INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 7, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Familylinks, 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.
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Observations
The facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
Client records were reviewed on March 7, 2019. Client record #3 contained letters sent to an outside agency without written consent by the client.
Client #3 was admitted on June 21, 2018 and discharged on November 27, 2018. Letters were sent to an outside agency on June 21, 2018 and September 13, 2018. There was no signed consent to release information to the outside agency documented in client record #3.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager reviewed findings with AOD clinical Staff during a meeting on March 19, 2019. During the meeting, 28 PA code 70928 Confidentiality & Department of Drug & Alcohol Program Confidentiality Guidelines for information sharing in accordance with PA Code 255.5 was reviewed and signed off by staff of understanding and implementing corrections. Process of Release of Information reviewed with AOD staff. Program manager/clinical supervisor will review each ROI prior to placing in client hard chart/electronic records. Program Manager/Clinical Supervisor will review all letters written for ROI as well as assuring information being released is within accordance of PA Code 255.5. Process implemented March 19, 2019 |
709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to document the specific information to be disclosed on the signed consents to release information in client records # 1 and 6.
Client records were reviewed on March 7, 2019. Client records #1 and 6 contained signed consents to release information that did not include the specific information to be disclosed.
Client #1 was admitted on August 9, 2018. Two releases of information signed by the client on August 9, 2018 did not include the specific information to be released.
Client #6 was admitted on September 19, 2018 and discharged on February 6, 2019. Four releases of information signed by the client on September 11, 2018 did not include the specific information to be released.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager reviewed findings with AOD staff on March 19, 2019. AOD staff reviewed 28 PA CODE 709.28 confidentiality and Department of Drug and Alcohol Program Confidentiality Guidelines for Information Sharing in Accordance with PA. Cod 255.5. Agency Release of Information form was reviewed with each staff how to complete the purpose of the disclosure and what specific information can be disclosed. Staff will document accordingly to the guidelines for information sharing. Program manager/Clinical Supervisor will review consents prior to being filed in client hard chart. AOD staff understand and this was implemented at completion of meeting on March 19, 2019. |
709.28 (c) (3) 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 must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
The facility failed to document the purpose of the disclosure on the signed consents to release information in client records # 1, 6 and 7.
Client records were reviewed on March 7, 2019. Client records #1, 6 and 7 contained signed consents to release information that did not include the purpose of the disclosure.
Client #1 was admitted on August 9, 2018. Two releases of information signed by the client on August 9, 2019 did not include the purpose of the disclosure.
Client #6 was admitted on September 19, 2018 and discharged February 6, 2019. Four releases of information signed by the client on September 11, 2019 did not include the purpose of the disclosure.
Client #7 was admitted on July 17, 2018 and discharged February 5, 2019. One release of information signed by the client on July 17, 2018 did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager reviewed findings with AOD staff on March 19, 2019. AOD staff reviewed 28 PA CODE 709.28 confidentiality and Department of Drug and Alcohol Program Confidentiality Guidelines for Information Sharing in Accordance with PA. Cod 255.5. Agency Release of Information form was reviewed with each staff how to complete the purpose of the disclosure. Staff will document accordingly to the guidelines for information sharing. AOD staff understand and this was implemented at completion of meeting on March 19, 2019. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
The facility failed to document that each buprenorphine patient was provided an average of 2.5 hours of psychotherapy per month for the patient's first 2 years.
Patient records were reviewed on March 7, 2019. Patient records #4, 5 and 6 did not include documentation of an average of 2.5 hours of psychotherapy per month.
Patient #4 was admitted on October 16, 2018. Patient #4 had 1.5 hours in November 2018, 1 hour in December 2018, 1.5 hours in January 2019 and 0 hours in February 2019.
Patient #5 was admitted on November 7, 2018. Patient #5 had .25 hour in December 2018 and 0 hours in January and February 2019.
Patient #6 was admitted on September 19, 2018. Patient #6 had 0 hours in November 2018, 20 minutes in December 2018 and 20 minutes in January 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
program manager reviewed deficiency with Therapists, medical Assistant, Physicians and CNRP on March 27, 2019.
Reviewed that all buprenorphine patient are required 2.5 hours of psychotherapy for the patients first 2 years. Action to be taken: Each Therapist will submit a weekly report to the Program manager and medical staff in the clinic if patient is compliant with attendance. If client is not compliant the Therapist will coordinate a meeting with patient and prescribing physician. A attendance contract will be reviewed during this time and sign off by all. If patient remains noncompliant with Psychotherapy the Therapist will move forward with a discharge plan and assist patient in seeking services outside of Familylinks. Action Review patient attendance for Psychotherapy with program goals in Treatment plan. Document how often patient will attend therapy. Monitor therapy and report weekly. If noncompliant with treatment team meeting, signed attendance contract. Implement on March 27, 2019 |