INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 27, 2018 to November 28, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection Crisis Management Services, 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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in 3 of 16 client records reviewed. Additionally, 5 of 16 client records had consent to release information forms that were missing required elements.
Client #2 was admitted on November 16, 2018 and was active at the time of inspection. There was a consult to a healthcare provider dated November 19, 2018 that identified the facility as the requesting agency and listed the client's name; however, there was no consent to release information form on file.
Client #3 was admitted on October 25, 2018 and was active at the time of the inspection. There was a consent to the funding source signed and dated by the client on October 25, 2018; however, the consent listed one of the items to be disclosed as "other" with no specification of what other information would be released.
Client #5 was admitted on May 8, 2018 and was discharged on July 5, 2018. There was a consult to a healthcare provider dated July 7, 2018 that identified the facility as the requesting agency and listed the client's name; however, there was no consent to release information form on file.
Client # 6 was admitted on April 26, 2018 and was discharged on May 28, 2018. There was a consent to the funding source signed and dated by the client on April 27, 2018; however, the consent listed one of the items to be disclosed as "other" with no specification of what other information would be released.
Client # 7 was admitted on June 2. 2018 and was discharged on July 31, 2018. There were two consults to healthcare providers dated July 17, 2018 and July 25, 2018 that identified the facility as the requesting agency and listed the client's name; however, there was no consent to release information form on file.
Client # 8 was admitted on October 31, 2018 and was active at the time of the inspection. There was a consent to the funding source signed and dated by the client on October 31, 2018; however, the consent listed one of the items to be disclosed as "other" with no specification of what other information would be released.
Client # 12 was admitted on March 30, 2018 and was discharged on April 16, 2018. There was a consent form signed and dated by staff on April 10, 2018; however, there was no dated client signature.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Confidentiality Policy and Procedure along with the actual confidentiality form will be reviewed with all staff of the Crisis Management Services River's Bend 3B Drug and Alcohol Treatment program. Instructions on the necessity to complete all items on the form will be provided with a special effort made to highlight the common items that are either filled out incompletely or neglected outright.
The project director/facility director will insure that staff are retrained on the confidentiality policy and procedure either via general training in-service or individual meetings.
The project director/facility director will conduct unannounced chart reviews on a monthly basis.
Clients whose records were cited, met with the program nurse or their individual therapist who reviewed the specific release form that was cited and explained to them all corrections that were made.
All active charts were corrected within 72 hours.
All corrections were reviewed by the Project Director/Facility Director
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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 facility failed to verify and document an emergency contact in one of four applicable client records. Client #1 was admitted on October 7, 2018 and was an active client at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The intake form used during client admission to obtain information needed to determine client identity and eligibility, including emergency contact information, for admission will be reviewed with all staff of the Crisis Management Services River's Bend 3B Drug and alcohol Treatment Program.
Instructions on how to properly complete the form will be provided with special attention on the need to complete all items particularly the emergency contact information section.
Upon intake, clients will be asked to provide any form of identification that they possess. Efforts will also be made to utilize the EVS (eligibility verification system) to obtain verification of client identity.
The Project Director/Facility Director will insure that staff have been retrained on the on the intake form either by a general in-service training or individual meetings.
The Project Director/Facility Director will conduct monthly unannounced chart reviews and will focus on proper completion of the intake form.
The one client whose record was cited, met with their assigned therapist who reviewed the intake form and added the emergency contact information
This was corrected within 72 hours
All corrections were reviewed by the Project Director/Facility Director.
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715.20 LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
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Observations
The facility failed to develop written transfer policies and procedures which require the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within seven days of the request of the patient.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new policy was developed to address the transfer policies and procedures which are required to transfer a client to another narcotic treatment program for continued detoxification or another treatment activity within seven days of the request of the patient.
Client would be able to remain in their current treatment program for seven days while the transfer process is completed. The Project Director/Facility Director will insure that staff have been retrained on the on the transfer policy and procedures either by a general in-service training or individual meetings.
The Project Director/Facility Director will conduct monthly unannounced chart reviews and will focus on proper adherence to the transfer policy. |
715.21(2) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(2) A patient terminated involuntarily, except a patient who commits or threatens to commit acts of physical violence, shall be afforded the opportunity to receive detoxification of at least 7 days. The detoxification may take place at the facility or the patient may be referred to another narcotic treatment program or hospital licensed and approved by the Department for detoxification.
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Observations
The facility failed to develop policies and procedures regarding involuntary terminations that include if a patient is terminated involuntarily, except a patient who commits or threatens to commit acts of physical violence, shall be afforded the opportunity to receive detoxification of at least 7 days. The detoxification may take place at the facility or the patient may be referred to another narcotic treatment program or hospital licensed and approved by the Department for detoxification.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility has developed new policies and procedures regarding the involuntary termination of clients.
These new procedures will address the need that involuntary terminations include the opportunity for a client who is being terminated involuntarily, except in cases where a patient commits or threatens to commit acts of physical violence, that these patients shall be afforded the opportunity to receive detoxification for at least 7 days. The detoxification may take place at the Facility or the client may be referred to another narcotic treatment program or hospital licensed and approved by the Department for detoxification.
The Project Director/Facility Director will insure that staff have been retrained on the on the involuntary termination policy and procedure either by a general in-service training or individual meetings.
The Project Director/Facility Director will conduct unannounced chart reviews and will focus on proper completion of the termination process.
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