INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 9, 2021 through March 10, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Providence Living LLC d/b/a Providence Treatment 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) (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 document the specific information to be disclosed on consent to release information forms in two of fourteen client records reviewed.
Client # 2 was admitted to the outpatient level of care on June 15, 2020 and was discharged on October 12, 2020. Release of information forms to a treatment provider, an external individual, and a funding source were signed and dated by the client on June 15, 2020 and each form did not document the specific information to be disclosed.
Client # 8 was admitted to the partial hospitalization level of care on February 27, 2020 and was discharged on March 13, 2020. A release of information form to an external individual was signed and dated by the client on March 5, 2020 and did not document the specific information to be disclosed. Additionally, a release of information form to a treatment provider was signed and dated by the client on February 26, 2020 and did not document the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #2 specific information to be disclosed is clarified and identified on his ROI dated 6/15/2020 as of 3/22/2021.
Client #8 specific information to be disclosed is clarified and identified on her ROIs dated 2/26/2020 and 3/5/2020 as of 3/22/2021.
The facility director provided training to all staff members in use of ROI forms on 3/12/2021. Attendance for this training was obtained and filed.
The facility director will perform quality check on ROI forms as part of monthly internal audits. |
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 document the purpose of disclosure on consent to release information forms in two of fourteen client records reviewed.
Client # 2 was admitted to the outpatient level of care on June 15, 2020 and was discharged on October 12, 2020. Release of information forms to a treatment provider, an external individual, and a funding source were signed and dated by the client on June 15, 2020 and each form did not document the specific information to be disclosed.
Client # 4 was admitted to the outpatient level of care on March 25, 2020 and was discharged on January 21, 2021. A release of information form to a workforce provider was signed and dated by the client on March 25, 2020, and the form did not document the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #2 purpose of disclosure is clarified and identified on his ROIs dated 6/15/2020 and 10/12/2020 as of 3/22/2021.
Client #4 purpose of disclosure and specific information to be disclosed is clarified and identified on her ROI dated 3/25/2020 as of 3/22/2021.
The facility director provided training to all staff members in use of ROI forms on 3/12/2021. Attendance for this training was obtained and filed.
The facility director will perform quality check on ROI forms as part of monthly internal audits. |
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 document the dated signature of a witness on release of information forms in two of fourteen client records.
Client # 10 was admitted to the partial hospitalization level of care on August 24, 2020 and was discharged on September 14, 2020. A release of information form to another treatment provider was signed and dated by the client on August 24, 2020 and did not document the dated signature of a witness.
Client # 11 was admitted to the partial hospitalization level of care on July 13, 2020 and was discharged on September 15, 2020. A release of information form to an external individual was signed and dated by the client on August 18, 2020 and did not document the dated signature of a witness.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #10 the date of witness signature is clarified and added on her ROI dated 8/24/2020 as of 3/22/2021.
Client #11 the dated witness signature is clarified and identified on his ROIs dated 8/18/2020 as of 3/22/2021.
The facility director provided training to all staff members in use of ROI forms on 3/12/2021. Attendance for this training was obtained and filed.
The facility director will perform quality check on ROI forms as part of monthly internal audits. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to a maintain a complete client record on an individual, which is to include follow-up information, in two of four applicable client records reviewed.
Client # 2 was admitted to the outpatient level of care on June 15, 2020 and was discharged on October 12, 2020. There was no follow-up information documented in the client record at the time of inspection.
Client # 3 was admitted to the outpatient level of care on June 26, 2020 and was discharged on January 30, 2021. There was no follow-up information documented in the client record at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #2 discharge follow up was conducted and documented on 3/12/2021.
Client #3 discharge follow up was conducted and documented on 3/12/2021.
Effective 3/12/2021, list of discharged clients will be compiled and included in weekly staff meeting agenda as a reminder to trigger follow-up calls for the following week.
The facility director is responsible for adding discharged client(s) to the agenda on a weekly basis.
The practice manager is responsible for reviewing the weekly meeting agenda and using it as a prompt to make follow-up calls to discharged clients.
The facility director will perform quality check on discharge follow ups as part of monthly internal audits. |