INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 2-3, 2020 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, Providence 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 (a) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
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Observations
Based upon a review facility policies and procedures and forms provided to the clients for their signature, the facility is out of compliance with 28 Pa. Code 709.28, 4 Pa. code 255.5 and 42 CFR in six of six client records reviewed.
Client records #1 - 6 contained one or more of the the following forms which were noncompliant with 42 CFR and 4 Pa. Code 255.5 regarding circumstances when client identifying information may be released.
Document labeled " Informed Consent Agreement " " GENERAL OUTPATIENT PROGRAM (GOP) " and " Informed Consent Agreement " " INTENSIVE OUTPATIENT PROGRAM (IOP) " allows for the release of information for Suicidality (active Suicidal plan) Homocidality (active homicidal Plan) and A report of abuse of an elderly person. This would exceed what is permissible under 42CFR and 4 Pa. Code 255.5
Document labeled "HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) ACKNOWLEDGEMENT FORM" allows for the release of information exceeding 42 CFR and 4 Pa. Code 255.5(b)
Section 1 - "All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member."
Section 2 - "There are some situations in which we are legally obligated to take actions, which we believe are necessary to attempt to protect others from harm and we may have to reveal some information about a client ' s treatment . ...If we have reason to believe that any adult patient who is either vulnerable and/or incapacitated and who has been the victim of abuse, neglect, financial exploration [sic], the law requires that we file a report with the appropriate state official, usually a protective services worker. ... If a client communicates an explicit threat of imminent serious physical harm to a clearly identified or identifiable victim and we believe that the client has the intent and ability to carry out such a threat, we must take protective actions that may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient."
The consent to release information forms required that revocation be in writing.
This was discussed with facility staff at the time of the inspection.
The facility made revisions to their policies and procedures along with the consent to release information forms upon learning of the issues during the inspection; however, they had not yet completed the process of informing all staff and clients of the changes as well as obtaining new consent forms from clients.
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Plan of Correction
During weekly staff meeting on 3/13/20, all staff members were informed and trained on:
1) revised policy and procedure on Confidentiality
2) revised consent to release information form
3) revised Informed Consent Agreement for GOP, IOP and PHP.
The revised forms were put into place starting 3/16/20. Due to COVID-19 public health crisis, we are not meeting our clients in person at our office. The Facility Director will obtain new consent forms from clients by 6/30/20.
The Facility Direction will perform monthly chart audit to ensure compliance of revised forms being used. |
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 upon a review of client records and in interview with facility staff, the facility failed to obtain an informed consent for the release of information for laboratory testing of urine drug screens and blood work in one of six records reviewed.
Client record # 3 contained documentation from a laboratory relative to the client's urine drug screening; however, there was no consent for the release of information to the laboratory in the client record. Nor was there a Qualified Service Organization Agreement (QSOA) in place.
The facility staff explained that the collection facility and the laboratory would not know that the client was a Drug and Alcohol (D&A) client since the facility does not deal directly with the collecton site or laboratory. The facility utilizes an intermediary company who makes arrangements for the client to go to a collection site for the screening. The collection site sends the blood and/or urines to a lab who then reeturns the results to the intermediary. The intermediary then returns the results to the facility. Thus the only entities that would know the client was a D&A client would be the intermediary and the facility. However the facility did not have a consent to release information to the intermediary company nor did they have a QSOA in place at the time of the inspection.
This was discussed with facility staff at the time of the inspection.
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Plan of Correction
The Chief Operation Officer (COO) has obtained QSOA with the intermediary agency on 3/12/2020 between the Covered Entity and the Business Associate to comply with 42 CPR Part 2 regarding the use and disclosure of client information in a substance abuse treatment facility. This QSOA agreement address the deficiency for Client #3. All future testing reporting is covered under this QSOA.
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based upon a review of client records, the facility failed to specify to whom the information was being released to in six of six records reviewed.
Client records # 1-6 contained facility consent ro release information forms that did not clearly identify to whom the information was being released.
The facility's consent to release information forms were being used as consents to release and consents to obtain. Additionally it was not clear as to who was releasing the information or who was receiving the information as the facility was listed as both the Release information from and the send information to parties. then there was a box that was checked indicating "other" in both sections with names of individuals or agencies noted.
This was discussed with facility staff at the time of the inspection.
The facility made revisions to the consent to release information forms upon learning of the issues during the inspection; however, they had not yet completed the process of informing all staff and clients of the changes as well as obtaining new consent forms from clients.
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Plan of Correction
During weekly staff meeting on 3/13/2020, the Facility Director informed and trained all staff members regarding the revised consent to release information form. The revised form was put into place on 3/16/2020. Due to COVID-19 public health crisis, we are not meeting our clients in person.
The Facility Director will obtain new consent form from all 6 clients by 6/30/2020.
