INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 16, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Ellen O'Brien Gaiser Addiction 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
Seven client records were reviewed on August 16, 2017. The facility failed to obtain an informed and voluntary consent in two of seven client records reviewed. Client #5 was admitted on February 8, 2017 and discharged on July 5, 2017. A consent to release information form, dated January 25, 2017 to a criminal justice agency, did not allow for the consent to be revoked, as it stated the following: "if you are participating in this program as a condition of the disposition of any criminal proceedings against you, or if your participation is a condition of parole or other release from criminal justice custody, be advised that you may not revoke your consent to release the specified information listed to the criminal justice system until the legal condition(s) requiring your participation in treatment have been terminated or otherwise discontinued". The client record contained documentation indicating that the facility released patient identifying information to the criminal justice agency on May 23, 2017 and July 10, 2017. Client #7 was admitted on April 26, 2017 and discharged on July 18, 2017. A consent to release information form, dated April 26, 2017 to a criminal justice agency, did not allow for the consent to be revoked, as it stated the following: "if you are participating in this program as a condition of the disposition of any criminal proceedings against you, or if your participation is a condition of parole or other release from criminal justice custody, be advised that you may not revoke your consent to release the specified information listed to the criminal justice system until the legal condition(s) requiring your participation in treatment have been terminated or otherwise discontinued". The client record contained documentation indicating that the facility released patient identifying information to the criminal justice agency on July 19, 2017. There were no court orders mandating treatment documented for these clients and therefore, the consents could be revoked verbally or in writing at any time.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 8/16/2017 the Clinical Supervisor updated and corrected the all "Drug & Alcohol Release of Information" client informed consents and removed the criminal justice system language in question. "if you are participating in this program as a condition of the disposition of any criminal proceedings against you, or if your participation is a condition of parole or other release from criminal justice custody, be advised that you may not revoke your consent to release the specified information listed to the criminal justice system until the legal condition(s) requiring your participation in treatment have been terminated or otherwise discontinued".
Has been removed. All Staff has been trained on 8/21/2017.
The Clinical Supervisor will randomly review and audit client records to ensure that all counselor and other staff are using the correct release of forms going forward.
Client #5 was discharged as of the date of inspection therefore consent was not able to be signed. In the future all correct consents will be signed by client.
Client # 7 was discharged at the time of inspection therefore we were not able to have the new appropriate consent signed. In the future all consents will be signed with the new information on them.
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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
Seven client records were reviewed for client rights on August 16, 2017. The facility failed to include on the facility's Patient Bill of Rights form in the Client Handbook the following verbiage: creed, color, marital status, and handicap.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/21/17 the Clinical Supervisor revised the Patient Bill of Rights given to each client upon admission to include the following:
"You have the right to receive treatment without regard to race, religious creed, ancestry, national origin, creed, ethnicity, color, marital status, handicap, religion, age sexual orientation, gender or economic status." All other DDAP required language was already included in the Patient Bill of Rights and all future clients will receive the corrected Bill of Rights.
All current clients were given the new patient bill of rights by their counselor.
All old copies of the client handbook with the incorrect bill of rights were destroyed by the Clinical Supervisor and Intake Coordinator. |