INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 26, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Samara House of Cywa 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) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of seven client records, the facility failed to ensure that all informed and voluntary consent to disclose information forms contained the name of the person, agency or organization to whom disclosure is made in one client record reviewed. Client #2 was admitted on February 2, 2022 and was still active at the time of inspection. An informed and voluntary consent to disclose information form was signed and dated on February 2, 2022, that failed to contain the name of the person, agency or organization to whom disclosure is made.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
On 5/4/22, the Program Assurance Liaison met with Client #2 to correct the Consent to Release Confidential Information form dated 2/2/22 to add name of the person, telephone number and address of emergency contact.
Effective 5/4/22, Upon the admission of all new clients, it will be the responsibility of the Lead Counselor Aide, Program Assurance Liaison, Counselor Assistant or the Clinical Supervisor to complete all intake admission forms to include the Consent to Release Confidential Information form. Within 48hours The Project/ Facility Director will review the new admission intake packet to include the Consent to Release Confidential Information form to ensure the form contains the name of the person, agency or organization to whom disclosure is made is present on the form. Additionally, as the client continues to need services throughout her treatment stay and a Consent to Release Confidential Information form is completed, it will be the responsibility of the Program Assurance Liaison, Lead Counselor Aide and Project/Facility Director to perform weekly chart audits to ensure all forms are in compliance with DDAP Regulation 709.28 |
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 of seven client records, the facility failed to ensure that all informed and voluntary consent to disclose information forms contained the specific information disclosed in one of seven records reviewed.Client #5 was admitted on October 25, 2021 and was discharged on April 1, 2022. An informed and voluntary consent to disclose information form was signed and dated on March 1, 2022, that failed to contain the specific information disclosed. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
On 5/4/22, the Project/Facility Director attached a letter to Consent to Release Confidential Information form dated 3/1/22 for Client #5, to void for any further use, effective 5/4/22, due to deficiency.
Effective 5/4/22, Upon the admission of all new clients, it will be the responsibility of the Lead Counselor Aide, Program Assurance Liaison, Counselor Assistant or the Clinical Supervisor to complete all intake admission forms to include the Consent to Release Confidential Information form. Within 48hours The Project/ Facility Director will review the new admission intake packet to include the Consent to Release Confidential Information form to ensure the form contains the specific information to be disclosed is present on the form. Additionally, as the client continues to need services throughout her treatment stay and a Consent to Release Confidential Information form is completed, it will be the responsibility of the Program Assurance Liaison, Lead Counselor Aide and Project/Facility Director to perform weekly chart audits to ensure all forms are in compliance with DDAP Regulation 709.28 |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of seven client records, the facility failed to ensure that all informed and voluntary consent to disclose information forms contained the purpose of the disclosure in one record reviewed. Client #5 was admitted on October 25, 2021 and was discharged on April 1, 2022. An informed and voluntary consent to disclose information form was signed and dated on March 1, 2022, that failed to contain the purpose of the disclosure.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
On 5/4/22 the Project/Facility Director attached a letter to the Consent to Release Confidential Information form dated 3/1/22 to void for further use to due deficiency.
Effective 5/4/22, Upon the admission of all new clients, it will be the responsibility of the Lead Counselor Aide, Program Assurance Liaison, Counselor Assistant or the Clinical Supervisor to complete all intake admission forms to include the Consent to Release Confidential Information form. Within 48hours The Project/ Facility Director will review the new admission intake packet to include the Consent to Release Confidential Information form to ensure the form contains the purpose of the disclosure is present on the form. Additionally, as the client continues to need services throughout her treatment stay and a Consent to Release Confidential Information form is completed, it will be the responsibility of the Program Assurance Liaison, Lead Counselor Aide and Project/Facility Director to perform weekly chart audits to ensure all forms are in compliance with DDAP Regulation 709.28 |
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
Based on a review of seven client records, the facility failed to ensure that all informed and voluntary consent to disclose information forms contained documentation that a copy of a client consent was offered to the client and a copy maintained in the client record. Client #5 was admitted on October 25, 2021 and was discharged on April 1, 2022. An informed and voluntary consent to disclose information form was signed and dated on March 1, 2022, that failed to contain documentation that a copy of a client consent was offered to the client and a copy maintained in the client record. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
On 5/4/22 the Project/Facility Director attached a letter to the Consent to Release Confidential Information form dated 3/1/22 for client #5 to void for further use to due deficiency.
Effective 5/4/22, Upon the admission of all new clients, it will be the responsibility of the Lead Counselor Aide, Program Assurance Liaison, Counselor Assistant or the Clinical Supervisor to complete all intake admission forms to include the Consent to Release Confidential Information form. Within 48hours The Project/ Facility Director will review the new admission intake packet to include the Consent to Release Confidential Information form to ensure the form contains documentation that a copy of a client consent was offered to the client and a copy is maintained in the client record is present on the form. Additionally, as the client continues to need services throughout her treatment stay and a Consent to Release Confidential Information form is completed, it will be the responsibility of the Program Assurance Liaison, Lead Counselor Aide and Project/Facility Director to perform weekly chart audits to ensure all forms are in compliance with DDAP Regulation 709.28 |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of seven client records, the facility failed to document an annual physical examination of the client in three of seven client records reviewed.Client #1 was admitted on February 22, 2022 and was still active at the time of the inspection. The most recent annual physical evaluation was due no later than February 29,2022; however, it was not documented as of the date of the inspection.Client #2 was admitted on February 2, 2022 and was still active at the time of the inspection. The most recent annual physical evaluation was due no later than February 9,2022; however, it was not documented as of the date of the inspection.Client #5 was admitted on October 25, 2021 and was discharge on April 1, 2022. The most recent annual physical evaluation was due no later than November 1, 2021 however, it was not documented as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/4/22 the Lead Counselor Aide scheduled an appointment for Client #1 and Client #2 on 5/18/22 to obtain current physical examination that will be performed and signed by the facility Medical Director. The signed forms will be placed in the client charts.
Effective 5/4/22, when the facility receives referrals for admission it will be the responsibility of the Project/Facility Director, Clinical Supervisor or Counselor Assistant to request a current physical examination be provided. If the referring agency is unable to provide documentation that a current physical examination has been performed then it will be the responsibility of the Lead Counselor Aide to schedule the doctor's appointment to have a physical examination completed within the first 7 days of admission. It will be the responsibility of the Program Assurance Liaison and Project/Facility Director to perform weekly audits to ensure the Physical Examination documentation has been received and present in the clients chart. |