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 November 23, 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, Peace Valley Recovery LLC. 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 a written informed and voluntary consent from the client for the disclosure of information contained in the client record in nine of fourteen client records reviewed.
Client #3 was admitted into the outpatient level of care on December 10, 2019 and was discharged on January 28, 2020. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client prior to the disclosures.
Client #4 was admitted into the outpatient level of care on September 1, 2020 and was discharged on October 12, 2020. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client prior to the disclosures.
Client #5 was admitted into the outpatient level of care on October 19, 2020 and was still active at the time of inspection. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client prior to the disclosures.
Client #6 was admitted into the outpatient level of care on October 22, 2020 and was still active at the time of inspection. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client prior to the disclosures.
Client #7 was admitted into the outpatient level of care on October 9, 2020 and was still active at time of inspection. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client prior to the disclosures.
Client #9 was admitted into the partial hospitalization level of care on January 28, 2020 and was discharged on February 19, 2020. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client prior to the disclosures.
Client #10 was admitted into the partial hospitalization level of care on August 6, 2020 and was discharged on September 1, 2020. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client prior to the disclosures.
Client #11 was admitted into the partial hospitalization level of care on September 10, 2020 and was discharged on October 19, 2020. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client prior to the disclosures.
Client #13 was admitted into the partial hospitalization level of care on November 9, 2020 and was active at time of inspection. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client prior to the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PVR created consents to the funding source for each client. Each consent is completed upon client's initial intake. Facility Director created the consents in the EHR on 11/27/2020. Facility Director and Clinical Director will ensure that the consents are being completed during regular chart checks. All active clients had new consents completed in their charts by 12/1/2020. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
The facility failed to ensure that all informed and voluntary consent to release information forms included the dated signature of a witness in fourteen of fourteen client records reviewed.
Client #1 was admitted into the outpatient level of care on March 26, 2020 and discharged on July 2, 2020. Release of information forms to a urinalysis laboratory, a medical billing service, and another treatment facility were all signed and dated by the client on March 26, 2020 and they all did not include the dated signature of a witness.
Client #2 was admitted into the outpatient level of care on May 18, 2020 and discharged on July 17, 2020. Release of information forms to a urinalysis laboratory, a medical billing service, and an outside individual were all signed and dated by the client on April 17, 2020 and they all did not include the dated signature of witness.
Client #3 was admitted into the outpatient level of care on December 10, 2019 and discharged on January 28, 2020. Release of information forms to a urinalysis laboratory, a medical billing service, and an outside individual were all signed and dated by the client on December 10, 2019 and they all did not not include the dated signature of witness.
Client #4 was admitted into the outpatient level of care on September 1, 2020 and discharged on October 12, 2020. Release of information forms to a urinalysis laboratory, a medical billing service, and an outside individual were all signed and dated by the client on August 6, 2020 and the all did not include the dated signature of witness.
Client #5 was admitted into the outpatient level of care on October 19, 2020 and was active at time of inspection. Release of information forms to a urinalysis laboratory, a medical billing service, and an outside individual were all signed and dated by the client on September 10, 2020 and they all did not include the dated signature of witness.
Client #6 was admitted into the outpatient level of care on October 22, 2020 and was active at time of inspection. Release of information forms to a urinalysis laboratory, a medical billing service, and an outside individual were all signed and dated by the client on October 1, 2020 and they all did not include the dated signature of witness.
Client #7 was admitted into the outpatient level of care on October 9, 2020 and was active at time of inspection. Release of information forms to a urinalysis laboratory, a medical billing service, and an outside individual were all signed and dated by the client on September 14, 2020 and they all did not include the dated signature of witness.
Client #8 was admitted into the partial hospitalization level of care on April 17, 2020 and discharged on May 18, 2020. Release of information forms to a urinalysis laboratory, a medical billing service, and an outside individual were all signed and dated by the client on April 17, 2020 and they all did not include the dated signature of witness.
Client #9 was admitted into the partial hospitalization level of care on January 28, 2020 and discharged on February 19, 2020. Release of information forms to a urinalysis laboratory, a medical billing service, and an outside individual were all signed and dated by the client on December 10, 2020 and they all did not include the dated signature of witness.
