INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 17, 2019 of Dreamlife Recovery LLC 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, Dreamlife Recovery 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) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to obtain an informed consent in accordance with 28 Pa. Code 709.28 and 42 CFR Part 2 for releases of information in client record #19.
Client#19 was admitted on May 21, 2019 and was discharged on June 14th 2019. A consent to release form was signed and dated on June 5, 2019 that failed to contain the name of the person, agency or organization.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Executive Director is scheduled to hold a staff training by 12/13/19, instructing the staff on how to properly complete ROI's which includes identifying the name of the person, agency or organization that the information is being released to. This training will be provided by the Executive Director, to the case management and behavioral health technician departments responsible for completing Release of Information forms.
To ensure ongoing compliance, auditing of ROI's has been added as a standing agenda item to the monthly Performance Improvement Committee agenda where the Executive Director and Quality Assurance Coordinator will review a random sampling of completed ROI's to verify that the staff are completing these forms properly. Outcomes of the monthly audit will be submitted to the Performance Improvement Committee, where at least 30% of open charts will be reviewed. If an instance of non-compliance is identified, a corrective action plan is required to be submitted to the Performance Improvement Committee with the audit report. |
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 failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record #19.
Client#19 was admitted on May 21, 2019 and was discharged on June 14th 2019. A consent to release form was signed and dated on June 6, 2019 to a county agency that allowed for the release of the treatment plans, psych assessments, physicals, Biopsychsocial's, aftercare and discharge summary.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Quality Assurance Coordinator and Executive Director collaborated on creating a Release of Information template which complies within the limits 4 Pa. Code 255.5 (b) and uploaded the revised template to the EMR. The Executive Director is scheduled to hold a staff training by 12/13/19, educating the staff on 4 Pa. Code 255.5 (b) and how to properly complete Release of Information forms where information is being released specifically to a judge, probation or parole officer, insurance company, health or hospital plan or government official. This training will be provided by the Executive Director, to the case management, behavioral health technician and clinician departments responsible for completing Release of Information forms.
To ensure ongoing compliance, auditing of ROI's has been added as a standing agenda item to the monthly Performance Improvement Committee agenda where the Executive Director and Quality Assurance Coordinator will review a random sampling of completed ROI's to verify that the staff are completing these forms properly. Outcomes of the monthly audit will be submitted to the Performance Improvement Committee, where at least 30% of open charts will be reviewed. If an instance of non-compliance is identified, a corrective action plan is required to be submitted to the Performance Improvement Committee with the audit report.
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709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of seven client records, the facility failed to ensure that compressive treatment plans include type and frequency of treatment and rehabilitation services in seven out of seven client records.
These findings were discussed with the facility during the inspection process.
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Plan of Correction
On 10/30/19, the Executive Director held a staff training educating the staff on proper formulation of comprehensive treatment plans which includes identifying the type and frequency of treatment and rehabilitation services. This training was provided by the Executive Director to the Primary Clinicians, who are responsible for formulating comprehensive treatment plans.
To ensure ongoing compliance, the Vice President of Clinical Operations will review and countersign all comprehensive treatment plans to ensure sustained compliance. If an instance of non-compliance is identified, a corrective action plan is required to be submitted to the Executive Director within 7 days.
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709.14(b)(4) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(4) Change in activity/discontinuance of an activity.
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Observations
Based on observation and interview with staff, the facility failed to notify the Department of a change in activity.
The facility was/is providing Buprenorphine services without prior approval/licensure from the department.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On 10/21/19, the Quality Assurance Coordinator completed the Buprenorphine Exception Request form and submitted it to the Department. On 11/15/19 the Department approved the request and Dreamlife Recovery received a revised License reflecting the additional service.
To ensure ongoing compliance, the Executive Director and Quality Assurance Coordinator collaborated to develop Policy #COC-1.013 Change of Activity, which states that the Department must be notified in writing, using department forms and approval from the Department must be received, prior to providing a change of activity.
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