INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection conducted on March 3, 2021, New Horizons Treatment 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.
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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 the review of client records, the facility failed to obtain an informed and voluntary consent form for the disclosure of information contained in the client record, in three of seven client records.
Client #1 was admitted on March 23, 2020 and is still an active client. The client's record documented that a letter, dated November 4, 2020, was sent to a probation department. There was no documentation of a consent to release for the probation department.
Client # 2 was admitted on June 30, 2020 and is still an active client. The client's documented releases for a third-party payor and a doctor's office that had not been signed by the client. Correspondence was released to the third-party payor and the doctor's office without a valid release.
Client # 6 was admitted on June 24, 2020 and discharged on November 30, 2020. The client's record documented a release for a third-party payor that had not been signed by the client. Correspondence was released to the third-party payor without a valid release.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All clinical staff have been advised that when providing any telehealth treatment service (telephonic or virtual) the document titled "Consent to Release Confidential Information" will not be valid if completed during that type of clinical contact. Therefore, all "Consent to Release Confidential Information" forms must be completed on site, via an in-person (face-to-face) contact in which the patient, as well as a witness, must provide their signature and corresponding date of that signature.
On March 3, 2021 Executive Director and Clinical Director met face to face with all clinical staff to advise of above statement. ie. no virtual/telephonic release of information will be considered a valid release.
As of March 3, 2021 Executive Director and Clinical Director advised all clinical staff that all Clinical Assessments can no longer be conducted in any telehealth format to ensure "all" Consent to Release of Information forms are signed in person and meet the State Standard.
Executive Director has included an addendum to the approved P&P manual that stipulates as of March 3, 2021 the above protocols replace any prior directives related to the provision of clinical treatment services via telehealth (Covid-19 Expansion). |
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 the review of client records, the facility failed to obtain an informed and voluntary consent form that included the dated signature of client, in three of seven client records.
Client # 1, admitted on March 23, 2020 and still an active client, documented releases of information for the disclosure of information that did not include a dated signature of the client.
Client # 2, admitted on June 30, 2020 and still an active client, documented releases of information for the disclosure of information that did not include a dated signature of the client.
Client # 6, admitted on June 24, 2020 and discharged on November 30, 2020, documented releases of information for the disclosure of information that did not include a dated signature of the client.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
All clinical staff have been advised that when providing any telehealth treatment service (telephonic or virtual) the document titled "Consent to Release Confidential Information" will not be valid if completed during that type of clinical contact. Therefore, all "Consent to Release Confidential Information" forms must be completed on site, via an in-person (face-to-face) contact in which the patient, as well as a witness, must provide their signature and corresponding date of that signature.
On March 3, 2021 Executive Director and Clinical Director met face to face with all clinical staff to advise of above statement. ie. no virtual/telephonic release of information will be considered a valid release.
As of March 3, 2021 Executive Director and Clinical Director advised all clinical staff that all Clinical Assessments can no longer be conducted in any telehealth format to ensure "all" Consent to Release of Information forms are signed in person and meet the State Standard.
Executive Director has included an addendum to the approved P&P manual that stipulates as of March 3, 2021 the above protocols replace any prior directives related to the provision of clinical treatment services via telehealth (Covid-19 Expansion). |