INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 3, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, SPHS Behavioral Health - New Kensington 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 and a plan of correction is due on March 28, 2010.
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, qualified service organization agreements and an interview with the facility director, the facility failed to document an informed and voluntary consent or a qualified service organization agreement when releasing urine samples to an outside agency for testing in five of five client records.
The findings include:
Ten outpatient client records were reviewed on March 3, 2010. Urine samples were sent to an outside agency in five client records. Client records # 6, 7, 8, 9 and 10 did not include a signed consent to release information form nor was a qualified service organization agreement in place for the outside agency.
The facility director was interviewed on March 3, 2010 and confirmed the facility did not have a qualified service organization agreement with the agency that conducts urine testing. The facility director also confirmed that informed and voluntary consents had not been completed for clients who were participating in urine testing. The facility director reported a qualified service organization agreement will be obtained with the agencies that provide this testing for the facility.
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Plan of Correction
Project Director will obtain a Qualified Service Organization Agreement with all testing companies for the purpose of releasing drug testing samples and bloodwork. Clinical Supervisor will train staff on use of Consent to Release Information for appropriate laboratory testing companies until the QSOA is signed and received by Facility.
It shall be the responsibility of the Project and Facility Directors to obtain and maintain all QSOAs with testing companies for drug testing and bloodwork. It shall be the responsibility of the Project and Facility Director to insure ongoing compliance with this regulation through yearly reviews of all QSOAs.
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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 and an interview with the clinical supervisor, the facility failed to document follow up contact in two of two outpatient client records.
The findings include:
Ten outpatient client records were reviewed on March 3, 2010. Two of the client records reviewed required a six month follow up contact, per agency policy. The facility did not document follow up contact in client records # 1 and 4.
Client #1 was admitted on April 14, 2009 and discharged on July 2, 2009. Follow up contact was due by January 2, 2010. There was no documentation of follow up contact in client record #1.
Client #4 was admitted on May 20, 2009 and discharged on July 15, 2009. Follow up contact was due by January 15, 2010. There was no documentation of follow up contact in client record #4.
An interview with the clinical supervisor took place on March 3, 2010 at approximately 10:30 AM. The clinical supervisor confirmed that there was no follow up documentation in the aforementioned client records.
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Plan of Correction
Clinical Supervisor will review Policy and Procedure regarding 6 month Follow-Ups with clerk-typist. Clerk typist is responsible for mailing all follow-up letters.
It shall be the responsibility of the Clinical Supervisor to insure all 6 month follow-up letters are mailed per Policy and regulation. |