INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 19, 2017 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, Freedom Healthcare Services LLC 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
The facility failed to document a complete release of information form prior to the disclosure of information in four of seven records reviewed during the July 19, 2017 annual inspection.
Client record #1, 2, and 4 had release of information forms that did not indicate to whom the information would be disclosed, the specific information to be disclosed, purpose of the disclosure, and expiration date. Client record #5 had a release of information to a government agency that exceeds the parameters of 255.5.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In order to become compliant with regulation 709.28 the Clinical Director assures that all staff will attend refresher training on how to properly complete the consent to release of information document in an accurate and legal manner. The training will provide detailed explanation to whom the information would be disclosed, the specific information to be disclosed and the purpose of the disclosure; additionally signifying that such information does not exceed the parameters of 255.5. This plan of correction will be completed by August 31, 2017. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
The facility failed to obtain a complete drug screen urinalysis prior to the administration of buprenorphine, a narcotic agent, and also monthly drug screen urinalysis results in four of four patient records reviewed during the annual inspection on July 19, 2017. A complete drug screen includes receiving the results from the CLIA and Department of Health approved laboratory. Patients 1, 2, 3 and 4 were missing drug screen results.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The plan of correction to become compliant with 715.14 began on June 23, 2017 when Application For Approval to Direct More Than Two Clinical Laboratories was submitted. In response to the deficiency at hand Freedom Health Care Services will complete a full panel drug screen prior to the administration of buprenorphine and monitor monthly drug screens on a regular and random basis. Such practice will involve a complete drug screen that includes the results from the CLIA and Department of Health approved laboratory. Expected date of full compliance began on August 11, 2017 and will remain as regular practice for Freedom Health Care Services. |