INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 27 - 28, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Ellen O'Brien Gaiser Addiction Center 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. The consent shall be in writing and include, but not be limited to:
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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 prior to the disclosure of information in five of seven client records.
The findings include:
Seven client records were reviewed on July 27, 2011. Seven of the seven client records were required to include an informed and voluntary consent from the client prior to the disclosure of information.
Client record #1 was admitted on 5-26-11. A consent to release information form for a funding source, signed on 5-26-11, did not include the specific information to be disclosed or the purpose of the disclosure. A consent to release information form for a dental referral, signed on 5-26-11, did not include the specific information to be disclosed or the purpose of the disclosure.
Client record #2 was admitted on 6-2-11. A consent to release information form for a dental referral, signed on 6-2-11, did not include the specific information to be disclosed or the purpose of the disclosure.
Client record #3 was admitted on 6-10-11. A consent to release information form for a dental referral, signed on 6-10-11, did not include the specific information to be disclosed or the purpose of the disclosure.
Client record #5 was admitted on 1-6-11 and was discharged on 3-24-11. Documentation in the client record included a fax form on 5-26-11 at 2:04 PM which disclosed information to another provider. A consent to release information form was not signed for the facility to disclose information to the provider.
Client record #6 was admitted on 2-8-11, and was discharged on 4-28-11. A consent to release information form for a funding source, signed on 4-27-11, included specific information that allowed for the disclosure of information that exceeded the parameters of 4 Pa. Code subsection 255.5 (b). Documentation in the client record included a fax form on 4-29-11 at 11:00 AM which disclosed information to another agency. A consent to release information form was not signed for the facility to disclose information to the agency.
This was discussed with and confirmed by the clinical supervisor on July 27, 2011.
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Plan of Correction
On September 28, 2011, the Gaiser Center Clinical Director, Dr. Jeff Geibel will hold a BDAP approved 6 hour in-house Confidentiality training for all Clinical and Administrative Staff. The training will include but not be limited to obtaining a proper informed consent, specific information permitted to be disclosed, filling out the consent properly, and the purpose of disclosures. |
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 client records, the facility failed to document dates the physical examinations were completed in three of five client records.
The findings include:
Seven records were reviewed on July 27, 2011. The facility policy states the physical examination will be completed within seven days of admission if the client has not been referred from a medical facility or had a physical examination with 180 days. Of the seven records, two of the physical examinations were transferred from another facility. Five of the seven records were required to have a physical examination done by the facility. Three of the five physical examinations did not include the date of the physical examination. Due to the physician not dating the physical examination, it could not be determined if the physical examination was completed with the seven day time frame. Client records # 2, 3, and 7 did not include dates on the physical examinations.
In client record #2, the individual was admitted on 6-2-11. The physical examination was to be completed by 6-9-11. The physical examination did not include a date.
In client record #3, the individual was admitted on 6-10-11. The physical examination was to be completed by 6-17-11. The physical examination did not include a date.
In client record #7, the individual was admitted on 6-30-11. The physical examination was to be completed by 7-7-11. The physical examination did not include a date.
This was discussed with and confirmed by the clinical supervisor on July 27, 2011.
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Plan of Correction
Immediately following the 7/25-7/29/11 State Licdnsing visit, Mary Beth Puryear, the Gaiser Center Nurse, was instructed by the Executive Director, Linda Franiewski, to have the physical examinations dated at the time they are performed. Effective immediately, Mary Beth Puryear, the Gaiser Center Nurse assures that the Gaiser Center Medical Director, Dr. Dennis Demby is performing physicals within 7 days of client intake and that the physicals are dated accurately. |