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 December 10, 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, Family Services of Warren County 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 document a signed, voluntary consent for the disclosure of client record information in two client records.
Client #1 was admitted on February 18, 2020 and is still an active client. There was information released to an outside agency on February 28, March 12, March 26, August 26 and September 30, 2020. There was no signed release of information documented in client record #1 for the receiving agency.
Client #3 was admitted on December 17, 2019 and is still an active client. There was a signed release of information documented for an outside agency in client record #3; however, it was limited to the information permitted by Pa Code 255.5. On February 10, 2020, there was a 6 page evaluation sent to the outside agency, which exceeds what is permitted by Pa Code 255.5 and what is permitted by the signed consent.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the April 8-9, 2019 inspection.
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Plan of Correction
The Facility Director/Clinical Supervisor will ensure all Drug and Alcohol Therapists receive DDAP approved Confidentiality training within 60 days. Following this training, the Clinical Supervisor will also complete an in-house training to review PA Code 255.5 regulations and applicable usage in treatment.
All release of client records will be completed by the Medical Records Specialist, who will review the client record for valid consent and review the information to be released with the Clinical Supervisor prior to the release of information. In the event of a event with immediate need for release of information, the therapist will review the information released directly with the clinical supervisor prior to the release of information. |
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 document the specific information to be disclosed on consents to release information in client records #2 and #4.
Client #2 was admitted on April 30, 2020 and is still an active client. There were two consents to release information signed on April 30, 2020 that had "other" checked on the information to be released and on the line next to it was written "records". This "records" does not indicate the specific information to be disclosed.
Client #4 was admitted on March 30, 2020 and discharged on June 26, 2020 There was a consent to release information signed on June 5, 2020 that had "other" checked on the information to be released and on the line next to it was written "records". This "records" does not indicate the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the April 8-9, 2019 inspection.
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Plan of Correction
The Facility Director/Clinical Supervisor will ensure all Drug and Alcohol Therapists receive DDAP approved Confidentiality training within 60 days. Following this training, the Clinical Supervisor will also complete an in-house training to review PA Code 255.5 regulations and applicable usage in treatment.
All release of client records will be completed by the Medical Records Specialist. Any need for release of information in addition to what is provided for in PA Code 255.5 will be reviewed with the Clinical Supervisor/Facility Director in conjunction with the Medical Records Specialist. In the event of a event with immediate need for release of information, the therapist will review the information released directly with the Clinical Supervisor/Facility Director prior to the release of information.
Client #2 was contacted on January 15, 2021 in reference to the two consents to release information dated April 30, 2020, and informed that his current consents permitted the release of information beyond the scope of 4 PA Code 255.5 (b), and also that no such violation had occurred. The client revoked both consents dated April 30, 2020 on January 15, 2021, and authorized new consents for both agencies referenced in the previous releases of information beginning January 15, 2021 restricted to the information permissible as outlined in 4 PA Code 255.5 (b). |
709.93(a)(9) LICENSURE Client records
709.93. 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in client record #4.
Seven client records were reviewed on December 10, 2020. Four of the seven clients reviewed were discharged; however, only one of the discharged clients reviewed completed treatment successfully and required the documentation of an aftercare plan. Client #4 was admitted on March 30, 2020 and successfully discharged on June 26, 2020. There was no aftercare plan documented for client #4.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Therapists will review upcoming successful completion discharges in consultation with the Clinical Supervisor or Facility Director at least 30 days prior to the discharge of the individual. Therapists will review the aftercare plan with both the individual and the Clinical Supervisor/Facility Director prior to the approval of the individual's discharge from care. This process will be reviewed in group supervision with Drug and Alcohol Therapists and the Medical Records Specialist on 1/7/21. |