INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 1, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Family Service Association of Bucks County 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 7 client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 2 records reviewed.
Client #5 was admitted on 02/24/2017 and was discharged on 07/11/2017. There was documentation of the facility billing the funding source throughout the client's treatment; however, there was no proper consent to release information form signed by the client prior to the disclosure of information.
Client #6 was admitted on 07/17/2017 and was discharged on 10/12/2017. There was documentation that a letter was facsimile was sent to a government agency on 09/15/2017; however, there was no proper consent to release information form signed by the client prior to the disclosure of information.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client #5 releases were obtained on 2/24/17. This was prior to the changes we made to the releases after our DDAP POC for the Langhorne audit held on 2/14/17 and 2/15/17. At the time, releases were all obtained in one electronic health record service and therefore not separate, distinct forms. Based on recommendation from our auditor, FS explored best practices and made the decision to separate the releases so each is its own distinct form. This helped ensure that the correct information was going to the correct form. This client is closed so an updated release cannot be obtained.
Client #6 had a letter sent to DPW without a release. This was a request made by the client and not to obtain the release was human error. This client is closed so a release can no longer be obtained.
To address concerns about releases moving forward, emails have gone out to clinicians and support staffs about, 1) ensuring releases have all necessary information; 2) that staffs are using the correct release (legal versus treatment); and 3) that clients are completing a release whenever there is any type of contact with someone else, even when the contact is requested by the client. Full compliance is expected by 12/1/17.
In ongoing efforts to address improve the releases, and to promote greater understanding of DDAP Confidentiality, we have reached out to our SCA with the request for Confidentiality Training for our staff at Family Service. While no date is yet confirmed, we are exploring January or February 2018 for this training, which will be a mandatory training.
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709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of 7 client records, the facility failed to provide documentation of the client's complete and accurate drug and alcohol history in 5 records reviewed.
Client #1 was admitted on 08/09/2017 and was still an active client at the time of the inspection.
Client #2 was admitted on 05/01/2017 and was still an active client at the time of the inspection.
Client #4 was admitted on 06/12/2017 and was still an active client at the time of the inspection.
Client #5 was admitted on 02/24/2017 and was discharged on 07/11/2017.
Client #6 was admitted on 07/17/2017 and was discharged on 10/12/2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
There were some incidents when a complete drug and alcohol history was not obtained by the clinician.
Client #1 is still active. Therapist will do an updated D&A hx with this client by 12/15/17.
Client #2 is still active. The client and clinician will complete an updated D&A hx by 12/15/17.
Client #4 is still active. Therapist will complete an updated D&A hx by 12/15/17.
Clients #5 and 6 are closed so no updates can be obtained.
To address the issue of incomplete histories, we reviewed our BPS assessment. In the form, clinicians are able to select the substances the client reports using. If there is no report of a particular substance being used, the clinician does not select the substance and therefore it does not show in the completed BPS. We reviewed and updated the list of substances and met with the System Administrator on 11/15/17 to determine what we can do in the electronic health system. To ensure that all substances addressed are shown in the BPS, she will make all substances required with a choice of "N/A" if no reported use or "Yes" if reported use. If "Yes" is chosen, the text box will open to allow clinicians to enter all required information. This will include the substance, age of first use; date of last use; route of admission; frequency; quantity and how often in last 30 days. Supervisors will work with clinicians to educate them about the need to completely gather and document the required information. Full compliance based on all corrective actions is expected by 12/15/17.
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