INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 1, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Conewago Snyder 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 of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information that could be disclosed in one out of fourteen client records.
Client #10 was admitted on June 7, 2024 and was still active at the time of the inspection. A release of information form was signed and dated on June 25, 2024 to a drug and alcohol facility that did not have the specific information could be released.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 07/09/24 the Clinical Staff received retraining on informed and voluntary consents for the disclosure of information. Training included specifics in regards to informed and voluntary consents especially in the areas of specific information that could be released for an informed and voluntary consent. To ensure future compliance consents will be reviewed during monthly chart reviews completed by the Firetree compliance team. |
709.63(a)(7) LICENSURE Discharge summary
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(7) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project, including a discharge summary in two of seven applicable records. The facility's policy and procedure manual states that a discharge summary is completed within five days of discharge.
Client #4 was admitted on February 11, 2024 and was discharged on February 16, 2024. A discharge summary was due no later than February 21, 2024; however, there is no documentation that one was completed.
Client #5 was admitted March 5, 2024 and was discharged on March 9, 2024 A discharge summary was due no later than March 14, 2024; however, there is no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 07/11/24 the Clinical staff received retraining on discharge summaries to include content of the discharge summary as well as specifics to the time frame for completion within five days of discharge as to company policy. To ensure future compliance discharge summaries will be reviewed during monthly chart audits completed by the Firetree compliance team. |