INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, 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 October 7, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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, Gaudenzia, Inc. People with Hope Short-Term Program 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 project failed to obtain informed and voluntary consent from the client for the disclosure of information contained in the client record in one of fourteen client records reviewed.
Client #1 was admitted on October 30, 2019 and was discharged on December 2, 2019. There was evidence of the facility billing for services; however, there was no informed and voluntary consent form documented for the funding source in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Together House Program will obtain an informed and voluntary consent from the client for the disclosure of specific information to funding sources disclosed in the charts during admission per 709.28 (c). We will review all other current open charts and obtain an informed and voluntary consent form for them as needed. This has been in effect since October 6, 2020 and charts will be reviewed on a monthly basis during CQI.
On November 11, 2020 a Record-Keeping training will be facilitated to review the 4 PA Code 255.5 Confidentiality Request to Release Information Form and DOH Policy 709.28 (c)(1).
All Consent to Release Information Forms will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Deputy Director
Program Director
Program Supervisor
Timeframe for Completion: November 11, 2020
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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 project failed to include the name of the person, agency, or organization to whom disclosure would be made to on an informed and voluntary consent to release information form in two of fourteen client records reviewed.
Client #7 was admitted on July 28, 2020 and was discharged on August 28, 2020. A release of information form, signed and dated by the client on July 28, 2020, failed to include the name of the person, agency or organization documented on the form.
Client #8 was admitted on October 17, 2019 and was discharged on October 23, 2019. A release of information form, signed and dated by the client on July 28, 2020, failed to include the name of the person, agency or organization documented on the form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The People With Hope Program (WSAC Detox) will obtain an informed and voluntary consent from the client for the disclosure of specific information to include the name of the person, agency, or organization to whom disclosure would be made to on an informed and voluntary consent to release information form per 709.28 (c).
We will review all other current open charts and obtain an informed and voluntary consent form for them as needed. This has been in effect since October 6, 2020 and charts will be reviewed on a monthly basis during CQI.
On November 11, 2020 a Record-Keeping training will be facilitated to review the 4 PA Code 255.5 Confidentiality Request to Release Information Form and DOH Policy 709.28 (c)(1).
All Consent to Release Information Forms will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Deputy Director
Program Director
Program Supervisor
Timeframe for Completion: November 11, 2020 |
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 project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in six of fourteen client records reviewed.
Client #2 was admitted on January 4, 2020 and was discharged on January 30, 2020. A release of information form to a probation agency was signed and dated on January 4, 2020 that allowed for the release of the discharge summary, which exceeds the limits established by 4 Pa. Code 255.5.
Client #3 was admitted on January 21, 2020 and was discharged on February 21, 2020. A release of information form to a probation agency was signed and dated on January 29, 2020 that allowed for the release of the treatment plans, which exceeds the limits established by 4 Pa. Code 255.5. Additionally, a release of information form to a funding source was signed and dated on January 21, 2020, that allowed for the release of ASAM forms, which exceeds the limits established by 4 Pa. Code 255.5.
Client #5 was admitted on March 22, 2020 and discharged on April 21, 2020. A release of information form to a funding source was signed and dated on March 22, 2020 that allowed for the release of assessments and progress notes, which exceeds the limits established by 4 Pa. Code 255.5.
Client #6 was admitted on January 14, 2020 and was discharged on February 1, 2020. A release of information form to a funding source was signed and dated by the client on January 14, 2020 that allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes and medication records, which exceeds the limits established by 4 Pa. Code 255.5.
Client #8 was admitted on October 17, 2019 and was discharged on October 23, 2019. A release of information form to a funding source was signed and dated by the client on October 17, 2019 that allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes and medication records, which exceeds the limits established by 4 Pa. Code 255.5.
Client #9 was admitted on May 26, 2020 and was discharged on May 30, 2020. A release of information form to a funding source was signed and dated by the client on May 29, 2020 that allowed for the release of psychological and psychiatric evaluations, treatment plans, case consults, mental health records, physical and medical records, discharge summary, progress notes and medication records, which exceeds the limits established by 4 Pa. Code 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The People With Hope Program (WSAC Detox) Program will keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information per 709.28 (c).
We will review all other current open charts and obtain an informed and voluntary consent form for them as needed. This has been in effect since October 6, 2020 and charts will be reviewed on a monthly basis during CQI.
