This report is a result of an on-site licensure renewal inspection conducted on June 2, 2016 through June 3, 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, Malvern Institute 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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Observations
Based on a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record #'s 1, 2, 3, 4, 5, 7, and 11. Additionally, client record #'s 1, 8, and 9 were missing specific information to be released or the name of the person/organization to whom the disclosure was made to.
4 Pa. Code states that information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of the code, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following:
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
#1 was admitted on 05/16/2016 and was an active client as of the date of the inspection. A consent to release form was signed and dated on 05/16/16 to the funding source that allowed for the release of the aftercare treatment plan and the lab reports/EKG. Additionally, there was a consent to release form signed and dated on 05/18/16 to a family member with no specific information to be released.
#2 was admitted on 06/01/2016 and was an active client as of the date of the inspection. A consent to release form was signed and dated on 05/18/16 to the funding source that allowed for the release of the aftercare treatment plan and the lab reports/EKG.
#3 was admitted on 05/15/2016 and was an active client as of the date of the inspection. A consent to release form was signed and dated on 05/15/16 to the funding source that allowed for the release of the aftercare treatment plan and the lab reports/EKG.
#4 was admitted on 05/31/2016 and was an active client as of the date of the inspection. A consent to release form was signed and dated on 05/31/16 to the funding source that allowed for the release of the aftercare treatment plan and the lab reports/EKG.
#5 was admitted on 05/20/2016 and was an active client as of the date of the inspection. A consent to release form was signed and dated on 05/20/16 to the funding source that allowed for the release of the aftercare treatment plan and the lab reports/EKG.
#7 was admitted on 04/29/2016 and was discharged on 05/20/2016. A consent to release form was signed and dated on 04/29/16 to the funding source that allowed for the release of the aftercare treatment plan and the lab reports/EKG.
#8 was admitted on 11/16/2015 and was an discharged on 12/15/2015. A consent to release form was signed and dated on 11/16/15 with the purpose of "Billing & Payments"; however, there was no name or organization to whom the disclosure was to be made to.
#9 was admitted on 01/15/2016 and was an discharged on 01/26/2016. A consent to release form was signed and dated on 01/15/216 with the purpose of "Billing & Payments"; however, there was no name or organization to whom the disclosure was to be made to.
#11 was admitted on 05/06/2016 and was discharged on 05/14/2016. A consent to release form was signed and dated on 05/06/16 to the funding source that allowed for the release of the aftercare treatment plan and the lab reports/EKG.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
--Malvern Institute does mandatory all staff training on Confidentiality and Pa Code 255.5 annually. Malvern Institute also has new employee orientation monthly for all new staff to the agency. During this monthly orientation, new staff receive education and training on Confidentiality and Pa Code 255.5.This allows for all new staff to be properly trained prior to starting their work at Malvern Institute.
--The Compliance Director of Malvern Institute will meet and re train all admissions and intake staff on Confidentiality and specifically PA Code 255.5.This training will occur by 8/30/2016. This training for admissions and intake staff will consist of the following information. A specific explanation and description of Pa Code 255.5. The 5 items that are allowed to be released will be specifically discussed 1 by 1. Discussed will also be who these 5 things can be released to in regards to funding sources, probation officers, governmental officials, judges and 3rd parties. IT will also be reiterated that the aftercare treatment plan and lab reports are to NOT be released to funding sources or any 3rd parties that fall under 255.5. Also included in this training for intake and admissions staff will be An education on the proper completion of authorizations/releases of information forms. This will include an explanation of the proper completion of filling out the name or organization to whom the disclosure is being made to.
--The Compliance Director in conjunction with The Director of Admissions and the Director of Utilization Review will redo and re organize the entire intake packet and all releases of information to ensure proper information and Protected Health Information is filled out. Once this information is redone the Compliance Director will consult the Malvern Institute attorney to ensure complete Compliance in this area.
--The following patients were active at time of the inspection--#1, #2, #3, #4 and #5. At the time of this POC all those patients had been discharged. The incorrect releases of these patients will be used as examples in the training and education that will be conducted for all intake and admissions staff. |