INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 27, 2019 to August 28, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Interim House West 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
The facility failed to document the name of the person, agency or organization to whom the disclosure was to be made to on a consent form in two of seven client records.
Client # 4 was admitted on November 19, 2018 and was discharged on March 1, 2019. There was a consent to release information form signed and dated by the client on November 19, 2018; however, the consent form did not include the specific name of the person, agency or organization.
Client # 6 was admitted on November 14, 2018 and was discharged on June 3, 2019. There was a consent to release information form signed and dated by the client on November 14, 2018; however, the consent form did not include the specific name of the person, agency or organization.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director will be responsible for conducting an in-services staff training to review 709.28 (c) (1) regulations as it pertains to release of information. The training will address the importance of identifying the person or organizations to whom information is disclosure. All current releases will be reviewed and updated to meet this regulation. Total Quality Management will conduct chart audits quarterly to ensure releases of information are completed correctly.
Program Director will ensure that in-service training form is filed in training manual and all staff adherence to policy 709.28
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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
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 one of seven client records. Additionally, the facility failed to include the specific information that was to be disclosed on a consent to release information form in two of seven client records.
Client # 1 was admitted February 8, 2019 and was active at the time of inspection. There was a consent to release information form to an organization signed and dated by the client on February 8, 2019; however, the consent form did not include the specific information to be disclosed.
Client # 6 was admitted on November 14, 2018 and was discharged on June 3, 2019. The record contained documentation of a facsimile sent on April 8, 2019 to the funding source that contained the client's psychiatric evaluation, psychiatrist progress notes, and UDS results. Additionally, there was a consent to release information form signed and dated by the client on November 14, 2018; however, the consent form did not include the specific information to be disclosed.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director will conduct an in-service staff training to review 709.28 ( c) (2) regulations as it pertains to informed and voluntary consent. Clinical Director in-services will address the importance of documenting specific information that is being disclosed. Training will be documented by signature of attendance sheets. Total Quality Management will conduct chart audits quarterly to ensure releases of information are completed correctly. |
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
The facility failed to document the purpose of disclosure on the consent form in two of seven client records.
Client # 6 was admitted on November 14, 2018 and was discharged on June 3, 2019. There were consents to release information forms to two individuals and one unnamed person/organization/agency,all signed and dated by the client on November 14, 2018; however, the consents to release information forms did not specify the purpose for disclosure.
Client # 7 was admitted on January 4, 2019 and was discharged on July 11, 2019. There was a consent to release information form to an individual signed and dated by the client on January 4, 2019; however, the consent to release information form did not specify the purpose for disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will conduct an in-service staff training to review 709.28 (c) (3) regulations as it pertains to informed and voluntary consent forms. The training will address the importance of specifying the purpose of disclosure information. The Clinical Director will conduct chart audits to ensure that all information disclosure properly in order to adhere to 709.28 (c) (3) regulations. Total Quality Management will conduct chart audits quarterly to ensure releases of information are completed correctly. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
The facility failed to document the dated witness signature on a consent form in one of seven client records.
Client # 1 was admitted on February 2, 2019 and was active at the time of the inspection. There was a consent to release information form to an external organization signed and dated by the client on February 8, 2019; however, the consent form did not include a dated witness signature.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director will conduct an in-service staff training to review 709.28 (c) (3) regulations as it pertains to informed and voluntary consent forms. Clinical Director will address the importance of dating the signature of the witness when completing consent forms. Total Quality Management will conduct chart audits quarterly to ensure releases of information are completed correctly. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
The facility failed to verify the individual's identity, including name, address and date of birth, prior to the administration of a narcotic agent in one of two applicable client records.
Client # 4 was admitted on November 19, 2018 and was discharged on March 1, 2019.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The Admission Director will verify potential individual eligibility for admission under regulations 715.9 (a) (2) by asking for identification. However, if the potential individual does not have identification the admission director will complete the narcotic treatment program identification verification form which includes name, date of birth, gender, race/ethnicity, signature and date. Admission Director will cross-reference this information with insurance provider who have approve individual for treatment. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
The facility failed to include documentation that the female clients were informed of the potential risks to her or her unborn child of continued use of illicit drugs, or withdrawal from a narcotic drug prescribed by the program in one of two applicable client records.
Client # 6 was admitted on November 14, 2018 and was discharged on June 3, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately the narcotic treatment physician will perform face-to-face with participant to informed and document the possible risk to her or her unborn child from continue of illicit drugs or withdrawal from a narcotic drug prescribed. This will be documented in the participant's chart. The registered nurse will work closely with narcotic treatment physician to ensure this document is adherence to policy 715.10 (f). The program director will monitor this via supervision with the registered nurse. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
The facility failed to ensure that the client signed an informed consent to treat prior to the administration of a narcotic agent in two of two applicable client records.
Client # 4 was admitted on November 19, 2018 and was discharged on March 1, 2019.
The client's initial dose was on November 21, 2018, but the informed consent to treat was not completed until January 4, 2019.
Client # 6 was admitted on November 14, 2018 and was discharged on June 3, 2019.
The client's initial dose was on November 17, 2018, but the informed consent to treat was not completed until January 4, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Prior to any implementation of medication assist narcotic treatment. The narcotic treatment physician will perform face-to-face with participant to obtain an informed consent to treat prior to administration of a narcotic. The registered nurse will work closely with narcotic treatment physician to ensure informed consent form is documented an adherence to policy 715.12 (1-5). The program director will monitor this via supervision with the registered nurse. Total Quality Management will conduct chart audits quarterly to ensure releases of information are completed correctly. |