INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted May 13, 2024 through May 14, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Malvern Institute 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) (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
Based on a review client records, the facility failed to document the specific information to be disclosed on release of information forms in two of fourteen client records reviewed.
Client #5 was admitted to the residential level of care on August 2, 2023 and was discharged on August 15, 2023. The release of information form to an emergency contact was signed and dated by the client on August 2, 2023, but the release form indicated the "entire record" to be released, which was not specific to the purpose of the disclosure. Additionally, the release of information form to a primary care physician was signed and dated by the client on August 3, 2023, but the release form indicated the "entire record" to be released, which was not specific to the purpose of the disclosure.
Client #7 was admitted to the residential level of care on October 23, 2023 and was discharged on November 16, 2023. The release of information form to an external treatment provider was signed and dated by the client on November 3, 2023, but the release form indicated the "entire record" to be released, which was not specific to the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Identification of Failure: Staff were operating with the assumption that they could use the "entire record" check box on the release of information forms.
Action: Staff were educated that they assist the patient in selecting each item to be released individually. The EMR was modified, and the 'entire record' checkbox has been removed.
Monitoring: Monitoring will be completed monthly by the clinical supervisors/designated staff and monitored by the Director of PI during monthly chart audits to establish compliance with selecting each item identified by the patient for release on the release of information forms in the EMR. 25 charts will be audited each month with a goal of 100% compliance for 3 months. |
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 a release of information form in one of fourteen client records reviewed.
Client #3 was admitted to the residential level of care on April 8, 2024 and was still active at the time of inspection. There was a release of information form to a funding source in the record, but the release form was not signed and dated by the client.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Identification of Failure: Staff completed the funding source release of information form prior to the actual conversion from the SCA to the new funding source and did not go back and get it signed.
Action: Staff were educated that they must complete all release of information forms with the patient's signature and date when completing a release of information form.
Monitoring: Monitoring will be completed monthly by the clinical supervisors/designated staff and monitored by the Director of PI during monthly chart audits to establish compliance with obtaining a patient signature and date on the release of information forms. 25 charts will be audited each month with a goal of 100% compliance for 3 months. |