INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and methadone monitoring inspection. The inspection was conducted on September 19 - 20, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, Alliance Medical 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 the 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
The facility failed to obtain an informed and voluntary consent in six patient records reviewed during the inspection on September 19 - 20, 2016.
Patient # 1- The facility failed to document what was being release on a consent form dated 5/27/16 for a government agency.
Patient #2 - The facility failed to document what was being release on a consent form dated 4/4/16 to the patient's funding source.
Patient #3 - The facility failed to document what was being release on a consent form dated 4/6/16 to the patient's emergency contact.
Patient # 4 - The facility failed to document what was being release on a consent form dated 4/8/16 to the patient's funding source.
Patient # 9 - The facility failed to document what was being release on two consent forms both dated 4/29/16 for the patient's funding source and the other a government agency.
Patient #10 - The facility failed to document what was being release on a consent form dated 4/22/16 to the patient's funding source.
These findings were discussed with the facility staff during the licensing process.
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Plan of Correction
Facility will implement new electronic health record on 10/4/16. This record will include releases of information. All staff will be trained on the proper completion of the new electronic releases by 10/7/16. This new process will eliminate issues found during the inspection. Clinical Supervisors will complete a chart review on all new admission charts within two weeks of admission and will continue to do weekly chart reviews on existing patient charts to ensure that all new releases are completed correctly. |