Client #10 was admitted into the partial hospitalization level of care on August 6, 2020 and discharged on September 1, 2020. Release of information forms to a urinalysis laboratory, a medical billing service, and an outside individual were all signed and dated by the client on August 6, 2020 and they all did not include the dated signature of witness.
Client #11 was admitted into the partial hospitalization level of care on September 10, 2020 and discharged on October 19, 2020. Release of information forms to a urinalysis laboratory, a medical billing service, and an outside individual were all signed and dated by the client on September 10, 2020 and they all did not include the dated signature of witness.
Client #12 was admitted into the partial hospitalization level of care on October 15, 2020 and was active at time of inspection. Release of information forms to a urinalysis laboratory, a medical billing service, and an outside individual were all signed and dated by the client on October 15, 2020 and they all did not include the dated signature of witness.
Client #13 was admitted into the partial hospitalization level of care on November 9, 2020 and was active at time of inspection. Release of information forms to a urinalysis laboratory, a medical billing service, and an outside individual were all signed and dated by the client on November 10, 2020 and they all did not include the dated signature of witness.
Client #14 was admitted into the partial hospitalization level of care on November 12, 2020 and was active at time of inspection. Release of information forms to a urinalysis laboratory, a medical billing service, and an outside individual were all signed and dated by the client on November 12, 2020 and they all did not include the dated signature of witness.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PVR created a dated time stamp in the Electronic Health Record next to the signature of each witness. Facility Director edited the signature time stamps in the EHR on 11/27/2020. Facility Director and Clinical Director will ensure that the consents are being completed during regular chart checks. All active clients had new consents completed in their charts by 12/1/2020. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
The facility failed to assure that a copy of a client consent was offered to the client and a copy maintained in the client record in fourteen of fourteen applicable client records.
Client #1 was admitted into the outpatient level of care on March 26, 2020 and discharged on July 2, 2020. Release of information forms to a urinalysis laboratory, a medical billing service, and another treatment facility were all signed and dated by the client on March 26, 2020; however, there was no documentation that the client was offered a copy of each of the consent forms.
Client #2 was admitted into the outpatient level of care on May 18, 2020 and discharged on July 17, 2020. Release of information forms to a urinalysis laboratory, a medical billing service, and an outside individual were all signed and dated by the client on April 17, 2020; however, there was no documentation that the client was offered a copy of each of the consent forms.
Client #3 was admitted into the outpatient level of care on December 10, 2019 and discharged on January 28, 2020. Release of information forms to a urinalysis laboratory, a medical billing service, and an outside individual were all signed and dated by the client on December 10, 2020; however, there was no documentation that the client was offered a copy of each of the consent forms.
Client #4 was admitted into the outpatient level of care on September 1, 2020 and discharged on October 12, 2020. Release of information forms to a urinalysis laboratory, a medical billing service, and an outside individual were all signed and dated by the client on August 6, 2020; however, there was no documentation that the client was offered a copy of each of the consent forms.
Client #5 was admitted into the outpatient level of care on October 19, 2020 and was active at time of inspection. Release of information forms to a urinalysis laboratory, a medical billing service, and an outside individual were all signed and dated by the client on September 10, 2020; however, there was no documentation that the client was offered a copy of each of the consent forms.
Client #6 was admitted into the outpatient level of care on October 22, 2020 and was active at time of inspection. Release of information forms to a urinalysis laboratory, a medical billing service, and an outside individual were all signed and dated by the client on October 1, 2020; however, there was no documentation that the client was offered a copy of each of the consent forms.
Client #7 was admitted into the outpatient level of care on October 9, 2020 and was active at time of inspection. Release of information forms to a urinalysis laboratory, a medical billing service, and an outside individual were all signed and dated by the client on September 14, 2020; however, there was no documentation that the client was offered a copy of each of the consent forms.
Client #8 was admitted into the partial hospitalization level of care on April 17, 2020 and discharged on May 18, 2020. Release of information forms to a urinalysis laboratory, a medical billing service, and an outside individual were all signed and dated by the client on April 17, 2020; however, there was no documentation that the client was offered a copy of each of the consent forms.
Client #9 was admitted into the partial hospitalization level of care on January 28, 2020 and discharged on February 19, 2020. Release of information forms to a urinalysis laboratory, a medical billing service, and an outside individual were all signed and dated by the client on December 10, 2020; however, there was no documentation that the client was offered a copy of each of the consent forms.
