INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on November 3, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated on-site inspection, Peniel Drug and Alcohol Residential Treatment Facility 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) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of seven client records, the project failed to obtain an informed and voluntary consent from five clients for the disclosure of information contained in the client record that included the date, event or condition upon which the consent will expire. Client #1 was admitted on February 10, 2020 and was still current at the time of the inspection. Client #1 had a release to probation that had no condition upon which the release would expire. Client #3 was admitted on October 16, 2019 and was still current at the time of the inspection. Client #3 had a release to probation that had no condition upon which the release would expire. Client #4 was admitted on January 8, 2020 and was still current at the time of the inspection. Client #4 had a release to probation that had no condition upon which the release would expire. Client #6 was admitted on May 22, 2020 and was discharged on July 2, 2020. Client #6 had a release to probation that had no condition upon which the release would expire. Client #7 was admitted on January 29, 2020 and was discharged on March 6, 2020. Client #7 had a release to probation that had no condition upon which the release would expire. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Plan of Correction:
Per the citation, the error related to Release of Information forms for Probation. It was found that these did not have a specific date, event or condition on which the Release would expire.
As the Clinical Supervisor, I have corrected the Authorization to Release Information form for all Legal contacts to include the statement "I understand that this consent is valid for eighteen (18) months."
Those clients currently in treatment who have legal contacts will be asked to sign the revised forms by December 4, 2020. This will be done by the Clinical Supervisor and the new forms will be filed directly behind the old ones in each clients' file.
This form will be used in place of the old one for all new admissions. This will be monitored and enforced by the Admissions Supervisor.
My office will notify all staff who utilize Release forms of this change writing today. They will be asked to discard the old forms and implement the revision immediately.
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