAP qualified trainings per 704.11(f)(2) and (3) by 12/30/17 and will complete a total of 25 training hours by 6/30/18.
The D/A Nursing Supervisor will insure that the CADC will complete 25 hours of training annually by performing a quarterly review of CADC's training hour completion and scheduling CADC for necessary hours of training within the required 1 year time frame.
To monitor completion of training hours, the Nursing Supervisor will maintain a progress report that will be updated with CADC's quarterly progress during the 6/30-7/1 time frame each year.
Date of Completion: 6/30/18
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Observations
The facility failed to document an informed and voluntary consent from the patient prior to disclosure of information in seven of seven patient records reviewed during the annual licensing inspection conducted on July 7, 2017. In addition, the facility exceeded the limitations imposed at 4 Pa. Code 255.5 in four of seven patient records.
The facility failed to adhere to the requirements outlined in the federal confidentiality regulations by requiring the patient to revoke the consent to release information in writing. The following records contained consents to release information that were signed by the patient during the intake process:
Patient # 1 was admitted into treatment on January 15, 2017 and discharged on January 19, 2017.
Patient # 2 was admitted into treatment on February 2, 2017 and discharged on February 5, 2017.
Patient # 3 was admitted into treatment on March 10, 2017 and discharged on March 13, 2017.
Patient # 4 was admitted into treatment on January 22, 2017 and discharged on January 26, 2017.
Patient # 5 was admitted into treatment on January 19, 2017 and discharged on January 24, 2017. Also, there was no documentation of a consent for the funding entity prior to the facility obtaining authorization for treatment payment.
Patient # 6 was admitted into treatment on February 2, 2017 and discharged on February 6, 2017.
Patient # 7 was admitted into treatment on January 14, 2017 and discharged on January 18, 2017.
In addition, the consent to release information forms for the funding entities in records # 1, 2, 3 and 7 exceeded 4 Pa. Code 255.5 by allowing for the release of the following items to the insurance company: history/physical exam, psychiatric evaluation, discharge summary, lab/pathology report, medication list, progress notes, behavioral health records, diagnostic imaging and HIV testing and results.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
L127 ? Confidentiality of Patient Records - §710.23(b)
The D/A Unit staff will keep patient records confidential and will release information per patient authorization in accordance with applicable Federal drug and alcohol regulations and confidentiality requirements and limitations in 4 PA Code §255.4 and 255.5. The Unit Nursing Supervisor will revise the Behavioral Health/ D/A Authorization for Use and Disclosure of PHI form, ("Consent") to allow patient revocation of Consent (i) in writing or (ii) by verbally stating desire to revoke. The D/A Unit staff will not release patient information to funding entities until patient Consent to release information is executed and will release only limited information to funding entities in accordance with 4 PA Code §255.5 (B)
The Nurse Manager will provide staff training sessions for 100% of Behavioral Health staff regarding (i) the ability of a patient to revoke Consent either verbally or in writing, (ii) the need for patient to execute a Consent form prior to staff release of patient information to funding entities, (iii) the limited scope of patient information that may be provided to funding entities. The training will include a review with 100% staff sign off of understanding of (i) the revised consent form and (ii) the necessity to obtain an informed Consent from the patient prior to providing information to the funding entity in compliance with 4 Pa. Code 255.5, and (iii) the limited scope of patient information that may be provided to funding entities per the limitations in 4 PA Code §255.5. Training will be completed by September 15, 2017.
The Nurse Manager will insure ongoing compliance by developing a competency training test covering execution of Consent forms, Consent revocation and provision of limited information to funding entities, which will be administered to current D/A/staff and new hires.
The Nurse Manager will conduct weekly audits of 100% of D/A patients from 9/15/17 ? 12/31/17 to monitor (i) staff compliance with obtaining patient Consent prior to releasing information to funding entities, (ii) staff provision of limited patient information to funding entities in conformity with 4 PA Code §255.5. The Nurse Manager will follow Administrative Policy 103.09, Discipline, with noncompliant staff members who provide patient information to funding entities without prior patient consent and/or who provide patient information to funding entities in excess of that permitted by 4 PA Code §255.5.
Date of audit completion: December 31, 2017.
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