The Facility Director will perform month audit to ensure compliance that the revised form is being used. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based upon a review of client records and interview with facility staff, the facility failed to specify the information being released and allowed for information to be released that exceeded what is permissible under 4 Pa. Code 255.5(b) in six of six records reviewed.
Client records # 1-6 contained consents that did not clearly identify the information being released. The consent to release information forms had a box to check that failed to specify exactly what information was being released as it simply stated "Sensitive protected health information including my substance abuse condition or treatment of my mental illness" Additionally, client records contained consent to release information forms that allowed the following information to be released to insurance companies.
Discharge Summaries
Psychiatric/psychosocial evaluations
Medication records
Psychosocial assessments
This was discussed with facility staff at the time of the inspection.
The facility made revisions to the consent to release information forms upon learning of the issues during the inspection; however, they had not yet completed the process of informing all staff and clients of the changes as well as obtaining new consent forms from clients.
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Plan of Correction
During weekly staff meeting on 3/13/2020, the Facility Director informed and trained all staff members regarding the revised consent to release information form. The revised form was put into place on 3/16/2020. Due to COVID-19 public health crisis, we are not meeting our clients in person.
The Facility Director will obtain new consent form from all 6 clients by 6/30/2020.
The Facility Director will perform month audit to ensure compliance that the revised form is being used. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of the facility's policies and procedures manual, an interview with facility staff, and a review of forms presented to clients and signed off by the client, the facility failed to include and inform clients of all their rights.
The policy and procedure manual and the client sign off forms did not include that clients shall retain their liberties except as provided by statute.
CRITERIA FOR ADMISSION section VIII under clients ' rights section V and was also missing "and liberties except as provided by statute".
This was discussed with facility staff at the time of the inspection.
The facility made revisions to the policies and procedures and forms upon learning of the issues during the inspection; however, they had not yet completed the process of informing all staff and clients of the changes as well as presenting/obtaining new forms from clients.
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Plan of Correction
During weekly staff meeting on 3/13/2020, the Facility Director informed and trained all staff members regarding the revised policy and procedure and orientation form about their liberties except as provided by statue. The revised form was put into place on 3/16/2020. Due to COVID-19 public health crisis, we are not meeting our clients in person.
The Facility Director will obtain new sign off form from all clients by 6/30/2020.
The Facility Director will perform month audit to ensure compliance that the revised form is being used. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the facility's policies and procedures manual, an interview with facility staff, and a review of forms presented to clients and signed off by the client, the facility failed to include and inform clients of all their rights.
Document labeled "OUTPATIENT SERVICES ORIENTATION PACKET ' does not list age and race
The policy and procedure manual and the client sign off forms did not include that project may not discriminate in the provision of services on the basis of age and race in the outpatient orientation packet.
This was discussed with facility staff at the time of the inspection.
The facility made revisions to the policies and procedures and forms upon learning of the issues during the inspection; however, they had not yet completed the process of informing all staff and clients of the changes as well as presenting/obtaining new forms from clients.
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Plan of Correction
During weekly staff meeting on 3/13/2020, the Facility Director informed and trained all staff members regarding the revised policy and procedure and orientation package to include age and race in the provision of services.
The revised form was put into place on 3/16/2020. Due to COVID-19 public health crisis, we are not meeting our clients in person.
The Facility Director will obtain new sign off form from all clients by 6/30/2020.
The Facility Director will perform month audit to ensure compliance that the revised form is being used. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in two of six client records reviewed.
Client # 2 was admitted on December 14, 2018 and was still an active client at the time of the inspection. The individual treatment plan and treatment plan updates indicated that the client was to receive 1.50 hours of group counseling once per week and 1.00 hours of individual counseling once per week. There were no progress notes or documented individual sessions in the client record since 1/30/2020.
Client #5 was admitted on July 1, 2019 and was still a client at the time of the inspection. The individual comprehensive treatment plan and treatment plan updates indicated that the client was to receive 1.50 hours of group counseling once per week and 1.00 hours of individual counseling once per week. There were no progress notes or documented individual sessions in the client record since January 22, 2020.
This was discussed with facility staff at the tie of the inspection.
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Plan of Correction
Client #2 and #5 were absent from treatment in the month of February due to away medical rotations.
For Client #2, his treatment plan was updated on 3/1/2020 to reflect his absence in February. His treatment resumed on 3/25/2020 and his subsequent treatment plan was updated to reflect his current treatment frequency.
For Client #5, his treatment plan was updated on 2/9/2020 to reflect his absence in February. His treatment resumed on 3/4/2020 and his subsequent treatment plan on 3/2/2020 was updated to reflect his current treatment frequency.
The facility director will perform monthly audits to ensure compliance of treatment plan that reflect current treatment frequency. |