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 October 1, 2020 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, Pennsylvania Adult and Teen Challenge 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) (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 the review of client records on October 1, 2020, the facility failed to document a completed informed and voluntary consent to release information form. In client record #6, "other" was checked for specific information to be disclosed without clarification on what other information could be released.
Client #6 was admitted on February 4, 2020 and discharged on September 17, 20202. A release of information form was dated November 18, 2019 during an admission to a higher level of care to an emergency services organization.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/14/2020 the patients in mention completed and signed new consent to release information forms. These forms were completed correctly ensuring all pertinent information involving specific information to be disclosed was correct along with including the specific purpose for the disclosure. The forms were also documented to include offering a copy to the patient. On 10/14/2020 a training was conducted with the clinical team on proper completion of authorization to release forms emphasizing confidentiality and DDAP 709.28 (c) (2), (3), and 709.28 (d). The clinical supervisor will conduct monthly record audits inspecting for proper completion of the authorization to release forms. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on the review of client records on October 1, 2020, the facility failed to document a completed informed and voluntary consent to release information form. In client record #'s 6 and 7, "other" was checked for purpose of disclosure without clarification on other purposes.
Client #6 was admitted on February 4, 2020 and discharged on September 17, 2020. A consent to release information form dated November 18, 2019 during a higher level of care was to an emergency services organization.
Client #7 was admitted on July 16, 2020 and discharged on September 15, 20202. A consent to release information form dated June 5 during a higher level of care was to a government agency.
These findings were reviewed with facility staff during a licensing process.
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Plan of Correction
On 10/14/2020 the patients in mention completed and signed new consent to release information forms. These forms were completed correctly ensuring all pertinent information involving specific information to be disclosed was correct along with including the specific purpose for the disclosure. The forms were also documented to include offering a copy to the patient. On 10/14/2020 a training was conducted with the clinical team on proper completion of authorization to release forms emphasizing confidentiality and DDAP 709.28 (c) (2), (3), and 709.28 (d). The clinical supervisor will conduct monthly record audits inspecting for proper completion of the authorization to release forms. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on the review of client records on October 1, 2020, the facility failed to document that a consent form was offered to the client in client record #'s 3, 5, 6 and 7.
Client #3 was admitted on September 8, 2020 and was still active at the time of the inspection. Seven consent to release information forms dated August 26, 2020 were to a pharmacy, a family member, four medical facilities, and a government agency. In addition, a form dated September 21, 2020 was to a family member.
Client #5 was admitted on April 30, 2020 and discharged on September 13, 2020. Six consent to release information forms dated April 30, 2020 were to four medical facilities, one treatment facility and one government agency.
Client #6 was admitted on February 4, 2020 and discharged on September 17, 2020. A consent to release information form dated November 21, 2019 during admission to a higher level of care was to a family member.
Client #7 was admitted on July 16, 2020 and discharged on September 15, 2020. Six consent to release information forms dated July 13, 2020 were to a pharmacy, four medical facilities and a government agency.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/14/2020 the patients in mention completed and signed new consent to release information forms. These forms were completed correctly ensuring all pertinent information involving specific information to be disclosed was correct along with including the specific purpose for the disclosure. The forms were also documented to include offering a copy to the patient. On 10/14/2020 a training was conducted with the clinical team on proper completion of authorization to release forms emphasizing confidentiality and DDAP 709.28 (c) (2), (3), and 709.28 (d). The clinical supervisor will conduct monthly record audits inspecting for proper completion of the authorization to release forms. |
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 client records on October 1, 2020, the facility failed to ensure that the clients had been made aware of their rights. The client rights signed by the clients did not include that they may not be discriminated against based on their sexual orientation in client record #'s 1, 2, 3, 4, 5, 6, and 7.
Client #1 was admitted on January 6, 2020 and was still active at the time of the inspection.
Client #2 was admitted on February 18, 2020 and was still active at the time of the inspection.
Client #3 was admitted on September 8, 2020 and was still active at the time of the inspection.
Client #4 was admitted on May 22, 2020 and was still active at the time of the inspection.
Client #5 was admitted on April 30, 2020 and discharged on September 13, 2020.
Client #6 was admitted on February 4, 2020 and discharged on September 17, 2020.
Client #7 was admitted on July 16, 2020 and discharged on September 15, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/2/2020 the client's rights document was updated to include that they may not be discriminated against based on their sexual orientation along with Clients have the right to inspect their own records. The project, facility, or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record. On 10/14/2020 the facility posted the new client's right document in the facility along with handing out the patients and having them sign a new copy of the new document. |
709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records on October 1, 2020, the facility failed to ensure that the clients had been made aware of their rights. The client rights signed by the clients did not include that reasons for removing sections of their record prior to inspection shall be documented in client record #'s 1, 2, 3, 4, 5, 6, and 7.
Client #1 was admitted on January 6, 2020 and was still active at the time of the inspection.
Client #2 was admitted on February 18, 2020 and was still active at the time of the inspection.
Client #3 was admitted on September 8, 2020 and was still active at the time of the inspection.
Client #4 was admitted on May 22, 2020 and was still active at the time of the inspection.
Client #5 was admitted on April 30, 2020 and discharged on September 13, 2020.
Client #6 was admitted on February 4, 2020 and discharged on September 17, 2020.
Client #7 was admitted on July 16, 2020 and discharged on September 15, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/2/2020 the client's rights document was updated to include that they may not be discriminated against based on their sexual orientation along with Clients have the right to inspect their own records. The project, facility, or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record. On 10/14/2020 the facility posted the new client's right document in the facility along with handing out the patients and having them sign a new copy of the new document. |