INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, 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 April 15, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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, Alternative Counseling Associates, Inc. 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 complete an informed and voluntary consent to release information form prior to the disclosure of information in three of nine client records reviewed.
Client # 3 was admitted on January 29, 2021 and was still active at the time of the inspection. There was evidence of a disclosure to a pharmacy on February 22, 2021; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
Client # 5 was admitted on December 31, 2019 and was discharged on March 24, 2020. There was evidence of a disclosure to an outside individual on January 2, 2020; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
Client # 6 was admitted on August 27, 2020 and was discharged on October 10, 2020. There was evidence of a disclosure to a pharmacy on August 28, 2020; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
At time of admission, admission staff is responsible to ensure each client completes a release of information for the new pharmacy. The assigned primary counselor will further verify this has been completed at time of session to complete bio-psychosocial.
The supervisor or project director, at time of paperwork sign-off will be responsible to check again and ensure there is a valid release for all disclosures.
Client #3 completed release on 4/19/21. |
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 a review of client records, the facility failed to document the purpose of the disclosure on consent to release information forms in two of nine client records reviewed.
Client # 2 was admitted on January 22, 2021 and was still active at the time of the inspection. The release of information form to another treatment provider was signed and dated by the client on January 22, 2021, but the release form failed to document the purpose of the disclosure
Client # 3 was admitted on January 29, 2021 and was still active at the time of the inspection. The release of information form to another treatment provider was signed and dated by the client on January 29, 2021, but the release form failed to document the purpose of the disclosure
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At time of admission, admission staff is responsible to ensure each client completes valid release of information forms.
The supervisor or project director, at time of paperwork sign-off will be responsible to ensure that release form have been accurately completed, including purpose of disclosure.
Release for client #2 and #3 were updated 4/19/21. |
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.
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Observations
Based on a review of the facility's November 2019 through March 2021 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following the September 22, 2020 event at the facility that required the presence of police or ambulance personnel at the facility.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The process had been reviewed and was revised to include a follow-up by the administrative coordinator.
Staff present and/or involved in unusual incident complete the agency incident report form. Report is provided to the Executive Director and copy to the administrative coordinator.
The Executive Director is responsible to submit the DDAP online system report. The administrative coordinator will follow-up with director prior to the 3 days to further ensure timely submission. |