INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 1 - 2, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, WPIC Center for Psychiatric and Chemical Dependency Services 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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715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
The facility failed to document that each female patient was fully informed of the possible risks to her or her unborn child in two of two female patient records reviewed during the annual licensing inspection conducted on August 1 - 2, 2016.
Patient # 8 was admitted into treatment on November 3, 2015 and prescribed Suboxone on July 12, 2016.
Patient # 9 was admitted into treatment on November 18, 2015 and prescribed Suboxone on March 31, 2016.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Under the direction of the Facility Director or designee:
A.)All physicians will be advised that all female individuals will be informed of possible risk should they become pregnant while on buprenorphine by 9/15/16.
B.)A review of harmful effects will be completed and signed by the physician and the individual on the first physician appointment beginning 9/1/16. For all active individuals who were cited in this audit ( #8,9) a harmful effects form will be reviewed and signed by these female patients on Buprenorphine by no later than 10/1/16.
C.)Monthly chart audits will be conducted by the program supervisors beginning 10/1/16 for 4 months to verify that a Harmful Effects document has been signed by female individuals.
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711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) 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
The facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in twelve of twelve client records reviewed during the annual licensing inspection conducted on August 1 - 2, 2016.
The facility utilizes a form (3CNTB number 0421-1015-(M)(P)(l)-KEY) entitled "UPMC - Consent for Mental Health and Drug and Alcohol Treatment, Payment and Health Care Operations (TPO)". This form is a combination of a consent to treatment and a consent to release information. The client is required to sign the consent form during the intake process in order to receive treatment services. This is not a voluntary consent, as the client cannot receive treatment without also consenting to release information at the same time. In addition, the form is not compliant with Federal and State confidentiality laws and regulations as follows:
Section I - number 4, Section IV - numbers 3 and 4 and Section V - numbers 3 and 7 violate Federal Law 42 CFR Part 2, Subpart C, in that they are a general consent to release information. The components of a valid consent are not included as required by 42 CFR Part 2, Subpart C, 2.31.
Section IV - number 2 - The statement pertaining to UPMC privacy practices, limits information released to agencies/individuals that are not restricted by 4 Pa. Code 255.5 (b).
The last section titled "minor able to consent for care" does not take into consideration the drug and alcohol laws and regulations pertaining to minors (71 P.S. 1690.112 (a)(b) and 42 CFR Part 2, Subpart B, 2.14 (b).
Client # 1 was admitted into treatment on September 21, 2015 and was discharged on April 13, 2016. The UPMC consent form was signed on September 21, 2015.
Client # 2 was admitted into treatment on September 16, 2015 and was discharged on February 17, 2016. The UPMC consent form was signed on September 16, 2015.
Client # 3 was admitted into treatment on October 13, 2015 and was discharged on May 31, 2016. The UPMC consent form was signed on October 13, 2015.
Client # 4 was admitted into treatment on December 10, 2015 and was discharged on April 27, 2016. The UPMC consent form was signed on December 10, 2015.
Client # 5 was admitted into treatment on August 17, 2015 and was discharged on June 6, 2016. The UPMC consent form was signed on August 17, 2015.
Client # 6 was admitted into treatment on November 12, 2015 and was discharged on April 25, 2016. The UPMC consent form was signed on November 12, 2015.
Client # 7 was admitted into treatment on September 9, 2015 and was discharged on December 29, 2015. The UPMC consent form was signed on September 9, 2015.
Client # 8 was admitted into treatment on November 3, 2015. The UPMC consent form was signed on November 3, 2015.
Client # 9 was admitted into treatment on November 18, 2015. The UPMC consent form was signed on November 18, 2015.
Client # 10 was admitted into treatment on February 3, 2016. The UPMC consent form was signed on February 3, 2016.
Client # 11 was admitted into treatment on October 20, 2015. The UPMC consent form was signed on October 20, 2015.
Client # 12 was admitted into treatment on January 6, 2016. The UPMC consent form was signed on January 6, 2016.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Under the direction of the Facility Director or designee:
A.)Effective 9/1/16, individuals will be offered releases of information to sign for their insurance providers upon admission and then annually. The release will be voluntary and separate from the consent to treatment. For all active individuals who were cited in this audit ( 8,9,10,11,12) consents to insurance provider will be reviewed and signed by 10/1/16.Consents utilized will be compliant with Federal and State confidentiality laws and regulations.
B.)Monthly chart audits will be conducted by the program supervisors beginning 10/1/16 for 4 months to verify that releases of information have been offered to individuals for their insurance company and documented in the medical record.
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711.93(c)(3) LICENSURE Copy-Client Consent
711.93. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
The facility failed to provide documentation that a copy of a client consent was offered to the client in twelve of twelve records reviewed during the annual licensing inspection conducted on August 1 - 2, 2016.
No documentation of this offer was included in the client orientation packet, consent to the funding entity or the client progress notes.
Client # 1 was admitted into treatment on September 21, 2015 and was discharged on April 13, 2016. A consent to the funding entity was signed on September 21, 2015.
Client # 2 was admitted into treatment on September 16, 2015 and was discharged on February 17, 2016. A consent to the funding entity was signed on September 16, 2015.
Client # 3 was admitted into treatment on October 13, 2015 and was discharged on May 31, 2016. A consent to the funding entity was signed on October 13, 2015.
Client # 4 was admitted into treatment on December 10, 2015 and was discharged on April 27, 2016. A consent to the funding entity was signed on December 10, 2015.
Client # 5 was admitted into treatment on August 17, 2015 and was discharged on June 6, 2016. A consent to the funding entity was signed on August 17, 2015.
Client # 6 was admitted into treatment on November 12, 2015 and was discharged on April 25, 2016. A consent to the funding entity was signed on November 12, 2015.
Client # 7 was admitted into treatment on September 9, 2015 and was discharged on December 29, 2015. A consent to the funding entity was signed on September 9, 2015.
Client # 8 was admitted into treatment on November 3, 2015. A consent to the funding entity was signed on November 3, 2015.
Client # 9 was admitted into treatment on November 18, 2015. A consent to the funding entity was signed on November 18, 2015.
Client # 10 was admitted into treatment on February 3, 2016. A consent to the funding entity was signed on February 3, 2016.
Client # 11 was admitted into treatment on October 20, 2015. A consent to the funding entity was signed on October 20, 2015.
Client # 12 was admitted into treatment on January 6, 2016. A consent to the funding entity was signed on January 6, 2016.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A.)Effective 9/1/16 individuals will be offered a copy of all consents. This will be documented in the orientation packet and an acknowledgment of receipt will be signed by the individual on intake to the program. For all active individuals who were cited in this audit ( 8,9,10,11,12)and orientation packet will be reviewed and signed by the patient by 10/1/16.
B.)Monthly chart audits will be conducted by the program supervisors beginning 10/1/16 for 4 months to verify that this signed acknowledgment is occurring and that a copy is in the medical record.
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