INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection starting on February 8, 2021 and concluding on February 19, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, SPHS Behavioral Health 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 client records, the facility failed to document a written informed and voluntary consent from the client for the disclosure of information contained in 6 of 7 client records.
Client #1 was admitted on August 18, 2020 and is currently active. " Verbal consent " was observed to be documented on releases of information documented in the client record.
Client #2 was admitted on July 7, 2020 and is currently active. " Verbal consent " was observed to be documented on releases of information documented in the client record.
Client #3 was admitted on September 3, 2020 and was discharged January 11, 2021. " Verbal consent " was observed to be documented on releases of information documented in the client record.
Client #5 was admitted on November 4, 2020 and is currently active. " Verbal consent " was observed to be documented on releases of information documented in the client record.
Client #6 was admitted on December 4, 2020 and is currently active. " Verbal consent " was observed to be documented on releases of information documented in the client record.
Client #7 was admitted on November 13, 2020 and discharged on January 15, 2021. " Verbal consent " was observed to be documented on releases of information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning April 1st, all intake assessments for new clients will be scheduled in person. All consents will be physically signed at intake. Current, active clients will have new consents submitted with physical signature upon returning to office for their first onsite appointment. For current, active clients who have been conducting telehealth, they will have to attend at least 1 session per month to ensure physical signatures can be obtained and up to date. The corrective action will commence as soon as approved and will take effect as early as April 1, 2021. This will be stipulated by the Program Supervisor and become requirements carried out be direct service staff from April 1, 2021 onward. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document a written informed and voluntary consent, including a dated client signature, from the client for the disclosure of information contained in 6 of 7 client records.
Client #1 was admitted on August 18, 2020 and is currently active. " Verbal consent " was observed to be documented on releases of information documented in the client record. There was no client signature documented.
Client #2 was admitted on July 7, 2020 and is currently active. " Verbal consent " was observed to be documented on releases of information documented in the client record. There was no client signature documented.
Client #3 was admitted on September 3, 2020 and was discharged January 11, 2021. " Verbal consent " was observed to be documented on releases of information documented in the client record. There was no client signature documented.
Client #5 was admitted on November 4, 2020 and is currently active. " Verbal consent " was observed to be documented on releases of information documented in the client record. There was no client signature documented.
Client #6 was admitted on December 4, 2020 and is currently active. " Verbal consent " was observed to be documented on releases of information documented in the client record. There was no client signature documented.
Client #7 was admitted on November 13, 2020 and discharged on January 15, 2021. " Verbal consent " was observed to be documented on releases of information documented in the client record. There was no client signature documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All consents will be completed at intake in person upon an individual's admission into the Drug and Alcohol program. The electronic health record (Credible) will capture physical signatures containing time and date stamps associated with the physical signature obtained. The same in person stipulation will apply to consents that are completed with active clients upon their return to the office. The corrective action will go into effect April 1, 2021 upon approval. The action will be mandated by the Program Supervisor and carried out by the direct service staff team. |
715.9(a)(1) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on a review of client records, the facility failed to document verification that the client reached 18 years of age, prior to the administration of an agent in three of four client records.
Client #1 was admitted on August 18, 2020 and is currently active. Client #1 was initially prescribed buprenorphine on September 29, 2020. There was no documentation of the verification of the client's age in client record #1.
Client #3 was admitted on September 3, 2020 and discharged on January 11, 2021. Client #3 was initially prescribed buprenorphine on October 9, 2020. There was no documentation of the verification of the client's age in client record #3.
Client #4 was admitted on June 30, 2020 and discharged on December 11, 2020. Client #4 was initially prescribed buprenorphine on July 24, 2020. There was no documentation of the verification of the client's age in client record #4.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Photo identification will be collected and scanned into client charts at the time of in person initial intake assessment. A Medication Assisted Treatment Checklist will also be utilized at the time of MAT Evaluation, which will review and ensure that identification is scanned into the chart prior to MAT assessment. The MAT developed by the Program Supervisor will be distributed for direct service staff use, and it will be incorporated into the Medication Assisted Treatment evaluation process beginning April 1, 2021.
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715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of client records, the facility failed to document verification of the client's identity prior to the administration of an agent in three of four client records.
Client #1 was admitted on August 18, 2020 and is currently active. Client #1 was initially prescribed buprenorphine on September 29, 2020. There was no documentation of the verification of the client's identity in client record #1.
Client #3 was admitted on September 3, 2020 and discharged on January 11, 2021. Client #3 was initially prescribed buprenorphine on October 9, 2020. There was no documentation of the verification of the client's identity in client record #3.
Client #4 was admitted on June 30, 2020 and discharged on December 11, 2020. Client #4 was initially prescribed buprenorphine on July 24, 2020. There was no documentation of the verification of the client's identity in client record #4.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Photo identification will be collected and scanned into client charts at the time of initial intake assessment. As was part of other corrective action plans, a Medication Assisted Treatment Checklist will also be reviewed at MAT Evaluation to ensure that identification is scanned into the client's electronic health record. The process will be initiated by the program supervisor and adhered to by the direct service staff workers. It will go into effect upon approval as early as April 1, 2021. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to document a consent to buprenorphine treatment prior to the administration of an agent in four of four client records.
Client #1 was admitted on August 18, 2020 and is currently active. Client #1 was initially prescribed buprenorphine on September 29, 2020. There was no documentation of a signed buprenorphine consent to treatment in client record #1.
Client #2 was admitted on July 7, 2020 and is currently active. Client #2 was initially prescribed buprenorphine on July 14, 2020. There was no documentation of a signed buprenorphine consent to treatment in client record #2.
Client #3 was admitted on September 3, 2020 and discharged January 11, 2021. Client #3 was initially prescribed buprenorphine on October 9, 2020. There was no documentation of a signed buprenorphine consent to treatment in client record #3.
Client #4 was admitted on June 30, 2020 and discharged December 11, 2020. Client #4 was initially prescribed buprenorphine on July 24, 2020. There was no documentation of a signed buprenorphine consent to treatment in client record #4.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Medication Assisted Treatment checklist will be completed before beginning the MAT evaluation and will include the following: Consent to Vivitrol, Consent to Suboxone, Benzodiazepine Policy, Pregnancy Policy, Narcan Contact Note, and copying of photo identification. The Program Supervisor will be responsible for distribution of the checklist to all direct service staff. The new process will go into effect upon approval as early as April 1, 2021. |