INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 23-24, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Blueprints For Addiction Recovery, LLC 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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709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of administrative documention, and a discussion with facility staff on September 23, 2019, the governing body failed to make an annual report available to the public.
This facility is one of several facilities within the Blueprints For Addiction Recovery project. The project has open since April 18, 2016. This facility and others in the project receive public funding and therefore the governing body be required to make an annual report available to the public.
This was discussed with facility staff at the time of the inspection. When discussed, facility staff indicated they were unaware that they were required to provide an annual report.
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Plan of Correction
The Director of Operations will make the annual report available to the public via a link on the company website by October 18, 2019. Linking the report has become a regular agenda item for the 4th quarter senior leadership compliance meeting. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents and an interview with facility staff, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services.
At the time of the onsite inspection, the facility was not able to provide an annual financial audit of the activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities. The facility did present a document from the accounting firm that they use for the business services the following day; however, it was not a financial audit.
The facility was informed of the findings on September 25, 2019 via phone upon receipt of the documents.
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Plan of Correction
The Chief Executive Officer will secure the services of an independent CPA to conduct a fiscal audit relevant to Blueprints' drug and alcohol services. Due to our fiscal year being the calendar year, we will utilize the services of the independent CPA to conduct audits for fiscal years 2018 and 2019. Both of these audits will be complete and available for review by June 1,2020. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of client records, the client handbook, facility policies and procedures, and internal documents the facility failed to ensure compliance with 42 CFR Part 2, 4 Pa. Code 255.5 and 28 Pa. Code 709.28 in seven of seven records reviewed.
The welcome packet which includes the "New Client Handbook" contains statements that contradict 42CFR Part 2 and 4 Pa. Code 255.
Page 3 of the welcome packet under the heading "When Don't We (Blueprints) Need an Authorization Form?" states:
"Under special circumstances your authorization is not needed. These circumstances include things like reporting to a government agency, abuse or neglect of a child, domestic violence, legal investigations, or else to avert a serious threat to health and safety."
Page 7 of the welcome packet under the heading "Mandated Treatment" states:
"If you've been mandated to treatment by a court, or by a probation or parole agency - you're required to sign a "Consent for Release of Information" to the mandating agency. This consent may not be revoked.
"Upon leaving the facility, the mandating agency may be contacted for updates on your discharge status."
42 CFR Part 2 limits the duration of the consent
and 42 CFR Part 2 requires that the written consent must state that it is revocable upon the passage of a specified amount of time or the occurrence of a specified, ascertainable event.
42 CFR Part 2 Disclosures to elements of the criminal justice system which have referred patients.
(a) A part 2 program may disclose information about a patient to those individuals within the criminal justice system who have made participation in the part 2 program a condition of the disposition of any criminal proceedings against the patient or of the patient's parole or other release from custody if:
(1) The disclosure is made only to those individuals within the criminal justice system who have a need for the information in connection with their duty to monitor the patient's progress (e.g., a prosecuting attorney who is withholding charges against the patient, a court granting pretrial or post-trial release, probation or parole officers responsible for supervision of the patient); and
(2) The patient has signed a written consent meeting the requirements of (except paragraph (a)(6) of this section which is inconsistent with the revocation provisions of paragraph (c) of this section) and the requirements of paragraphs (b) and (c) of this section.
(b) Duration of consent. The written consent must state the period during which it remains in effect. This period must be reasonable, taking into account:
(1) The anticipated length of the treatment;
(2) The type of criminal proceeding involved, the need for the information in connection with the final disposition of that proceeding, and when the final disposition will occur; and
(3) Such other factors as the part 2 program, the patient, and the individual(s) within the criminal justice system who will receive the disclosure consider pertinent.
(c) Revocation of consent. The written consent must state that it is revocable upon the passage of a specified amount of time or the occurrence of a specified, ascertainable event. The time or occurrence upon which consent becomes revocable may be no later than the final disposition of the conditional release or other action in connection with which consent was given.
