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 August 20, 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, Lehigh County Center for Recovery 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 the review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in client records #1.
Client #1 was admitted on August 16, 2020 and was still an active client at the time of the inspection. There was documentation that a fax report was made to the funding source on August 17, 2020; however, there was no proper consent to release information form signed by the client prior to disclosure.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Program Director held a training on September 16 and September 17th for clinical, nursing and admission staff to review that a valid release of information is completed prior to disclose. Admissions staff will review all ROIs are completed for new admits on a daily basis. Weekly chart audits of all open charts will be conducted by Clinical Director to ensure compliance. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to ensure that all releases included specific information to be released.
Client#11 was admitted on August 10, 2020 and was an active client as of the date of the inspection. A consent to release form was signed and dated on August 15, 2020 to an outside provider that did not include specific information to be released. Additionally, there was a consent to release form signed and dated on August 19, 2020 to a PCP with no specific information to be released.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Program Director held a training on September 16 and September 17th for clinical, nursing and admission staff to review that specific information to release has been documented on the ROI prior to disclosure. Weekly chart audits of all open charts will be conducted by Clinical Director to ensure compliance. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to include purpose of disclosure on all constent to release forms.
Client#11 was admitted on August 10th, 2020 and was an active client as of the date of the inspection. A consent to release form was signed and dated on August 15, 2020 to an outside provider with no purpose of disclosure. Additionally, there was a consent to release form signed and dated on August 19, 2020 to a PCP with no purpose of disclosure.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Program Director held a training on September 16 and 17th for clinical, nursing and admission staff to review that the purpose of the disclosure has been documented on the ROI prior to disclosure. Weekly chart audits of all open charts will be conducted by Clinical Director to ensure compliance. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to ensure all consents contained a dated signature of wintess.
Client#11 was admitted on August 10th, 2020 and was an active client as of the date of the inspection. A consent to release form was signed and dated on August 19, 2020 to a PCP that failed to document the dated signature of witness.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Program Director held a training on September 16th for clinical, nursing and admission staff that a witness signature is documented on the ROI prior to disclosure. Weekly chart audits of all open charts will be conducted by Clinical Director to ensure compliance. |
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 client records, the facility failed to ensure all consents contained the date, event or condition upon which the consent will expire.
Client#11 was admitted on August 10th, 2020 and was an active client as of the date of the inspection. A consent to release form was signed and dated on August 19, 2020 to a PCP that failed to document the date in which the consent will expire.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Program Director held a training on September 16th and 17th for clinical, nursing and admission staff that an expiration date is documented on the ROI prior to disclosure. Weekly chart audits of all open charts will be conducted by Clinical Director to ensure compliance. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure a copy of a client consent shall be offered to the client and a copy maintained in the client record.
Client#11 was admitted on August 10th, 2020 and was an active client as of the date of the inspection. A consent to release form was signed and dated on August 19, 2020 to a PCP that failed to document whether or not the client was offered a copy of the consent.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Program Director held a training on September 16th and 17th for clinical, nursing and admission staff that the client was offered a copy of the completed consent and it is documented on the ROI. Weekly chart audits of all open charts will be conducted by Clinical Director to ensure compliance. |