INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 8-9, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Habit OPCO, Inc. 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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent for the disclosure of information contained in the client record in 7 of 16 client records reviewed.
The findings include:
Sixteen client records were reviewed April 8-9, 2014. Sixteen client records were required to include documentation of an informed and voluntary consent from the client for the disclosure of information contained in the client record.
Client record # 3 contained two consent to release information forms for funding sources that were dated March 21, 2014. The facility released "information for payment" that exceeded the limitations imposed at 4 Pa. Code subsection 255.5 (b).
Client record # 8 contained a consent to release information form dated 4-3-14 to release information to a government agency. The facility released information that exceeded the limitations imposed at 4 Pa. Code subsection 255.5 (b). The information released included information on mental health issues, urinalysis results and treatment recommendations. Another consent to release information dated 3-21-14 to a funding source exceeded the limitations imposed at 4 Pa. Code subsection 255.5 (b) by releasing the psychosocial evaluation and utilization review information.
Client record # 9 contained a consent to release information form to a probation officer dated 3-31-14. This form allowed for the release of "information requested" failing to list the specific information that would be released. The purpose for the release of information was listed as "all information requested". This consent to release information form exceeded the limitations imposed at 4 Pa. Code subsection 255.5 (b) and was a general consent to release information which is prohibited at 42 CFR Part 2, Subpart C, subsection 2.32. A third consent to release information documented in this record included under the purpose section the language "possible transfer, "all records needed". This was again a general consent to release information which is prohibited at 42 CFR Part 2, Subpart C, subsection 2.32.
Client record # 10 contained an incomplete consent to release information form which had been signed by the client but was blank relative to the specific information that would be released, the purpose of the release of information and the name of the entity that was to receive the information. This is also a violation of the federal regulations at 42 CFR Part 2, Subpart C, subsection 2.31.
Client record # 11 contained a consent to release information form to a probation officer dated 4-1-14 allowing for the release of "all information required regarding client's participation". This consent to release information form exceeded the limitations imposed at 4 Pa. Code subsection 255.5 (b) and was a general consent to release information which is prohibited at 42 CFR Part 2, Subpart C, subsection 2.32.
Client record # 15 contained a consent to release information form dated 3-25-14 to the client's funding source allowing for the release of the client's psychosocial evaluation and utilization review information. This consent to release information form exceeded the limitations imposed at 4 Pa. Code subsection 255.5 (b).
Client record # 16 contained two consent to release information forms to funding sources which allowed for the release of information that exceeded the limitations imposed at 4 Pa. Code subsection 255.5(b).
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Plan of Correction
A presentation was offered to all staff during the Monthly staff meeting on April 23, 2014 in concert with the contents that are allowable under 4 PA code § 255.5 per varying agencies. A detailed in-service will be prepared and presented to all staff related to this subject matter to ensure continued compliance. The in-service training was provided on 05/14/2014 to ensure continued and knowledgeable compliance by all departments related to this subject matter and the accurate and legal completion of authorizations.Ongoing compliance will be monitored via random chart reviews by Clinic Director. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on the review of client records, the facility failed to ensure all verbal medication orders were signed and dated within 24 hours as required in two of three client records.
The findings include:
Sixteen client records were reviewed April 8-9, 2014. Three client records contained documentation of verbal medication orders issued by a physician. Two client records contained verbal medication orders that were signed by the physician more than 24 hours after the verbal order was issued.
Client record # 10 contained two separate verbal orders that were not signed by the physician within 24 hours. A verbal order was issued by the physician on 4-3-14, but not signed by the physician until 4-5-14. Another verbal order issued on 4-6-14 was not signed until 4-8-14.
Client record # 14 contained a verbal order issued by the physician on 4-5-14, but was not signed by the prescribing physician until 4-8-14.
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Plan of Correction
As a result of previous noted deficiencies to this end, continued IT steps have been taken to correct log on ability of the Physician to ensure Physician access to the EHR when Physician is not on site. It has been confirmed that these steps are resolved as of April 16, 2014.
Additionally, nursing staff have commenced with electronic notification(s) to the Physician that verbal orders are ready for signing at the end of each business day to ensure compliance to this regulation is met. Physician has received education from Supervisory staff to this end as well.
Ongoping compliance will be monitored via random chart audits by Clinic Director. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on the physical plant inspection conducted during the inspection, the facility failed to display the hours of project operation conspicuously to the general public as required.
The findings include:
A physical plant inspection was conducted April 9, 2014. It was noted that the project operation hours were not displayed for the general public as required.
Facility staff confirmed the hours were no longer posted for the general public.
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Plan of Correction
A new sign, listing the hours of operation and emergency contact information has been created and posted as of April 28, 2014. Sign has been placed in a very conspicuous location for public view at the front entry. The Security Associate will check to ensure that it remains posted when conducting Safety and Sanitation Inspections on a weekly basis. He/she will report findings to the Clinic Director. |