INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 4, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Wpic Center for Psychiatric and Chemical Dependency 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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711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent form for the disclosure of information contained in the client record, in five of seven client records.
Client # 1 was admitted on March 23, 2020 and still an active client. The client's record documented a release for a third-party payer that had not been signed by the client. Correspondence was released to the third-party payer without a valid release.
Client # 3 was admitted on September 25, 2020 and still an active client. The client's record documented a release for a third-party payer that had not been signed by the client. Correspondence was released to the third-party payer without a valid release.
Client # 5 was admitted on January 6, 2020 and discharged on August 24, 2020. The client's record documented a release for a third-party payer that had not been signed by the client. Correspondence was released to the third-party payer without a valid release.
Client # 6 was admitted on June 24, 2020 and discharged on November 20, 2020. The client's record documented a release for a third-party payer that had not been signed by the client. Correspondence was released to the third-party payer without a valid release.
Client # 7 was admitted on July 1, 2020 and discharged on February 16, 2021. The client's record documented a release for a third-party payer that had not been signed by the client. Correspondence was released to the third-party payer without a valid release.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
CPCDS Director or designee will ensure that all releases of information will be valid . Supervisors will review consents in monthly chart audits to ensure compliance. Effective Date-8/26/21 |
711.93(c)(2)(iv) LICENSURE Signature Client/Guardian
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(iv) The dated signature of the client or guardian.
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent form that included the dated signature of client, in five of seven client records.
Client # 1, admitted on March 23, 2020 and still an active client, documented releases of information for the disclosure of information that did not include a dated signature of the client.
Client # 3, admitted on September 25, 2020 and still an active client, documented releases of information for the disclosure of information that did not include a dated signature of the client.
Client # 5, admitted on January 6, 2020 and discharged on August 24, 2020, documented releases of information for the disclosure of information that did not include a dated signature of the client.
Client # 6, admitted on June 24, 2020 and discharged on November 20, 2020, documented releases of information for the disclosure of information that did not include a dated signature of the client.
Client # 7, admitted on July 1, 2020 and discharged on February 16, 2021, documented releases of information for the disclosure of information that did not include a dated signature of the client.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
CPCDS Director or designee will ensure that all consents for disclosure of information will be signed and dated by the patient. Supervisors will review consents in monthly chart audits to ensure compliance. Effective date 8/25/21. |