INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 14, 2017 and August 15, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Ellen O'Brien Gaiser Addiction Center 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:
|
Plan of Correction
|
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.
|
Observations
Seven client records were reviewed on August 14, 2017 and August 15, 2017. The facility failed to obtain an informed and voluntary consent in two of seven client records reviewed.
Client #4 was admitted on November 21, 2016 and discharged on January 16, 2017. A consent to release information form, dated November 21, 2016 to a criminal justice agency, did not allow for the consent to be revoked, as it stated the following: "if you are participating in this program as a condition of the disposition of any criminal proceedings against you, or if your participation is a condition of parole or other release from criminal justice custody, be advised that you may not revoke your consent to release the specified information listed to the criminal justice system until the legal condition(s) requiring your participation in treatment have been terminated or otherwise discontinued". The client record contained documentation indicating that the facility released patient identifying information to the criminal justice agency on November 21, 2016. There was no court order mandating treatment documented for this client and therefore, the consent could be revoked verbally or in writing at any time.
Client #7 was admitted on March 14, 2017 and was discharged on June 2, 2017. The client record contained documentation indicating that the facility released patient identifying information to a treatment provider and failed to obtain an informed and voluntary consent or QSOA prior to the disclosure.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 8/16/2017 the Clinical Supervisor updated and corrected the all "Drug & Alcohol Release of Information" client informed consents and removed the criminal justice system language in question. "if you are participating in this program as a condition of the disposition of any criminal proceedings against you, or if your participation is a condition of parole or other release from criminal justice custody, be advised that you may not revoke your consent to release the specified information listed to the criminal justice system until the legal condition(s) requiring your participation in treatment have been terminated or otherwise discontinued".
Has been removed. All Staff has been trained on 8/21/2017.
The Clinical Supervisor will randomly review and audit client records to ensure that all counselor and other staff are using the correct release of forms going forward.
Client #4 was already discharged from treatment therefore we were not able to obtain appropriate new consent from client. Moving forward all incorrect consents have been destroyed by the clinical supervisor and intake coordinator.
Client #7 was also discharged before the consents were corrected therefore we were not able to obtain appropriate consent.
The Clinical Supervisor did inform all staff members at inpatient through training and company wide memo on 9/22/2017 that they must obtain a consent on the updated appropriate consent. |
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.
|
Observations
Seven client records were reviewed for client rights on August 14, 2017 and August 15, 2017. The facility failed to include on the facility's Patient Bill of Rights form in the Client Handbook the following verbiage: creed, ethnicity, color, marital status, handicap and religion.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 8/21/17 the Clinical Supervisor revised the Patient Bill of Rights given to each client upon admission to include the following:
"You have the right to receive treatment without regard to race, religious creed, ancestry, national origin, creed, ethnicity, color, marital status, handicap, religion, age sexual orientation, gender or economic status." All other DDAP required language was already included in the Patient Bill of Rights and all future clients will receive the corrected Bill of Rights.
All current clients were given the new patient bill of rights by their counselor.
All old copies of the client handbook with the incorrect bill of rights were destroyed by the Clinical Supervisor and Intake Coordinator. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
Seven client records were reviewed on August 14, 2017 and August 15, 2017. The facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.
Client #3 was admitted to treatment on May 4, 2017 and was still an active client at the time of the inspection. A informational note contained in the client record, dated July 21, 2017 indicated that the client was transported from the facility by ambulance to the hospital during a medical emergency on July 21, 2017. A review of the facility's unusual incident reports indicated that an unusual incident report was completed by facility staff on July 21, 2017, but it was not filed with the Department as of the date of the licensing inspection.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
On 9/19/2017 the Clinical Supervisor submitted the client unusual incident report on Client #3 written unusual incident report as referenced in observation #0362. The report was created on July 21, 2017 indicating that the client was transported from the facility by ambulance to the hospital during a medical emergency on July 21, 2017. While the report was completed on 7/21/17 the agency failed to submit report to DDAP. On 9/19/17 The Clinical Supervisor emailed a reminder to all Gaiser Center Staff outlining the DDAP incidents that rise to the level of requiring an Unusual Incident report so that future incidents will all be correctly reported within the required 3 days.
Effective on 8/31/2017 The Clinical Supervisor will be responsible to monitor the "unusual Incident" folder that is kept in the Facilities Manager's office to ensure that all Unusual Incidents are reported in the correct timeframes to the appropriate licensing bodies, providers, and insurance providers. The clinical supervisor will monitor this unusual incident log daily. |