INITIAL COMMENTS
|
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 October 28, 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, 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:
|
Plan of Correction
|
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.
|
Observations
Based on one of seven client records reviewed, the facility failed to document an informed and voluntary consent from the client for the disclosure of information in client record # 2. Client # 2 was admitted on August 5, 2020 and was still active at the time of the inspection. There was no documentation of an informed and voluntary consent form to the funding source in the client record. After confirmation with the facility director and review of the client chart, it was established that disclosures were still occurring for the funding source.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
It will be the responsibility of the Counselor that is designated to the specific client to ensure that all intake forms are accounted for within the intake packet. During the intake process it will be the responsibility of the Counselor that is designated to the specific client to confirm that the consent to release confidential information is completed and placed in the correct clients chart. Counselor that is designated to the specific client will also sign on the chart setup form that the consent form has been completed and has been placed in the intake section of the chart.
The Program Director and the Facility Director will review each client chart on a weekly basis to ensure program and state compliancy and accuracy.
Person Responsible: Facility Director, Counselor
Compliance: Immediate 10/28/2020
|
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.
|
Observations
Based on five of eight client records reviewed, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record #'s 1, 3, 4, 5, and 6.Client # 1 was admitted on August 27, 2020 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information contained in the client record to children and youth services dated September 8, 2020 allowed for the release of treatment plans. Also, an informed and voluntary consent from the client for the disclosure of information contained in the client record to a funding source dated August 27, 2020 allowed for the release of intake information, psychosocial, treatment plan, and aftercare plan.Client # 3 was admitted on April 2, 2020 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information contained in the client record to children and youth services dated April 2, 2020 and October 2, 2020 allowed for the release of treatment plans. Client # 4 was admitted on May 20, 2020 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information contained in the client record to multiple funding agencies dated May 20, 2020 allowed for the release of treatment plans.Client # 5 was admitted on January 29, 2020 and was discharged on April 13, 2020. An informed and voluntary consent from the client for the disclosure of information contained in the client record to a funding source dated January 29, 2020 allowed for the release of treatment plans. Client # 6 was admitted on May 20, 2020 and was discharged on August 20, 2020. An informed and voluntary consent from the client for the disclosure of information contained in the client record to multiple funding agencies dated May 20, 2020 allowed for the release of treatment plans.The findings were reviewed with facility staff during the licensing inspection process.
|
Plan of Correction
The Facility Director will work along with the Counselor to assure that the appropriate responses are accurately marked off on the client consent form. During our weekly audits and case consult meetings the Facility Director, Counselor and Project Director will continually monitor the accuracy of all client consent release forms.
Person Responsible: Facility Director, Counselor
Compliance: Immediate 10/28/2020
|
709.54(c) LICENSURE Follow-up policy
709.54. Project management services.
(c) The project shall develop a written client follow-up policy.
|
Observations
Based on a review of the facility policy and procedure manual, the facility failed to provide a written client follow-up policy.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director completed a written policy regarding client Aftercare/Follow Up on 10/28/2020. This policy was reviewed at the staff meeting on 11/9/2020. It will be the responsible for the Lead Counselor/PAL to follow up and monitor the client's progress post discharge within the appropriate timeline. It will be the responsibility of the Lead Counselor Aide/PAL will follow-up with any client that has successfully completed treatment, for a time-frame of 7 days, 3 months and 6 months. It will be the responsibility of the Lead Counselor Aide/PAL to follow up with clients that AMA are medically discharged, or who are administratively discharged by our facility for a time-frame of 7 days. All follow up calls will be documented on our follow up log form and placed in the Follow up Log Book.
Person Responsible: Facility Director, Counselor, Lead Counselor Aide/PAL
Compliance: Immediate 10/28/2020
|