INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 1-3, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Diakon Family Life Services 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) (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 two of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include a dated signature of the client but instead had "verbal" in the client signature line.
Client # 1 was admitted on November 10, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated November 15, 2021 to a funding agency and probation officer, and emergency contact did not have a valid signature by the client but instead had "verbal" in the signature line.
Client # 2 was admitted on March 29, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated March 22, 2022 to a funding agency and emergency contact did not have a valid signature by the client but instead had "verbal" in the signature line.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 9, 2021 annual licensing inspection.
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Plan of Correction
Whereby telehealth is done the project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. This will be done by scheduling the client in person for the initial session when releases are secured. 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). When verbal consent is given during a telehealth session the clinical staff person will follow up with a written consent prior to the release of confidential client information. This will be in compliance effective 6/20/2022. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Coordinator through staff meetings, staff training, quality review and supervision. |
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 two of five applicable client records reviewed, the facility failed to provide a complete client record to include case consultation notes in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate case consultations to occur at least quarterly for the first year of service.
Client # 1 was admitted on November 10, 2021 and was still active at the time of the inspection. A case consultation was due to occur no later than February 10, 2022 and May 10, 2022. There were no case consultations documented in the client record.
Client # 4 was admitted on January 20, 2022 and was still active at the time of the inspection. A case consultation was due to occur no later than April 20, 2022. There were no case consultations documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical staff shall assure a complete client record 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. The clinical staff will complete case consultations at Intake and at least every 90 days per Diakon Family Life Service's policy. Case consultations will be reviewed and signed off on by the immediate supervisor. This will be in compliance effective 6/20/2022. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Coordinator through staff meetings, staff training, quality reviews and supervision. |
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 one of three applicable client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facilities policy and procedure manual. The facility policy and procedure manual indicated follow-up information to occur sixty days after discharge by letter.
Client # 6 was admitted on December 7, 2021 and was discharged on February 23, 2022. A follow-up was due to occur no later than April 23, 2022. There was no documentation of follow-up information in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical staff shall assure 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. It is the responsibility of the clinical staff person to make an attempt to follow up on a client's status after being discharged from the program. The clinical staff will complete follow up per Diakon Family Life Service's policy and a copy of the letter will be placed in the client record when completed. This will be in compliance effective 6/20/2022. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Coordinator through staff meetings, staff training, quality reviews and supervision. |