INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 11, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Hispanic American Organization 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) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure was to be made to on consent to release information forms in two of seven client records reviewed.
Client #1 was admitted on September 9, 2024 and was active at the time of inspection. A release of information form, signed and dated by the client on September 9, 2024, indicated the name of the person to whom disclosure would be made to as "Adult Probation/Parole pending", which is not specific.
Client #3 was admitted on October 1, 2024 and was active at the time of inspection. A release of information form, signed and dated by the client on October 1, 2024, indicated the name of the person to whom disclosure would be made to as "Adult Probation/Parole pending", which is not specific.
This is a repeat citation from the February 15, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Actions Taken/Planned:
Immediate Correction of Client Records:
We will update the consent to release information forms for Client #1 and Client #3 within 48 hours to clearly specify the name of the person, agency, or organization to whom the disclosure will be made. The vague term "Adult Probation/Parole pending" will be replaced with specific and identifiable information.
Person responsible for the implementation: Program Director
Staff Training:
A mandatory staff training session will be scheduled within 7 days to ensure that all staff members involved in the intake and documentation process understand the importance of specificity when completing consent to release information forms. This training will reinforce confidentiality practices and HIPAA compliance.
Person responsible for the implementation: Program Director
Process Improvement:
The consent to release information form template will be reviewed and revised to include a field that prompts for the specific name of the individual, agency, or organization to whom the disclosure will be made, ensuring no ambiguity in future consent forms.
Ongoing Quality Assurance:
We will establish a quarterly audit system to review client records for compliance with documentation standards, including correct and specific consent to release information forms. Any discrepancies will be addressed immediately, and corrective actions will be implemented.
Person responsible for the implementation: Program Director
Timeline for Completion:
Immediate updates to the records for Client #1 and Client #3 will be made within 48 hours.
Staff training will be conducted within 7 days.
The updated consent form template will be implemented within 14 days.
The first audit will be conducted within 30 days.
Person responsible for the implementation: Program Director |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on an administrative review, the facility failed to maintain a data collection and recordkeeping system that allowed for the efficient retrieval of data needed to measure the project's performance, in relation to its stated goals and objectives.
Prior to the onsite inspection, the facility was asked to have an accurate client list, with admission and discharge dates, available upon the Licensing Representative ' s arrival on inspection day. The same request was again made on the day of the onsite inspection at 9:15am; however, the complete client list was not provided until after 11:00am.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Actions Taken and Planned:
Immediate Corrective Action:
We have taken immediate steps to update and organize our data collection and recordkeeping system. The complete client list, with admission and discharge dates, has now been properly compiled and will be available for inspection at all times moving forward. This is being done by keeping a record of clients' names, active and discharge, with the specifics dates, and will be updated on a daily basis and as needed. This process has started with an excel spreadsheet and also we will have it done electronically with our EMR system.
Person responsible for the implementation: Program Director
Improvement of Data Management Systems:
We will implement a new digital tracking system that will allow for the efficient and immediate retrieval of client data, including admission and discharge dates, program progress, and outcomes. This system will be designed to meet the performance measurement needs of the project and ensure that all required data is easily accessible at all times.
We are working with our IT team to finalize the setup of this system, and we expect it to be fully operational within 14 days.
Person responsible for the implementation: Program Director
Staff Training and Accountability:
We will conduct a mandatory training session for all relevant staff on the importance of accurate recordkeeping and the proper use of the new data management system. This will include training on how to input, update, and retrieve client information, as well as the steps to ensure timely and accurate documentation of client admission and discharge dates.
The training will be completed within 7 days to ensure all staff are properly equipped to use the system effectively.
Ongoing Monitoring and Audits:
To ensure ongoing compliance, we will implement monthly audits of the data collection system to verify the accuracy and completeness of client records. Any discrepancies or issues identified during these audits will be addressed immediately, and corrective actions will be taken as necessary.
We will also designate a data management coordinator who will be responsible for ensuring the integrity and efficiency of the recordkeeping system on a day-to-day basis.
Timeline for Completion:
The immediate correction of the client list and recordkeeping system will be completed within 48 hours.
The digital tracking system will be fully operational within 14 days.
Staff training will be completed within 7 days.
Monthly audits will commence starting next month.
Person responsible for the implementation: Program Director |