INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 1, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Newvitae, 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) (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
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in two of seven client records reviewed.
Client #2 was admitted on June 29, 2022 and was still active at the time of the inspection. The release of information form to a probation officer was signed and dated by a witness on July 13, 2022, but the form did not include the dated signature of the client.
Client #5 was admitted on January 18, 2021 and was discharged on February 28, 2022. The release of information forms to the funding source and the emergency contact were signed and dated by a witness on January 19, 2022, but both of the forms did not include the dated signature of the client.
This is a repeat citation from the November 12, 2020 and November 4, 2021 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
At next in person individual session, Therapist, will explain that although verbal consent was given at the time of the release being obtained on July 13, 2022, client #2 will need to physically sign the release of information that violates DDAP code 4 Pa. Code 255.5 (4) due to lack of client signature. Updated release with signature will be added to the clinical record and Therapist will document correction in collateral contact note.
Client #5s record cannot be updated with physical signatures because client is already discharged.
To address this violation, an all staff meeting with be held on 1/12/23 at 2 pm to review our agency's updated policy that requires all intakes to be completed in person (rather than telehealth) to get signatures on needed documents.
All staff will be made aware that we have an Adobe Sign account that can be utilized at this time for virtual signatures. In addition, we are exploring adding a client portal option to our existing EHR to allow for virtual signatures to be obtained.
Both errors occurred in consents entered at a date later than intake by clinical staff (rather than administrative admission team). This indicates a need to further train clinical staff on DDAP code 4 Pa. Code 255.5 (4). A group supervision meeting will be held to review the policy and retrain clinicians on the policy related to client signature versus verbal consent. Individual supervisors will utilize individual supervision to review all active DDAP client's releases to ensure policy is being met.
A quarterly audit related specifically to this policy will be instituted and implemented by internal audit team to ensure this will not continue as a repeat violation.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for documenting the dated signature of the client on release of information forms were submitted and approved by the Department for the November 4, 2021 and November 12, 2020 annual licensing inspections. Documenting the dated signature of the client on release of information forms was again found to be a deficiency in the December 1, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A quarterly audit related specifically to this policy will be instituted and implemented by the internal audit team to ensure this will not continue as a repeat violation. The first meeting of the year will be held on 1/16/23 at 2 pm and the facility Director will review the recurrent citation with the audit team.
All staff are aware of the updated plan of correction from the 2022 review. The Clinical Supervisor and Lead Clinician, will conduct internal audits during individual and group supervision on ROIs completed by the clinical team.
The Program Director and Office Manager will meet during monthly supervision to do additional auditing of DDAP chart documentation to ensure this error does not continue and will not reoccur at next licensing inspection.
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