INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 10 - 11, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Arc Manor 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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709.83(a) LICENSURE Client records
709.83. 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record including medication records in two of four partial hospitalization client records.
The findings include:
Four partial hospitalization client records were reviewed on February 10 - 11, 2015. Four client records were reviewed for medication records including the name, dosage and frequency of use. The facility failed to document a medication record including the dosage and frequency of use in client records # 6 and 8.
Client # 6 was admitted into treatment on January 6, 2015. Client # 6 is prescribed the following medications: lithium, Prozac, Prilosec, Lamictal, Lipitor and Synthroid. The facility failed to document the dosage and frequency of use of these prescribed medications.
Client # 8 was admitted into treatment on November 10, 2014. Client # 6 is prescribed Adderall and trazodone. The facility failed to document the dosage and frequency of use of these prescribed medications.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This issue will be reviewed with all Clinicians in clinical staffing on Thursday, February 26, 2015 so that all staff have the understanding that this information is necessary on the client's psychosocial evaluation. In addition, treatment supervisors will clearly review the information presented in the physical and behavioral health sections of the psychosocial to ensure that dosage and frequency of use are noted before signing the psychosocial document. All staff will be advised that, if the client is not aware of the dosage or frequency of the medication, that this should be clearly noted in these sections of the psychosocial evaluation. |
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, the facility failed to obtain a written, informed and voluntary consent from the client for the disclosure of information contained in the client record in one of fourteen client records. In addition, the facility exceeded the limitations imposed at 4 Pa. Code 255.5 regarding the specific client information to be released to an insurance company in two of fourteen client records.
The findings include:
Fourteen client records were reviewed for written consents to release information from the client on February 10 - 11, 2015. The facility failed to obtain a written consent to release information from the client prior to releasing information contained in the client record to an insurance company in client record # 5. The facility exceeded the limitations imposed at 4 Pa. Code 255.5 regarding the specific client information to be released to an insurance company in client records # 5 and 12.
Client # 5 was admitted into treatment on December 3, 2014. A fax was sent to an insurance company on January 7, 2015. The fax included a copy of the client's drug screen results. The facility failed to obtain a written consent to release information from the client prior to the disclosure of information to the insurance company. The facility exceeded the limitations imposed at 4 Pa. Code 255.5 regarding the release of the drug screen results to the insurance company.
Client # 12 was admitted into treatment on June 2, 2014. A fax was sent to an insurance company on July 3, 2014. The fax included a copy of the client's drug screen results. The facility exceeded the limitations imposed at 4 Pa. Code 255.5 regarding the release of the drug screen results to the insurance company.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediately following the licensing exit interview, this information was reviewed with the current nursing staff who are assisting with the Buprenorphine treatment programming. This information was also reviewed with the Assistant Director and the Outpatient Treatment supervisor. At this point, it appears that the primary issue has been that specific commercial insurance physical health plans require confirmation of the client's most recent urine test from the client record for their prior authorization process in order to fund payment for the medication. Since the licensing inspection, we have submitted a letter on agency letterhead to the insurance provider with information that falls within the confidentiality guidelines of 4 Pa. Code 255.5 and no further drug test results will be released. To ensure compliance with this plan of correction, a quarterly spot check of Buprenorphine client files will be completed by the Clinical Director to monitor the information released to insurance companies for prior authorization. This spot check will be reviewed in the quarterly Evaluation & Monitoring Committee meetings.
Regarding the information that was released without a valid client consent, the counselor in question is no longer an employee of this agency and therefore, no individual supervision can occur to correct the issue. However, to ensure overall agency compliance with Confidentiality regulations, ARC Manor Board of Directors is now requiring all staff to attend DDAP approved confidentiality training every 2 years. |