Page 10 of the welcome packet under the heading "Confidentiality" states:
"As a facility, we have to follow guidelines concerning what's called Mandated Reporting. This means that should you disclose any sensitive information regarding abuse or neglect in varying degrees, we may be required to report that information to the appropriate agencies or individuals, Also, if licensed staff members determine that you present a danger to yourself or others, this information will be reported in the interest of both your safety and the safety of the community."
42 CFR Part 2 addresses the applicability of the regulations and exceptions relative to reporting threats of crimes on the facility premises or against facility personnel, and cases of suspected abuse or neglect; however, the exceptions to the applicability are specific. Releasing information that would identify a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or though verification of such identification by another person for the purposes of "Duty to Warn" would be restricted to the allowances at 42 CFR Part 2 and (6)
42 CFR Part 2 Applicability states:
(a) General-(1) Restrictions on disclosure. The restrictions on disclosure in the regulations in this part apply to any information, whether or not recorded, which:
(i) Would identify a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person.
42 CFR Part 2 - (5) Crimes on part 2 program premises or against part 2 program personnel. The restrictions on disclosure and use in the regulations in this part do not apply to communications from part 2 program personnel to law enforcement agencies or officials which:
(i) Are directly related to a patient's commission of a crime on the premises of the part 2 program or against part 2 program personnel or to a threat to commit such a crime; and
(ii) Are limited to the circumstances of the incident, including the patient status of the individual committing or threatening to commit the crime, that individual's name and address, and that individual's last known whereabouts.
42 CFR Part 2 - (6) Reports of suspected child abuse and neglect. The restrictions on disclosure and use in the regulations in this part do not apply to the reporting under state law of incidents of suspected child abuse and neglect to the appropriate state or local authorities. However, the restrictions continue to apply to the original substance use disorder patient records maintained by the part 2 program including their disclosure and use for civil or criminal proceedings which may arise out of the report of suspected child abuse and neglect.
The facility's document labeled "Notice of Privacy Form", indicates that the facility may release information under Duty to Warn, Elder Abuse, and to prevent or lessen a serious imminent threat to the heath or safety of a person or the public.
Neglect or abuse of a child is permissible to be released under federal and state laws without client consent. The facility may not release information without the client's consent to avert a serious threat to health and safety, domestic violence, to government agencies or for legal investigations unless the client has given consent. Any release of information to a government agency or the legal system is restricted under 4 Pa. Code 255.5(b). 42 CFR Part 2 prohibits the release of information :
4 Pa. Code 255.5(b) limits what may be released as follows:
(b) Restrictions. Information released to judges, probation or parole officers, insurance company health or hospital plan or governmental officials, under subsection (a)(1), (2), (4), (7) and (8), is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following:
(1) Whether the client is or is not in treatment.
(2) The prognosis of the client.
(3) The nature of the project.
(4) A brief description of the progress of the client.
(5) A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
42 CFR Part 2 restricts disclosures without consent to the following:
Subpart D -
2.15 Medical emergencies
2.52 Research
2.53 Audit and Evaluation
Subpart E Court Orders Authorizing Disclosure and Use ( 2.61 -2.67)
42 CFR Part 2 Restriction on use.
The restriction on use of information to initiate or substantiate any criminal charges against a patient or to conduct any criminal investigation of a patient (42 U.S.C. 290dd-2(c)) applies to any information, whether or not recorded, which is drug abuse information obtained by a federally assisted drug abuse program after March 20, 1972 (part 2 program), or is alcohol abuse information obtained by a federally assisted alcohol abuse program after May 13, 1974 (part 2 program); or if obtained before the pertinent date, is maintained by a part 2 program after that date as part of an ongoing treatment episode which extends past that date; for the purpose of treating a substance use disorder, making a diagnosis for the treatment, or making a referral for the treatment.
