INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and a methadone monitoring inspection conducted on March 22, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, RHJ Medical Center Inc./Vandergrift 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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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document a consent to release information form that included the name of the person, agency or organization to whom disclosure is made in two of seven records.
A consent documented during intake did not include the name of the person, agency or organization to whom disclosure is made in the following records:
Client # 1 was admitted October 1, 2021 and discharged January 26, 2022.
Client # 2 was admitted October 19, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director is responsible to ensure that this regulation is in compliance. Documentation was reviewed by the leadership and training team. A training will be held to review the releases and discuss the regulation and the importance of compliance with DDAP regulations. The form will be updated as necessary documentation to reflect the name of the person, agency or organization to whom the disclosure will be made. During the meeting staff will be instructed to have the form completed including name of the person, agency or organization to whom the disclosure will be made prior to receiving the client signature and to review the document for completeness prior to filing in the client chart. Chart audits will be completed to ensure ongoing compliance with this regulation. |
715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
Based on a review of patient records, the facility failed to document the previous narcotic treatment program was contacted for the patient's treatment history in one of two records.
Patient # 1 was admitted October 1, 2021 and discharged January 26, 2022. Documentation in patient record # 1 indicated the patient was in treatment in 2021 at another narcotic treatment program. There was no documentation as to whether the previous facility was contacted for the treatment history of patient # 1 or if the patient refused contact with the facility.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director is responsible to ensure compliance with this regulation. Leadership reviewed the citation and a staff meeting will be held to review the regulation and obtain staff understanding of the importance of attempting to obtain records on previous treatment of clients who are now in treatment with RHJ for a continuum of treatment for the client. The process of obtaining this information will also be reviewed. Chart audits will be completed to ensure continued compliance with this regulation. |