INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 2, 2018 through February 5, 2018 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 WES Corporation 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 a review of 8 client records, 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 1 client record. Additionally, 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 # 1 was admitted on 8/24/17 and was still an active client at the time of the inspection. There was documentation of a phone call made to another agency on 11/13/17; however, there was no proper consent form on file prior to disclosure.
Client # 5 was admitted on 5/8/17 and was discharged on 9/21/17. The record contained a consent to release information form to a probation officer, signed and dated on 5/31/17, which allowed for the release urine screening results, which exceeded the limits established by 4 Pa. Code 255.5. There was documentation that a phone call was made to the probation officer on 6/12/17 in which urine screening dates and results were released.
Client # 6 was admitted on 2/21/17 and was discharged on 6/14/17. There was a consent to release information form signed and dated by the client on 3/2/17 to the funding source; however, the consent form expired on 3/2/17. There was no updated consent to release to the funding source documented at the time of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Based on the State's finding for our audit review on 2/2/2018 the Drug and Alcohol program director and quality management director met with the team to discuss deficiencies. Each team member has been given up to 10 days to review their caseload to make sure every member has all appropriate consents currently on file and to obtain needed consents for those that are missing. Each team member has been instructed to review each of their client's consents to make sure all information and dates on their consent are correct. Where there are any corrections needed a new consent has been instructed to be completed and signed by the client. After the 10 day period, the program director will met individually with each team member to review their caseload and make sure there are present consents for all agencies, supports, and affiliates; and that all changes and updates have been made.
The program director and quality management director will have training with the drug and alcohol program team to instruct and review when to obtain consents, for whom they are needed and the limitations of information that should be given to individuals when consent is present. We will also review completing the consent and the information that should be present. We will give examples of how to decline providing information without a proper consent present and how to follow-up with the client. The training will take place within 30 days and will be recorded with a sign-in document.
Going forward to make sure this occurrence is not repeated, the program director and quality management team will review charts on an on-going basis (quality management team reviews weekly) with included emphasis on proper consents. The director will review progress notes to make sure release of information is being adhered to and confidentiality is maintained.
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709.93(a)(11) LICENSURE Client records
709.93. 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:
(11) Follow-up information.
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Observations
Based on a review of 8 client records, the facility failed to provide a complete client record in 5 of 5 applicable client records.
Client # 4 was admitted on 7/14/17 and was discharged on 12/22/17. The record did not contain documentation of follow-up.
Client # 5 was admitted on 5/8/17 and was discharged on 9/21/17. The record did not contain documentation of follow-up.
Client # 6 was admitted on 2/21/17 and was discharged on 6/14/17. The record did not contain documentation of follow-up.
Client # 7 was admitted on 1/6/17 and was discharged on 8/15/17. The record did not contain documentation of follow-up.
Client # 8 was admitted on 5/2/17 and was discharged on 7/16/17. The record did not contain documentation of follow-up.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Based on the State's findings regrading code 709.93, the director has met with the Drug and Alcohol team to discuss follow-up procedures when an individual is discharged. For each member discharged, it will be the responsibility of the team to make sure follow-up outreach is done within 30 days after discharge, via face-to-face, telephone contact, or mail. Each follow-up will be documented in the clients chart with a case management note indicating the type of follow-up outreach that was done. This is instructed to begin immediately.
To insure this is not repeated in the future, each team member is expected to keep a discharge log of each member they discharge. Until follow-up is made and documented, the team will not remove and update the client's status as discharged in their electronic medical record chart (EMR). This will be reviewed and checked by the director during regular on-going individual supervision. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on the review of the facility's policy and procedure manual on February 2, 2018, the facility failed to develop and write a client follow-up policy.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
WES's Quality Management Director, is currently developing a follow-up policy for the Drug and Alcohol program to be completed within 30 days; thereafter the program will adhere to the new policy immediately.
The drug and Alcohol program will place a copy of the new follow-up policy, via the Quality Management Director, in the drug and alcohol procedure manual to be available for review whenever requested.
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