INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 24 & 31, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Deerfield Center for Addictions Treatment 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 a review of the client records, the facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in one of six client records.
The findings include:
On March 31, 2016, six client records were reviewed for informed and voluntary consent to release information forms.
Client #2 was admitted to treatment on 9-16-2015, and discharged on 1-20-2016.
A release of information was completed for an emergency contact, but failed to include a date of the client signature, a dated witness signature, and the expiration date is documented as the admit date (9-16-2015).
A release of information was completed for a probation department, but failed to include a date of the client signature, and a dated witness signature.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
During the staff meeting on 4/5/16 the clinical Supervisor remind staff that all sections of the Consent form need to be completed before information can be disseminated. In addition, if information is being given to the client for a third person, staff were instructed to obtain a consent from the client that received the information and a consent for the person intended to receive the information. A support staff person has also been instructed to review consent forms that are completed at the time of intake. The Clinical Supervisor will review 5 random charts over the next 2 months to ensure that consent forms are being completed accurately. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to offer the client a copy of the client consent in five of six client records.
The findings include:
On March 31, six client records were reviewed for offering the client a copy of the consent, and five records, #1, #2, #3, #4, and #5, were missing.
Client #1 was admitted to treatment on 5-13-2015 and discharged on 8-26-2015. Release of information forms were completed, but failed to indicate a copy was accepted/declined by the client.
Client #2 was admitted to treatment on 9-16-2015, and discharged on 1-20-2016.
Release of information forms were completed, but failed to indicate a copy was accepted/declined by the client.
Client #3 was admitted to treatment on 11-4-2015. Release of information forms were completed, but failed to indicate a copy was accepted/declined by the client.
Client #4 was admitted to treatment on 7-8-2015. Release of information forms were completed, but failed to indicate a copy was accepted/declined by the client.
Client #5 was admitted to treatment on 8-5-2015. Release of information forms were completed, but failed to indicate a copy was accepted/declined by the client.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On 4/5/16 a staff meeting was held and the Clinical Supervisor instructed staff that client's needed to complete the section indicating whether the client accepted/declined a copy of the consent form. The Clinical Supervisor will review consent forms over the next month to ensure they are being completed accurately |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of the client records, the facility failed to provide a physician signature on treatment plans and treatment plan updates in one of one client records.
The findings include:
Six client records were reviewed on March 31, 2016. One of the six client records was required to have a physician signature on the treatment plan and treatment plan updates. Patient #4 did not have a physician signature documented on the 8-26-2015 treatment plan or the 1-13-2016 or 3-2-2016 treatment plan updates.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor, during the staff meeting on 4/5/16, informed the staff and the program physician that MA funded clients need to have their treatment plans and treatment plan update forms reviewed and signed by the program physician. The Clinical Supervisor will identify clients that are funded through MA and work with the program physician to see that treatment plans and treatment plan updates are signed. The clinical Supervisor will review 6 MA client charts monthly for the next 3 months to ensure that new client Treatment Plans are being signed and Treatment Plan Updates are also being signed. |