Client #10 was admitted into the partial hospitalization level of care on August 6, 2020 and discharged on September 1, 2020. Release of information forms to a urinalysis laboratory, a medical billing service, and an outside individual were all signed and dated by the client on August 6, 2020; however, there was no documentation that the client was offered a copy of each of the consent forms.
Client #11 was admitted into the partial hospitalization level of care on September 10, 2020 and discharged on October 19, 2020. Release of information forms to a urinalysis laboratory, a medical billing service, and an outside individual were all signed and dated by the client on September 10, 2020; however, there was no documentation that the client was offered a copy of each of the consent forms.
Client #12 was admitted into the partial hospitalization level of care on October 15, 2020 and was active at time of inspection. Release of information forms to a urinalysis laboratory, a medical billing service, and an outside individual were all signed and dated by the client on October 15, 2020; however, there was no documentation that the client was offered a copy of each of the consent forms.
Client #13 was admitted into the partial hospitalization level of care on November 9, 2020 and was active at time of inspection. Release of information forms to a urinalysis laboratory, a medical billing service, and an outside individual were all signed and dated by the client on November 10, 2020; however, there was no documentation that the client was offered a copy of each of the consent forms.
Client #14 was admitted into the partial hospitalization level of care on November 12, 2020 and was active at time of inspection. Release of information forms to a urinalysis laboratory, a medical billing service, and an outside individual were all signed and dated by the client on November 12, 2020; however, there was no documentation that the client was offered a copy of each of the consent forms.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PVR added to the consent forms two check boxes either accepting or declining a copy of the completed consent forms in the Electronic Health Record. Facility Director created two check boxes at the bottom of each consent in the EHR on 11/27/2020. The check boxes indicate whether or not the client declines or accepts a copy. Facility Director and Clinical Director will ensure that the consents are being completed during regular chart checks. All active clients had new consents completed in their charts by 12/1/2020. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
The facility failed to develop a written policy and procedure regarding the client's rights to inspect their own record, that the project, facility, or clinical director may temporarily remove portions of the record if deemed detrimential to the client, and that the reasons for removing sections must be documented in the client record. Additionally, there was no documentation of written acknoweldgement that the clients were notified of these rights.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PVR updated the Client Rights Policy and Procedure as well as the Client Handbook to reflect the regulations from code 709.30. Facility Director updated the Client Rights Policy in the policy and procedure manual as well as the client handbook on 11/27/2020. The Board of Directors approved the policy update on 11/25/2020. Facility Director will ensure that the new and updated client handbook is being passed out to new clients upon intake. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
The facility failed to develop a written policy and procedure regarding the client's right to appeal a decision limiting access to their records directly to the director. Additionally, there was no documentation of written acknoweldgement that the clients were notified of these rights.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PVR updated the Client Rights Policy and Procedure as well as the Client Handbook to reflect the regulations from code 709.30. Facility Director updated the Client Rights Policy in the policy and procedure manual as well as the client handbook on 11/27/2020. The Board of Directors approved the policy update on 11/25/2020. Facility Director will ensure that the new and updated client handbook is being passed out to new clients upon intake. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
The facility failed to develop a written policy and procedure regarding the client's right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their record. Additionally, there was no documentation of written acknoweldgement that the clients were notified of these rights.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PVR updated the Client Rights Policy and Procedure as well as the Client Handbook to reflect the regulations from code 709.30. Facility Director updated the Client Rights Policy in the policy and procedure manual as well as the client handbook on 11/27/2020. The Board of Directors approved the policy update on 11/25/2020. Facility Director will ensure that the new and updated client handbook is being passed out to new clients upon intake. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
The facility failed to develop a written policy and procedure regarding the client's right to submit rebuttal data or memoranda to their own record. Additionally, there was no documentation of written acknoweldgement that the clients were notified of these rights.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PVR updated the Client Rights Policy and Procedure as well as the Client Handbook to reflect the regulations from code 709.30. Facility Director updated the Client Rights Policy in the policy and procedure manual as well as the client handbook on 11/27/2020. The Board of Directors approved the policy update on 11/25/2020. Facility Director will ensure that the new and updated client handbook is being passed out to new clients upon intake. |