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 January 20, 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, Project Transition 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
The facility failed to obtain a written, informed and voluntary consent from the client for the disclosure of information contained in the client record in three of seven client records.
Client # 1 was admitted on October 9, 2019 and active at time of inspection. The release of information to the funding source was signed and dated by the client on October 9, 2019; however, the form expired on October 8, 2020. There was documentation of disclosures to the funding source after expiration of the initial release of information.
Client # 2 was admitted on October 2, 2019 and active at time of inspection. The release of information to the funding source was signed and dated by the client on October 2, 2019; however, the form expired on October 1, 2020. A second release of information to the funding source was signed and dated by the client on January 15,2021; however, there was documentation of disclosures after expiration of the first release and prior of the second release of information form.
Client # 3 was admitted on November 4, 2019 and active at time of inspection. The release of information to the funding source was signed and dated by the client on October 17, 2019; however, the form expired on October 16, 2020. A second release of information to the funding source was signed and dated by the client on January 14, 2021; however, there was documentation of disclosures after expiration of the first release and prior of the second release of information form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
These findings were reviewed with the Project Director and the Facility Director. Based on the review of these findings, all consents will be audited and any missing consents will be created and signed by both the staff and Member by 2/15/21. To prevent this issue from occurring in the future, Project Transition is implementing a Quality Review at the program level, which will include monitoring consents for all Members. This will be monitored by the Facility Director. Project Transition will also add consents that are expiring soon to the staff dashboard in the EHR. This will be completed by 3/15/21 and will be monitored by the Facility Director. |
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 ensure that all consent to release information forms documented the purpose of disclosure in two of seven client records reviewed.
Client # 2 was admitted on October 2, 2019 and active at time of inspection. A release of information was signed and dated by the client on October 2, 2019 and did not indicate the purpose of disclosure.
Client # 3 was admitted on November 4, 2019 and active at time of inspection. A release of information to the funding source was signed and dated by the client on October 17, 2019 and did not indicate the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
These findings were reviewed with the Project Director and the Facility Director. Based on the review of these findings, Project Transition will need to re-design the consent. The consent will be updated by 3/15/21 and will include purpose of disclosure. The Director of Outcomes and Systems Development will ensure the consent is updated in the EHR. The Facility Director will ensure consents are completed for all Members. |
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
The facility failed to ensure that all consent to release information forms documented the dated signature of the client in one of seven client records.
Client # 1 was admitted on October 9, 2019 and active at time of inspection. There was a release of information form to a funding source that was signed and date by staff on January 15, 2021; however, the dated signature of the client was not documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
These findings were reviewed with the Project Director and the Facility Director. Based on the review of these findings, it was determined that some of the deficiencies were created by staff when the Member was unable to sign In these cases, staff never went back and obtained the Member's signature. Any consents that have been created without the Member's signature will be de-activated and new consents will be created and signed by both the staff and Member by 2/15/21. To prevent this issue from occurring in the future, Project Transition is implementing a Quality Review at the program level, which will include monitoring consents for all Members. This will be monitored by the Facility Director. |