INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 26, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Treatment Services 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 the review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in two out of seven client records reviewed. Client #1 was admitted on May 25, 2021 and was discharged on August 30, 2021. There was documentation to a county agency on May 25, 2021 and June 15, 2021; however, there was no proper consent to release information form signed by the client prior to disclosure.Client #7 was admitted on July 21, 2021 and was still active at the time of the inspection. There was documentation to two county agencies dated July 21, 2021 and July 28, 2021; however, there was no proper consent to release information form signed by the client prior to disclosure.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All patients are asked to come into the agency for their intake sessions to assure releases of information are being signed. If for some reason they are unable to, patients are given a "signature session" date and time to come sign releases or releases are being mailed out and sent back in extreme cases.
This process will be reviewed weekly in our QA meeting and Quality Management Officer will touch base with intake workers daily to assure this is occurring.
Full compliance will be achieved on February 21,2022.
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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, the facility failed to inform the client of all of their rights. The client rights form given to the client did not identify that 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 in seven out of seven records.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As a result of licensing, we have contacted our EMR system and will have adjustments made and added onto the "Client Bill of Rights" form that is already in our EMR system to fully address the patient's rights to inspect their records.
The Executive Director and Quality Management officer will make sure these changes are made and explained to the patient when signing off on the form.
Full compliance will be achieved by February 28, 2022. |
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 a review of client records, the facility failed to inform the client of all of their rights. The client rights form given to the client did not identify that clients have the right to appeal a decision limiting access to their records to the director in seven out of seven records. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As a result of licensing, we have contacted our EMR system and will have adjustments made and added onto the "Client Bill of Rights" form that is already in our EMR system to fully address the patient's right to appeal a decision in their records.
The Executive Director and Quality Management officer will make sure these changes are made and explained to the patient when signing off on the form.
Full compliance will be achieved by February 28, 2022. |
709.30 (5) 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.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records, the facility failed to inform the client of all of their rights. The client rights form given to the client did not identify that clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in seven out of seven records. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As a result of licensing, we have contacted our EMR system and will have adjustments made and added onto the "Client Bill of Rights" form that is already in our EMR system to fully address the patient's right to request the correction of information from their records.
The Executive Director and Quality Management officer will make sure these changes are made and explained to the patient when signing off on the form.
Full compliance will be achieved by February 28, 2022. |
709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to inform the client of all of their rights. The client rights form given to the client did not identify that clients have the right to submit rebuttal data or memoranda to their own records in seven out of seven records. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As a result of licensing, we have contacted our EMR system and will have adjustments made and added onto the "Client Bill of Rights" form that is already in our EMR system to fully address the patient's right to submit rebuttal or memoranda to own records.
The Executive Director and Quality Management officer will make sure these changes are made and explained to the patient when signing off on the form.
Full compliance will be achieved by February 28, 2022. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of client records, the facility failed to inform the Department of an unusual incident within the required three days. It was discovered that the facility had an unusual incident occur on July 3, 2021, July 10, 2021 and July 29, 2021 all which involved death of a clients. Upon further inspection, it was discovered that the facility had not submitted a written unusual incident report to the Department within the regulatory three business day timeframe.These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
As a result of the licensing visit, Executive Director and Quality Management officer reviewed the process for reporting unusual incidents on DDAP website to provide clarification and guidance.
Quality Management Officer will report these unusual incidents within three days following the incident to DDAP and maintain a copy of the report here in a facility file.
Full compliance will be achieved on February 21, 2022. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in two out of three discharged records reviewed.Client #1 was admitted on May 25, 2021 and was discharged on August 30, 2021. Client #3 was admitted on July 8, 2021 and was discharged on November 2, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Follow up sessions are outlined at our Agency to contact the patient within 60 days after a successful completion. If efforts were successful, a follow up survey will be completed in the chart. If we are unable to contact the patient, a general contact will be noted that attempts were made to complete follow up. if the 60 day follow up is successful, then a 6 month follow up will occur again and noted in the chart.
Staff will be re-educated on this process by the Quality Management Officer and the QMO will also check for follow up sessions being scheduled.
Full compliance by February 21, 2022. |