INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 5, 2020, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, Providence Treatment, 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 investigation.
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Plan of Correction
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709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
The facility failed to protect client identity and records.
On March 5, 2020 at 9:20 am DDAP staff arrived at the facility. A client was observed in the waiting area of the facility, however there were no staff in the facility at the time. Client identifying information was observed on the receptionist ' s desk in the waiting area.
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Plan of Correction
On 3/9/2020, the Facility Director has conducted all staff training that no client will be in the waiting area when the staff has to step away from their workstation.
When the staff steps away from their workstation, they must ensure that the office door is locked and no client is present in the waiting ware.
Effective 3/9/2020, a signage will be posted about when the staff will return to the office if they need to step away for whatever reason.
On 3/9/2020, the Facility Director provided staff training to secure all client's identifying information at their workstation when the staff has to step away.
The Facility Director will perform daily audit to ensure compliance of the security of the client's information. |
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 voluntary consent from the client prior to the disclosure of information.
On March 5, 2020 there was a yoga group being conducted in the group room of the facility. There was a contract submitted to DDAP staff between the treatment provider and the agency conducting the yoga group, however, there was no Qualified Service Organization Agreement (QSOA) or individual consents to this agency. Additionally, an individual who was not a staff member of Providence Treatment was permitted to participate in staff meetings at the facility without obtaining prior written consent of the clients at the facility.
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Plan of Correction
The facility will obtain QSOA with the yoga agency by 3/25/2020 between the Covered Entity and Business Associate to comply with 42 CFR Part 2 regarding the use and disclosure of substance abuse treatment information.
As of 3/9/2020, the yoga group activity was suspended due to COVID-19 health crisis.
As of 3/9/2020, only Providence Treatment staff members will attend and participate in staff meetings. Non staff member is permitted to participate in staff meetings. |