INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 20, 2016 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, RHD - Womanspace 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:
|
Plan of Correction
|
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.
|
Observations
Based on the review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in client record #3.Client #3 was admitted on 10/30/2015 and was still an active client at the time of the inspection. There was documentation that face-to-face contact between a staff member and the client's significant other occurred on 03/21/2016; however, the client did not sign a consent to release information form for this individual until 04/04/2016.The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Consent to Release Information documentation that is informed and voluntary will be completed prior to disclosure of any client information moving forward, regardless of verbal consent or client presence in the exchange of information. Program Director will review and provide instruction on Consent to Release Information policy and procedure with all program staff at 8/10/16 staff meeting. Consent to Release Information documentation forms will be located on the first floor in addition to the third floor office to facilitate ease of access and use. Program Director and Assistant Director will monitor use of Consent to Release Information documentation at Womanspace through internal chart audits and all staff will check for Consent to Release Information documentation before sharing any information about a client. If documented Consent to Release Information does not exist, the client will be provided with informed and voluntary choice of whether or not to complete Consent to Release Information documentation. If Consent to Release Information is not documented, information will not be provided. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
Based on a review of patient records, it was discovered that on 06/02/2016, the facility had requested ambulance/EMS personnel assistance at the facility to assist with a possible overdose situation that Client #5 (an active patient, at that time) had been having. Ultimately, the client was transported to the local hospital via ambulance. The facility subsequently discharged the client on 06/03/2016 as the patient disappeared from the hospital against medical advice and did not return to the facility that evening. Upon further inspection, it was discovered that the facility had not submitted a written unusual incident report to the Department within the regulatory 3 business day timeframe.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 7/28/16, Womanspace Staff will utilize the Unusual Incident Report form in communicating to DDAP all future incidents that are included in the DDAP Reporting of Unusual Incidents Licensing Alert 5-97 guidelines. Additionally, on 7/28/16 Program Director completed and submitted to DDAP an Unusual Incident Report for the incident that occurred on 6/2/2016 involving Client #5. Additionally, Program Director will provide instruction on procedure for DDAP Reporting of Unusual Incidents to all Womanspace Staff during the next Womanspace All Staff Meeting on 8/10/16. This will include review of how to utilize the Unusual Incident Report form, where to send the form, and types of incidents to report as per the DDAP Reporting of Unusual Incidents Licensing Alert 5-97 guidelines. Following future unusual incidents, including use of EMT/Ambulance, Womanspace Program Administration, including Program Director, Assistant Director/ Lead Therapist and Lead Community Care Specialist will follow up within the 3 business days of the incident to ensure that the DDAP Unusual Incident Report has been submitted, with a copy retained on site. |