On November 11, 2020 a Record-Keeping training will be facilitated to review the 4 PA Code 255.5 Confidentiality Request to Release Information Form and DOH Policy 709.28 (c)(1).
All Consent to Release Information Forms will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Deputy Director
Program Director
Program Supervisor
Timeframe for Completion: November 11, 2020 |
709.63(a)(3) LICENSURE Progress notes
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(3) Progress notes.
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Observations
The facility failed to document a complete client record on an individual which includes information relative to the client's involvement with the project that included progress notes in six of seven client records reviewed.
Client #8 was admitted on October 17, 2019 and was discharged on October 23, 2019. There were no progress notes documented in the client record as of the date of the inspection.
Client #9 was admitted on April 29, 2020 and was discharged on May 4, 2020. There were no progress notes documented in the client record as of the date of the inspection.
Client #10 was admitted on May 26, 2020 and was discharged on May 30, 2020. There were no progress notes documented in the client record as of the date of the inspection.
Client #11 was admitted on May 28, 2020 and was discharged on June 2, 2020. There were no progress notes documented in the client record as of the date of the inspection.
Client #13 was admitted on June 29, 2020 and was discharged on July 3, 2020. There were no progress notes documented in the client record as of the date of the inspection.
Client #14 was admitted on July 9, 2020 and was discharged on July 14, 2020. There were no progress notes documented in the client record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The People With Hope Program (WSAC Detox) Program will review all other current open charts and document a complete client record on an individual which includes information relative to the client's involvement with the program that includes progress notes documenting that per 709.63 (a) Client Records.
This has been in effect since October 6, 2020 and charts will be reviewed on a monthly basis during CQI.
On November 11, 2020 a Record-Keeping training will be facilitated to review DDAP Policy
All client records will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Deputy Director
Program Director
Program Supervisor
Timeframe for Completion: November 11, 2020
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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 program failed to verify the individual's identity, including name, address, date of birth, emergency contact and other identifying data prior to the administration of an agent in three of four applicable records reviewed.
Client #1 was admitted on October 30, 2019 and was discharged on December 2, 2019. The verification of the client's identity and emergency contact was not documented in the record.
Client #2 was admitted on January 4, 2020 and was discharged on January 30, 2020. The verification of the client's identity and emergency contact was not documented in the record.
Client #4 was admitted on February 25, 2020 and was discharged on March 2, 2020. The verification of the client's identity and emergency contact was not documented in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During an assessment and prior to administration of Medication Assisted Treatment (MAT), the WSAC Assessment Counselor will assess each referral to determine eligibility for admission. During that assessment they will verify the individual 's identity, which includes their name, address, date of birth, emergency contact and other identifying data.
On November 13, 2020, a training on DDAP Policy 715.9 (a)(2) will be facilitated with the assessment and clinical staff to increase their understanding of the need to use identifying data before treating the members.
All client records will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Deputy Director
Program Director
Assessment/Clinical Staff
Timeframe for Completion: November 13, 2020
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715.9(a)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
The program failed to have a narcotic treatment physician document whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment in three of four applicable records reviewed.
Client #1 was admitted on October 30, 2019 and was discharged on December 2, 2019. Current physiologically dependency upon a narcotic drug and physiological dependency for at least 1 year was not documented in the client record by a narcotic treatment physician.
Client #2 was admitted on January 4, 2020 and was discharged on January 30, 2020. Current physiologically dependency upon a narcotic drug and physiological dependency for at least 1 year was not documented in the client record by a narcotic treatment physician.
Client #3 was admitted on January 21, 2020 and was discharged on February 21, 2020. Current physiologically dependency upon a narcotic drug and physiological dependency for at least 1 year was not documented in the client record by a narcotic treatment physician.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Health Services Director will meet with each provider physician individually and provide a one to one in-service on the location and completion of the Buprenorphine Physician Review Form listed under the Health and Medical section of the Avatar chart. This form verifies length of active addiction and that the individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment.
There will be a Medical Provider Avatar/Order Connect review on November 13, 2020 which will also review the location of this information.
The charts will be reviewed on a monthly basis during CQI meetings to ensure that the form is being completed.
Persons Responsible:
Deputy Director
Health Services Director
Provider Physicians
Timeframe for Completion: November 13, 2020
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