This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically methadone, in the treatment of narcotic addiction. This inspection was conducted on December 19, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Aldie Foundation, Inc. was found not to be in compliance with the applicable chapters of 4 PA Code and 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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Observations
Based on a review of patient records, the facility failed to ensure the confidentiality of all patient records in accordance with 42 CFR 2.22 and 709. 28 relating to confidentiality.
The findings included:
Twenty one patient records were reviewed December 17-19, 2013. Thirteen records were reviewed specifically for compliance with confidentiality regulations.
Client # 1 was admitted August 6, 2013 and signed a blank consent.
Client # 10 transferred to another treatment program December 16, 2012. There was no consent for the information that was sent to the receiving facility.
Client record # 11 contained a consent to release allowing the treatment plan to be released to the funding source.
Client records # 13, 15, 18, 20 and 21 all contained consents to release information to the funding source allowing the release of treatment plans, discharge summaries and after care plans.
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Plan of Correction
We have scheduled a mandatory confidentiality training for all staff to review applicable confidentiality laws, including limitations of 255.5. This training will also include examples of how to properly complete a release form and instructions for having a release form signed only after it has been filled in completely. We have also revised our release of information form for insurance companies and funding sources, so they may only receive the 5 items outlined under 255.5. Additionally, completed release of information forms will be reviewed upon completion by the immediate supervisor to ensure accuracy and completion. All transfer packets will be reviewed by the Clinical Supervisor prior to sending to receiving facility to ensure that there is a valid release form included.
The staff training will be conducted by the Clinical Director. The Clinical Director will also be responsible for monitoring the review process by the supervisors. |