INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 29, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Casa De Consejeria Drug and Alcohol Counseling Program, Inc., 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection conducted at approximately 3:00pm on 5/29/18, the facility failed to ensure privacy of counseling sessions as the Licensing Specialist overheard an individual counseling session while standing in the hallway outside of Room E4.These findings were reviewed with facility staff during the licensing process
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Plan of Correction
The project director has already purchased and installed white noise boxes on every floor in the organization in order to address the issue of over hearing confidential information while counselors are performing individual sessions. The project director has also assigned the clinical supervisor to ensure that they are on and functioning daily and our maintenance person will also check and test them monthly for preventative maintenance. In the case that any white noise box is reported as malfunctioning the project director will replace it immediately. One additional box was purchased and stored as a back up. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on the physical plant inspection conducted at approximately 3:00 pm on 5/29/18, it was discovered that the facility failed to secure patient records in locked storage containers as the file room door on the second floor was unlocked, wide open, and unattended.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director will train filing clerk on confidentiality to ensure that when the file room is unattended to please lock the door at all times with no exceptions. In order to prevent this from occurring again, the project director will make arrangements to replace the door to self close once anyone leaves or enters the filing room and install a lock that utilizes a programmable code to enter. Individual codes will be programmed for each pertinent staff member to use when they need to access the file room. The programmable lock will also be equipped with a manual key in case the lock malfunctions. The key will be kept in a secured key box for emergency purposes only. Only the project and facility directors have access to the centralized key box where all important organizational keys are kept for emergencies. Our maintenance person will check the door during his weekly facility reviews to ensure proper function and provide preventable maintenance. |
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.
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Observations
Based on the review of 7 client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 4 client records. Client # 1 was admitted on 8/15/16 and was still active at the time of the inspection. There were release of information forms to the funding source, a probation officer and a urinalysis lab, all signed/dated on 8/15/16 and expired on 8/15/17. There was documentation that communication was made between the facility and all the agencies between the expiration date and the date of the inspection without an updated, client-signed consent to release information form in place prior to disclosure.Client # 3 was admitted on 1/17/17 and was still active at the time of the inspection. There were release of information forms to the funding source, a probation officer and a urinalysis lab, all signed/dated on 1/17/17 and expired on 1/17/18. There was documentation that communication was made between the facility and all the agencies between the expiration date and the date of the inspection without an updated, client-signed consent to release information form in place prior to disclosure.Client # 5 was admitted on 12/1/16 and was discharged 3/22/18. There were release of information forms to the funding source, a probation officer and a urinalysis lab, all signed/dated on 12/1/16 and expired on 12/1/17. There was documentation that communication was made between the facility and all the agencies between the expiration date and the date of the inspection without an updated, client-signed consent to release information form in place prior to disclosure.Client # 6 was admitted on 12/29/19 and was discharged 4/19/18. There were release of information forms to the funding source and a urinalysis lab, both signed/dated on 12/29/16 and expired on 12/29/17. There was documentation that communication was made between the facility and all the agencies between the expiration date and the date of the inspection without an updated, client-signed consent to release information form in place prior to disclosure.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The quality assurance specialist has already amended the time frame on releases to state the the release will be valid one year from the date or admission or when the participant has completed treatment. To prevent this from occurring, the clinical supervisor will hold an in service training to discuss changes, essential information and forms which will facilitate compliance to general guidelines of client confidentiality framed by 4 Pa Code 255.5 regulations and 42 CFR Part 2. The nature of the release and the circumstances by which the information may be released, the specific content and limited nature of the information to be released, to whom, the purpose of the disclosure, the method of releasing the information as well as the timeframes for the release, signature of client and witness, date of signatures and whether client received a copy will be discussed in addition to other privacy practices outlined in CASA's confidentiality policy and procedures. This will be completed by 7/31/18.
Clinical staff shall continue to attend recommended Department of Health training and provide documentation in areas such as confidentiality and client recordkeeping. This will be monitored by HR on an annual basis.
The quality assurance specialist will also conduct quarterly audits to specifically check the accuracy of releases and the clinical supervisor will also ensure to address confidentiality and the changes to the forms during individual supervisions and as part of client case consultations. This will be implemented immediately.
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