The facility's document labeled "Notice of Privacy Form", indicates that the facility may act upon a verbal permission to release information to family members that are directly involved in the client's treatment.
28 Pa. Code 709.28(c)
(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:
(1) Name of the person, agency or organization to whom disclosure is
made.
(2) Specific information disclosed.
(3) Purpose of disclosure.
(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).
(5) Dated signature of witness.
(6) Date, event or condition upon which the consent will expire.
(d) A copy of a client consent shall be offered to the client and a copy maintained
in the client record.
(e) When consent is not required, the project personnel shall:
(1) Fully document the disclosure in the client records.
(2) Inform the client, as readily as possible, that the information was disclosed,
for what purposes and to whom.
These findings were discussed with the facility at the time of the inspection.
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Plan of Correction
The executive team (Executive Director, Director of Operation, and Clinical Director) will meet to review 42 CFR Part 2, 4 Pa. Code 255.5 and 28 Pa. Code 709.28 and update all of the relevant documents stated in the observations. The executive team will be responsible for updating all of these documents to ensure compliance with 42 CFR Part 2, 4 Pa. Code 255.5 and 28 Pa. Code 709.28. This is expected to be completed by October 31, 2019. Policies and procedures and internal documents will be reviewed on a annual basis to ensure ongoing compliance. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the client bill of rights presented to clients upon entering treatment, the facility failed to develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights in seven of seven records reviewed.
The "Client Bill of Rights" contained in the "New Client Handbook" which is presented to all clients did not include that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Plan of Correction
The Clinical Director will update the "Client Bill of Rights" in the "New Client Handbook" to reflect all the client rights covered in 028 Pa. Code 709.30. Staff will become aware of the change via a company wide memo which will include the updated "Client Bill of Rights" and "New Client Handbook" which they will begin utilizing immediately. Our orientation session which is conducted with every new admission will include provisions for reviewing and ensuring the newly admitted client is aware of their rights. The client will acknowledge their understanding through signing our orientation session note uploaded into the client record. For clients who are currently in treatment with Blueprints, the updated "New Client Handbook" will be provided to them and these clients will sign that they have received the new handbook in a revised note in the record. This is to be completed and implemented by no later than October 31, 2019. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of the client bill of rights presented to clients upon entering treatment, the facility failed to develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights in seven of seven records reviewed.
The "Client Bill of Rights" contained in the "New Client Handbook" which is presented to all clients failed to indicate that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Instead, it indicated that the attending physician would make that determination.
While it was documented that the reasons for removing sections would be documented and kept on file, it did not indicate that this would be kept in the client record.
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Plan of Correction
The Clinical Director will update the "Client Bill of Rights" in the "New Client Handbook" to reflect all the client rights covered in 028 Pa. Code 709.30. Staff will become aware of the change via a company wide memo which will include the updated "Client Bill of Rights" and "New Client Handbook" which they will begin utilizing immediately. Our orientation session which is conducted with every new admission will include provisions for reviewing and ensuring the newly admitted client is aware of their rights. The client will acknowledge their understanding through signing our orientation session note uploaded into the client record. For clients who are currently in treatment with Blueprints, the updated "New Client Handbook" will be provided to them and these clients will sign that they have received the new handbook in a revised note in the record. This is to be completed and implemented by no later than October 31, 2019. |
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 complete a follow up on the client in one of one records where applicable.
Client #5 was admitted on June 5, 2019 and was discharged on July 16, 2019. Facility policy states that a follow up will be conducted at 7 days following discharge as well as at 30, 60 and 180 days after the client's discharge date. there was no follow up documented for client #5 at the time of the inspection.
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Plan of Correction
The facility policy will remain the same (follow up will be conducted at 7 days following discharge as well as at 30, 60 and 180 days after the client's discharge date). The office manager at each site location is responsible for the completion and documentation of follow ups. The lead office manager will be responsible for training of other office manager staff, follow up, and oversight to ensure this deficiency does not occur again. This change will occur effective immediately. |