INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 4, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Newvitae, 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of four applicable personnel records reviewed.
Employee # 5 was hired as a counselor on June 22, 2020 and was due to have the HIV/AIDS training and the TB/STD training no later than June 22, 2021. The HIV/AIDS and TB/STD trainings were not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new tracking system will be put in place and overseen by lead clinician. All staff listed on DDAP roster will be signed up for needed trainings within 6 months of program involvement and will provide documentation of completion to lead clinician.
Employee #5 is scheduled for HIV on 12/8/21 and 12/9/21. TB/STD is scheduled for 12/6/21. Once complete she will provide completion certificate to lead clinician.
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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
Based on a review of client records, the facility failed to keep consent forms for the disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (a) for releases of information in three of seven client records reviewed.
Client # 5 was admitted on June 10, 2019 and was still active at the time of the inspection. There was a release of information form to a government agency, signed and dated by the witness on June 24, 2021, that allowed for the release of medications, recovery plans and therapy notes, all of which exceeded the limits established by 4 Pa. Code 255.5.
Client # 6 was admitted on March 31, 2021 and was discharged on August 12, 2021. There was a release of information form to the funding source, signed and dated by the witness on March 31, 2021, that allowed for the release of the discharge summary, continuing support (aftercare) plan, medications, medical history/medical information, psychological evaluation/testing report, recovery plans and lab reports (bloodwork/UDS, etc.), all of which exceeded the limits established by 4 Pa. Code 255.5.
Client # 7 was admitted on April 29, 2021 and was discharged on June 11, 2021. There was a release of information form to the funding source, signed and dated by the witness on April 9, 2021, that allowed for the release of the discharge summary, continuing support (aftercare) plan, medications, medical history/medical information, psychological evaluation/testing report, recovery plans and lab reports (bloodwork/UDS, etc.), all of which exceeded the limits established by 4 Pa. Code 255.5.
This is a repeat citation from the November 12, 2020 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Office administrator will remove the release of information from the eclinical record of client #2 that violates DDAP code 4 Pa. Code 255.5 (b). A new release will be completed by assigned clinician at next individual session.
Review citation and the error that occurred with all clinical staff to ensure they are aware of the limitations of release of information. Complete in house training on 4 Pa. Code 255.5 during clinical group supervision and review agency release of information form with the specific areas of release that fall within this code.
New staff and all office support staff that assist with intake or auditing will attend the DDAP confidentiality training as offered/available.
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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in four of seven client records reviewed.
Client # 4 was admitted on February 28, 2018 and was still active at the time of the inspection. The release of information forms to the emergency contact, the funding source, and the primary care physician were signed and dated by the witness on October 4, 2021, but none of the forms documented the dated signature of the client.
Client # 5 was admitted on June 10, 2019 and was still active at the time of the inspection. The release of information form to a government agency was signed and dated by the witness on June 24, 2021, but the form did not document the dated signature of the client.
Client # 6 was admitted on March 31, 2021 and was discharged on August 12, 2021. The release of information forms to another treatment provider, an emergency contact, and a funding source, were signed and dated by the witness on March 31, 2021, but none of the forms documented the dated signature of the client.
Client # 7 was admitted on April 29, 2021 and was discharged on June 11, 2021. The release of information forms to another treatment provider, a primary care physician, an emergency contact, and a funding source, were signed and dated by the witness on April 9, 2021, but none of the forms documented the dated signature of the client.
This is a repeat citation from the November 12, 2020 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During all staff meeting, director will review the citation and explain the confidentiality policy 709.28 (c) which requires a physical signature on all releases of information, noting that this regulation has not been suspended in conjunction with the Emergency Order related to the pandemic. All staff will sign understanding of new procedures in place.
Intake process will be updated to include mailing a physical copy of any signed releases to the client with return envelope. A collateral note will be completed to document the sending of documents and any additional attempts to request returning the document. Once returned, signed releases will be scanned to e-clinical record. No release of information will occur until signed consent is secured.
A new policy will be implemented and clients will be notified at initial referral that all intakes are mandatory in person unless they are unable to do so, at which time they can schedule a future date to report on site and provide a signatures for all verbal consent ROIs.
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