INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on October 22, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Colonial House Outpatient 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
Based on four of seven client records reviewed, the facility failed to provide documentation of an informed and voluntary consent from the client for the disclosure of information prior to the release of information.
Client # 1 was admitted on May 23, 2020 and was still active at the time of the inspection. An informed and voluntary consent to disclose form dated May 20, 2020 to a funding source, a parole officer, a lab, and a medical center was not signed by the client. After confirmation with the facility director and review of the client chart, it was established that disclosures were still occurring for the funding source, parole office, lab, and medical center.
Client # 3 was admitted on February 27, 2020 and was still active at the time of the inspection. An informed and voluntary consent to disclose form dated June 18, 2020 to a funding source, and a drug and alcohol program was not signed by the client. After confirmation with the facility director and review of the client chart, it was established that disclosures were still occurring for the funding source and drug and alcohol program.
Client # 5 was admitted on August 27, 2020 and was discharged on October 16, 2020. An informed and voluntary consent to disclose form dated August 27, 2020 to a funding source, and a medical center was not signed by the client. After confirmation with the facility director and review of the client chart, it was established that disclosures were still occurring for the funding source and medical center. Also, Faxes with the client ' s evaluation and assessment report was released on August 27, 2020 without a valid consent to release form.
Client # 6 was admitted on June 18, 2020 and was discharged on August 6, 2020. An informed and voluntary consent to disclose form dated June 10, 2020 to a funding source, probation officer, and drug and alcohol program was not signed by the client. After confirmation with the facility director and review of the client chart, it was established that disclosures were still occurring for the funding source, probation officer, and drug and alcohol program.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will be responsible for ensuring that staff are making every attempt to ensure that while conducting Telehealth services, consent to release and client rights forms are being signed by clients. Clients will be given the opportunity to either come to the office to sign the document and/or that the document is mailed to the client for the client to return. These attempts will be documented within the clinical documentation of staffs attempts. The Clinical supervisor will also be responsible for conducting monthly chart audits to ensure that these procedures are followed.
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on three of seven client records reviewed, the facility failed to provide written acknowledgement by clients that they have been notified of their rights in client records # 1, 5, and 6. Client rights forms provided in the client records did not provide a signature or other written documentation of acknowledgement.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will be responsible for ensuring that staff are making every attempt to ensure that while conducting Telehealth services, clients will provide written acknowledgement that they have been notified of their rights. Clients will be given the opportunity to either come to the office to sign the document and/or that the document is mailed to the client for the client to return. These attempts will be documented within the clinical documentation of staffs attempts. The Clinical supervisor will also be responsible for conducting monthly chart audits to ensure that these procedures are followed. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on review of seven of seven client records, the facility failed to document on the client rights form the verbiage "sex" when notifying clients that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will ensure that the Client's Rights Form is changed to include the verbiage 'sex" when notifying clients that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. |