INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 12-13, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the inspection, Lehigh County Center for Recovery 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
The patients' records reviewed during the onsite inspection had informed and voluntary consent to release information forms that did not list the purpose of the release of information for patients #10, #12 and did not list the information to be released for patient #13.
Patient #10's informed consent to release information form for a health care provider signed by the patient on 01/13/2017 did not list the purpose of the release.
Patient #12's informed consent to release information form for the funding source for the patient's treatment signed by the patient on 01/02/2017 did not list the purpose of the release.
Patient #13's informed consent to release information form for the patient's family member signed by the patient on 01/30/2017 did not list the information be released.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
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.
Clinical Supervisor responded to deficiency #0276.
Patient #10's informed consent to release information form for a health care provider signed by the patient on 01/13/2017 did not list the purpose of the release. This individual had been discharged at the time of the audit. Therefore the deficiency could not be corrected.
Patient #12's informed consent to release information form for the funding source for the patient's treatment signed by the patient on 01/02/2017 did not list the purpose of the release. This individual had been discharged at the time of the audit. Therefore the deficiency could not be corrected.
Patient #13's informed consent to release information form for the patient's family member signed by the patient on 01/30/2017 did not list the information be released. This individual had been discharged at the time of the audit. Therefore the deficiency could not be corrected.
Commencing May 1, 2017, the Clinical and Nursing Supervisors will retrain employees in their respective departments regarding appropriate completion of all releases. Particular attention will be paid to retraining staff regarding obtaining consent for the purpose for which consent to release is obtained and those items of information to be released.
The above mentioned supervisors will verify that each employee demonstrates understanding and compliance regarding obtaining and recording informed consent for each category of release used in their respective departments.
Effective 5/1/17, the Nurse Manager and Clinical Supervisor will conduct weekly spot checks of that week's admissions, and ensure that all areas of the releases found in the individual's chart have been appropriately completed. Subsequent reviews will be conducted prior to discharge to ensure compliance.
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715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of facility records conducted during the onsite inspection, the facility failed to verify the identities of four patients who were admitted for narcotic treatment.
Patient #2 was admitted for treatment on 01/18/2017 and was discharged on 01/23/2017.
Patient #3 was admitted for treatment on 01/09/2017 and was discharged on 01/13/2017.
Patient #4 was admitted for treatment on 01/11/2017 and was discharged on 01/15/2017.
Patient #5 was admitted for treatment on 01/16/2017 and was discharged on 01/21/2017.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
715.9(a)(2) LICENSURE (a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall: (2) verify the individual's identity, including name, address, date of birth, emergency contact and other identifying data.
Commencing June 1, 2017, the Intake coordinator (or nursing after for after hour admissions) will request verification of the individual's identity and other demographic information.
This verification may include:
* Any federal, state or local photo identification card, or legible copy of one (expired are acceptable), the facility will document on the back of any copy the source and/or sender. i.e. driver's license, non-driver license photo ID card, passport, PA citizen identify card, or any other form of photo identification that is provided by a governmental agency which include date of birth. *Student ID will be acceptable if it has the individual's date of birth.
* Unaltered check cashing photo identification Card.
If an individual does not have photo identification: a social security card and one of the following will be accepted:
*Birth Certificate
*Certificate of US citizenship or Consular report of Birth.
*Certificate of Naturalization.
After obtaining the appropriate identification, a photocopy will be made and placed in the individual's record.
The Nurse Manager will be responsible for continued compliance and will monitor the plan through weekly chart audits for a period of 3 months, through August 30, 2017.
Date of completion: June 1, 2017
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