INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 16, 2018 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, Community Service Foundation, Inc. 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 the review of 7 client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 3 records reviewed. Additionally, 1 client record had consent to release information forms that were missing the purpose of disclosure.
Client #1 was admitted on 3/8/17 and was an active client at the time of the inspection. There was documentation that the facility had billed the funding source for services provided on 3/8/17; however, the consent to the funding source was not signed and dated until 3/9/17.
Client #3 was admitted on 11/3/17 and was an active client at the time of the inspection. There was documentation that the facility had billed the funding source for services provided on 11/3/17; however, the consent to the funding source was not signed and dated until 11/7/17.
Client #5 was admitted on 8/1/17 and was discharged on 11/15/17. There were two consent to release information forms signed and dated on 8/1/17 to a family member and to the funding source; however, they did not include the purpose for disclosure.
Client #7 was admitted on 1/25/17 and was discharged on 6/9/17. There was documentation that the facility had billed the funding source for services provided on 1/25/17; however, the consent to the funding source was not signed and dated until 1/26/17.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project director and/or the facility director will ensure that all consent forms are signed prior to any service being provided. This is changed to assure compliance with regulation 709.28(c)Confidentiality. The clinical supervisors will supervise the counselors to implement this change starting February 1, 2108. |
709.34 (b) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(1) Documentation of the unusual incident.
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Observations
Based on the review of the facility's unusual incident policies and procedures on January 8, 2018, the procedures failed to include appropriate documentation on the implementation of the following items:
(1) Implementation of a timely and appropriate corrective action plan, when indicated.
(2) Ongoing monitoring of the corrective action plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy that specifically states the reporting of unusual incidents as outlined in 709.34 (a) is being revised by the Project Director and/or Facility Director with Quality Assurance Committee to be presented to the board of directors for approval at the next board meeting in Spring 2018. We will submit the board of directors approved POC by April 30, 2018 to DDAP. |