INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 17, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Fayette County Drug and Alcohol Commission 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 prior to the disclosure of information contained in the client record in six of seven client records reviewed on August 17, 2021.The facility released client information without written consent from the client during the intake process in the following records.Client # 1 was admitted May 27, 2021 and discharged August 16, 2021. The facility disclosed the name and diagnosis of the client when requesting funding authorization.Client # 3 was admitted June 7, 2021. The facility disclosed the name and diagnosis of the client when requesting funding authorization. The facility also disclosed the name and diagnosis when releasing urine samples to a lab without client written consent or a Qualified Service Organization Agreement.Client # 4 was admitted February 18, 2021 and discharged April 20, 2021. The facility disclosed the name and diagnosis of the client when requesting funding authorization. The facility also disclosed the name and diagnosis when releasing urine samples to a lab without client written consent or a Qualified Service Organization Agreement.Client # 5 was admitted January 11, 2021 and discharged April 1, 2021. The facility disclosed the name and diagnosis of the client when requesting funding authorization. The facility also disclosed the name and diagnosis when releasing urine samples to a lab without client written consent or a Qualified Service Organization Agreement.Client # 6 was admitted January 29, 2021 and discharged April 6, 2021. The facility disclosed the name, diagnosis, and prescription information of the client to a pharmacy without client written consent or a Qualified Service Organization Agreement. Client # 7 was admitted December 21, 2020 and discharged April 12, 2021. The facility disclosed the name and diagnosis of the client when releasing urine samples to a lab without client written consent or a Qualified Service Organization Agreement.The findings were reviewed with staff during the licensing process.
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Plan of Correction
Treatment Supervisor will ensure that releases are signed at time of intake. Expectations of releases with physical signatures were reviewed in Treatment meeting on 9/7/21. All clients that are in treatment currently will physically sign releases by 10/7/21. |
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 an informed and voluntary consent from the client that included the dated signature of the client in six of seven client records reviewed on August 17, 2021.Consents were documented during the intake process in the following client records.Client # 1 was admitted May 27, 2021 and discharged August 16, 2021. Consents for insurance, probation and a government agency did not include the dated signature of the client.Client # 3 was admitted June 7, 2021. Consents for insurance and laboratory did not include the dated signature of the client.Client # 4 was admitted February 18, 2021 and discharged April 20, 2021. Consents for insurance, probation, laboratory and a government agency did not include the dated signature of the clientClient # 5 was admitted January 11, 2021 and discharged April 1, 2021. Consents for insurance, probation, laboratory, treatment provider and a government agency did not include the dated signature of the clientClient # 6 was admitted January 29, 2021 and discharged April 6, 2021. Consents for insurance, laboratory, emergency contact and a government agency did not include the dated signature of the client Client # 7 was admitted December 21, 2020 and discharged April 12, 2021. Consents for probation, laboratory, emergency contact and a government agency did not include the dated signature of the clientThe findings were reviewed with staff during the licensing process.
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Plan of Correction
Treatment Supervisor will ensure that releases are signed at time of intake. Expectations of releases with physical signatures were reviewed in Treatment meeting on 9/7/21. All clients that are in treatment currently will physically sign releases by 10/7/21. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of quarterly inspection reports of the medication storage area from August 2019 through July 2021, the facility failed to document quarterly inspections for the first quarter of 2020 and the first quarter of 2021.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Agency Nurse will conduct the inspection of medication storage area on a quarterly basis. This will be monitored by lead clerical staff. If Agency Nurse is not present at the time that the inspection needs to be completed, the Lead Clerical staff will conduct the inspection and document in the log. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document the review and update of treatment and rehabilitation plans at least every 60 days in two of two client records reviewed on August 17, 2021.Client # 5 was admitted January 11, 2021 and discharged April 1, 2021. The individual treatment plan was completed January 14, 2021. No treatment plan updates were documented.Client # 7 was admitted December 21, 2020 and discharged April 12, 2021. The individual treatment plan was completed January 8, 2021. No treatment plan updates were documented.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client Caseload spread sheet will be reviewed by both Treatment Supervisor and Lead counselor weekly which will identify treatment plan due dates to ensure that they are completed every 60 days. Treatment plan requirements were reviewed in Unit Staff meeting on 9/7/2021. A minimum of 5 charts will be reviewed monthly by either Treatment Supervisor or Lead counselor (combined) to audit completion of documents. Audit findings will be stored in a binder in Treatment Supervisor's office. This will begin in September 2021. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a complete client record including case consultation notes every 90 days, per facility policy, in one of one client records reviewed on August 17, 2021.Client # 7 was admitted December 21, 2020 and discharged April 12, 2021. No case consultation notes were documented in client record # 7.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client Caseload spread sheet will be reviewed by both Treatment Supervisor and Lead counselor weekly which will identify Case Consult due dates to ensure that they are completed every 90 days per agency policy. Case Consult requirements were reviewed in Unit Staff meeting on 9/7/2021. A minimum of 5 charts will be reviewed monthly by either Treatment Supervisor or Lead counselor (combined) to audit completion of documents. Audit findings will be stored in a binder in Treatment Supervisor's office. This will begin in September 2021. |