INITIAL COMMENTS
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This report is a result of an onsite licensure renewal inspection. The inspection was conducted on September 24-28, 2012 by staff from the Division of Program Licensure. Based on the findings of the onsite inspection, Drug and Alcohol Rehabilitation Services, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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 the review of administrative materials and interviews with the Project and Facility Directors, the facility failed to document Qualified Service Organization Agreements or consents to release information for entities which provide services to the project and in providing those services are exposed to client identifying information.
The findings include:
Administrative materials including policies and procedures and letters of agreement were reviewed during the annual licensure renewal inspection conducted on September 24-28, 2012. There was no documentation of Qualified Service Organization Agreements (QSOA)or consents to release information for businesses that provide services to the Project. There was no documentation of a QSOA or individual consent to release information forms for releases of information to a pharmacy.
Interviews with the Project and Facility Directors on 9/25/2012 verified that no such agreements or consents to release were documented at the time of the inspection . The findings were reviewed with the Directors and were disputed, but no additional documentation was provided to demonstrate that the requirements of this regulation were met.
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Plan of Correction
DARS, Inc. Manos House will develop and maintain Qualified Service Organization Agreements (QSOA) with contracted service agencies to ensure that restrictions related to client confidentiality set forth at 42 C.F.R. and at 4 Pa. Code 255.5 are maintained. QSOA's will be developed with all current contracted service providers including, but not limited to, the Queen Street Pharmacy, which was established on October 26, 2012. All other releases of client information will be obtained and maintained by the primary counselor through signed release of information forms filed in the individual client's file. All QSOA's will be developed by the Treatment Director, and maintained with Administrative materials. Any future contracted agencies will be required to sign a QSOA prior to completing a service. This again will be developed and maintained by the Treatment Director. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on the review of client records, the facility failed to ensure that each client received a physical examination within seven days of admission in three of six client records.
The finding includes:
Documentation of a physical examination was required in six of seven client records reviewed from September 24-28, 2012. Three of the six client records failed to include documentation of a physical examination upon admission.
Client record # 1- The client was admitted on 1/17/12. The physical examination was documented on 1/30/12, thirteen days after admission.
Client record # 2- The client was admitted on 8/27/12. There was no documentation of a physical examination in the client record as of September 26, 2012.
Client record # 3- The client was admitted on 9/6/12. There was no documentation of a physical examination in the client record as of September 26, 2012.
The findings were reviewed with the Project and Facility Directors and were not disputed.
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Plan of Correction
Upon admission, DARS, Inc. Medical Department will gather all necessary information to ensure that all clients receive their physicals within seven business days. If a client's insurance information is unavailable or the previous Primary Care Physician cannot be switched to a local Primary Care Physician, within the allotted timeframe, DARS, Inc. has established a corporate care account with MedExpress Urgent Care located in Lancaster, PA. This location will render all physical exams that cannot be completed through the client's primary insurance. Monitoring of this procedure will be maintained by the DARS, Inc. Medical Department with additional oversight through the Treatment Director. A physical exam for Client #2 was completed on 8/20/12, and placed in the client's file. A physical exam for Client #3 was completed on 9/13/2012 and placed in the client's file. |