INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on June 17, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Glenbeigh Center of Erie 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 client records, the facility failed to document a written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record in six of seven client records reviewed on June 17, 2021.
The facility obtained authorization from the funding entity for drug and alcohol services during the intake process and billed for services without written consent from the client in the following records.
Client # 2 was admitted October 19, 2020 and discharged March 17, 2021.
Client # 3 was admitted November 17, 2020 and discharged April 7, 2021. In addition, bi-weekly progress reports were released to a lawyer and social worker without written client consent.
Client # 4 was admitted August 31, 2020 and discharged January 20, 2021. In addition, bi-weekly progress reports were released to a physician without written client consent.
Client # 5 was admitted January 11, 2021 and discharged May 26, 2021.
Client # 6 was admitted February 15, 2021.
Client # 7 was admitted February 18, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All corrective action's will be implemented by Project Director. A client portal was generated and put into place that allows clients to electronically sign their releases of information and all other intake paperwork in a way that is HIPPA compliant. Project Director will train all staff on how to use the portal, and how to teach clients how to use the portal. All telehealth clients will be taught how to use the portal by staff and all releases of information shall be verified to be electronically signed before treatment begins or any information is released to any entity. All outstanding releases identified in the audit will be signed by the clients in the portal. Project Director will audit these charts to ensure that the outstanding releases were signed. Project Director will conduct random audits to ensure that all future releases of information are being signed before client begins treatment. |
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 on a review of client records, the facility exceeded the limitations imposed at 4 Pa. Code 255.5 when documenting the specific information to be disclosed to an employer on the consent to release information form in one of seven client records reviewed on June 17, 2021.
Client # 1 was admitted October 12, 2020 and discharged March 12, 2021. A consent to release information form dated October 16, 2020 documented the following information would be released to an employer exceeding 4 Pa. Code 255.5: medical history, biopsychosocial assessment, drug screen results, treatment progress, progress reports, discharge plan, discharge summary, continuing care and lab reports. In addition, bi-weekly progress reports were released to the employer that included: attendance, assignments, participation and attendance of twelve step meetings.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director created a new release of information and it was generated for employers only that outlines the information to be released and said release of information shall be used for employers going forward. This release of information is compliant with PA Code 255.5. Staff shall be trained by Project Director on the new release of information and what information is allowed to be released to employers. Staff will ensure that existing clients will sign this new release of information and all future clients shall also sign this new release of information. Staff will be trained by Project Director as to which information is able to be released to said employers, and Project Director will conduct random chart audits to ensure that no information other than the information allowed to be released is released, and that releases of information are signed. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client that included the dated signature of the client in four of seven client records reviewed on June 17, 2021.
Consents were documented during the intake process in the following client records.
Client # 2 was admitted October 19, 2020 and discharged March 17, 2021. Consents for insurance and a significant other did not include the dated signature of the client.
Client # 3 was admitted November 17, 2020 and discharged April 7, 2021. Consents for a law firm, social worker and a significant other did not include the dated signature of the client.
Client # 4 was admitted August 31, 2020 and discharged January 20, 2021. Consents for insurance, primary care physician and spouse did not include the dated signature of the client.
Client # 5 was admitted January 11, 2021 and discharged May 26, 2021. Consents for insurance and spouse did not include the dated signature of the client.
The findings were reviewed with staff during the licensing process.
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Plan of Correction
All corrective action's will be implemented by Project Director. A client portal was generated and put into place that allows clients to electronically sign their releases of information and all other intake paperwork in a way that is HIPPA compliant. Project Director will train all staff on how to use the portal, and how to teach clients how to use the portal. All telehealth clients will be taught how to use the portal by staff and all releases of information shall be verified to be electronically signed before treatment begins or any information is released to any entity. All outstanding releases identified in the audit will be signed by the clients in the portal. Project Director will audit these charts to ensure that the outstanding releases were signed. Project Director will conduct random audits to ensure that all future releases of information are being signed before client begins treatment. |