INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 12 - 13, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Cornell Abraxas I 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 the client records, the facility failed to provide the name of the person, agency, or organization to whom the disclosure is made on a release of information for a funding source.
Client record #1 was admitted to treatment on September 11, 2020 and discharged on December 8, 2020. A release of information signed on 9-12-2020 did not indicate the agency.
Client record #3 was admitted to treatment on September 21, 2020 and discharged on December 14, 2020. A release of information signed on 9-21-2020 did not indicate the agency.
Client record #7 was admitted to treatment on March 8, 2021. A release of information signed on March 8, 2021 did not indicate the agency.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On May 4, 2021, the clinical director met with the treatment supervisors and reviewed the required components of a valid consent to release information form. The clinical director emphasized that each consent to release information form in the client record must include the name of the person, agency or organization to whom the disclosure is made.
Effective May 5, 2021, the treatment supervisor completing the intake process with each client is responsible to verify that each consent to release information form contains the name of the person, agency or organization to whom disclosure is made.
Beginning June 1, 2021, the clinical director will complete monthly client chart audits of the previous month's intakes to verify the consent to release information forms are properly completed. The quality & compliance specialist will monitor the process for 90 days or until compliance is achieved and sustained.
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709.34 (c) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(5) Outbreak of a contagious disease requiring CDC notification.
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Observations
Based on a review of the client records, the facility failed to notify the Department of an outbreak of a contagious disease requiring CDC notification.
Client record # 3 included a report dated 11-27-2020 documenting a COVID positive test.
Client record #4 each included a report dated 12-17-2020 documenting a COVID positive test.
The Department was not notified of these incidents.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Following the licensing inspection, the quality & compliance specialist clarified with the program's leadership team that positive COVID-19 test results must be reported to the Department, in accordance with the Department's unusual incident reporting requirements. Reports to the Department include outbreaks of any contagious disease reported to the Pennsylvania Department of Health that may subsequently be reported to the CDC.
Effective May 1, 2021, the quality & compliance specialist is responsible for submitting unusual incident reports in compliance with the Department's reporting requirements, to include an outbreak of any contagious disease requiring CDC notification. The facility director will monitor the process for 90 days or until compliance is achieved and sustained.
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