INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 12, 2020 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, ARS of Ephrata, LLC 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 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on the review of client records on November 12, 2020, the facility failed to document a completed informed and voluntary consent to release information form that included whether a copy was offered to the client in client record #1.
Client #1 was admitted on October 30, 2020 and was still active at the time of the inspection. Two releases of information forms to a government agency and another treatment facility did not indicate whether the client was offered a copy.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will provide a training to all staff on how to appropriately execute a voluntary consent to release information form. All new staff will be trained during their orientation on how to successfully execute a consent/release.
Quarterly peer review audits will be conducted on patient charts to ensure continued compliance with appropriately completing voluntary consent to release information forms.
During the review process, if a voluntary consent to release information form is completed incorrectly, it will be redone and signed by the patient at their next office visit. |
709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records on November 12, 2020, the failed to ensure that the client was made aware of their rights, including that reasons for removing sections shall be documented in the record in client record #'s 1, 2, 3, 4, 5, 6 and 7.
Client #1 was admitted on October 30, 2020 and was still active at the time of the inspection.
Client #2 was admitted on October 23, 2020 and was still active at the time of the inspection.
Client #3 was admitted on October 27, 2020 and was still active at the time of the inspection.
Client #4 was admitted on October 29, 2020 and was still active at the time of the inspection.
Client #5 was admitted on October 15, 2020 and was still active at the time of the inspection.
Client #6 was admitted on November 5, 2020 and was still active at the time of the inspection.
Client #7 was admitted on October 15, 2020 and was still active at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 11/12/2020 the Patient Bill of Rights consent form was updated in our EMR to include "that portions of the chart can be temporarily removed prior to the inspection of the records by the patient if it is determined that the information may be detrimental if presented to the patient and that the reasons for removing sections will be documented in the patient's chart."
All current patients received flags on their chart to have the new Bill of Rights signed by 11/30/2020. All new patients will sign this new Bill of Rights at admission and annually. |
709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on the review of client records on November 12, 2020, the facility failed to document a completed informed and voluntary consent to release information form that included whether a copy was offered to the client in client record #1.
Client #1 was admitted on October 30, 2020 and was still active at the time of the inspection. Two releases of information forms to a government agency and another treatment facility did not indicate whether the client was offered a copy.
The findings were reviewed with facility staff during the licensing process.
Based on a review of client records on November 12, 2020, the failed to ensure that the client was made aware of their rights, including that clients have the right to appeal a decision limiting access to their records in client record #'s 1, 2, 3, 4, 5, 6 and 7.
Client #1 was admitted on October 30, 2020 and was still active at the time of the inspection.
Client #2 was admitted on October 23, 2020 and was still active at the time of the inspection.
Client #3 was admitted on October 27, 2020 and was still active at the time of the inspection.
Client #4 was admitted on October 29, 2020 and was still active at the time of the inspection.
Client #5 was admitted on October 15, 2020 and was still active at the time of the inspection.
Client #6 was admitted on November 5, 2020 and was still active at the time of the inspection.
Client #7 was admitted on October 15, 2020 and was still active at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 11/12/2020 the Patient Bill of Rights consent form was updated in our EMR to include "that patients have the right to appeal a decision limiting their access to their records."
All current patients received flags on their chart to have the new Bill of Rights signed. All new patients will sign this new Bill of Rights at admission and annually.
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