INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 12, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Newvitae, Inc. 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) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in one of five client records reviewed.
Client # 2 was admitted on June 10, 2019 and was still active at the time of the inspection. There was a release of information form to the funding source, signed and dated by the client on June 8, 2020, that allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5, which included the release of demographic information, discharge summary, continuing support (aftercare) plan, diagnosis, medications, medical history/medical information, psychiatric evaluations, psychological evaluations/testing report, recover plan and lab reports (bloodwork, UDS, etc.)
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Office administrator will immediately remove the release of information from the e-clinical record of client #2 that violates DDAP code 4 Pa. Code 255.5 (b). Assigned clinician will call Client #2 and a new release of information will be completed immediately.
Director will review citation and the error that occurred with all clinical staff to ensure they are aware of the limitations of release of information. Director will also conduct an in house training on 4 Pa. Code 255.5 during clinical group supervision and review agency release of information form with the specific areas of release that fall within this code.
As trainings become available in this area, all staff who have not completed the DDAP Confidentiality training will be registered and will provide certificate of completion to supervisor. |
709.28 (c) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
The facility failed to ensure that all consent to release information forms documented the dated signature of the client in two of five client records reviewed.
Client # 2 was admitted on June 10, 2019 and was still active at the time of the inspection. Release of information forms to another treatment provider, to a public defender, to a parole officer, to a primary care physician, to an emergency contact and to a funding source were all signed and dated by the witness on June 8, 2020.
Client # 3 was admitted on November 2, 2020 and was still active at the time of the inspection. Release of information forms to a family member, to a physician, and to a funding source were all signed and dated by the witness on November 2, 2020.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Intake process will be updated to include mailing a physical copy of any signed releases to the client with return envelope. A collateral note will be completed to document the sending of documents and any additional attempts to request returning the document. Once returned, signed releases will be scanned to e-clinical record. No release of information will occur until signed consent is secured.
During all staff meeting, director will review the citation and explain the confidentiality policy 709.28 (c) which requires a physical signature on all releases of information, noting that this regulation has not been suspended in conjunction with the Emergency Order related to the pandemic. All staff will sign understanding of new procedures in place.
All releases without physical signatures will be printed and mailed to respective clients.
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