Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, 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 June 23 - 24, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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, Dreamlife Recovery LLC 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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Observations
Based on a review of client records, the facility exceeded the limitations imposed at 4 Pa. Code 255.5 when documenting the specific information to be disclosed to an employer on the consent to release information form in two of fourteen client records reviewed on June 23 - 24, 2021.
Client # 1 was admitted June 2, 2021 and discharged June 8, 2021. A consent to release information form dated June 3, 2021 documented the following information would be released to an employer exceeding 4 Pa. Code 255.5: family medical leave, short-term disability and employment information.
Client # 9 was admitted December 2, 2020 and discharged December 9, 2020. A consent to release information form dated December 3, 2020 documented the following information would be released to an employer exceeding 4 Pa. Code 255.5: progress in treatment, treatment plans, psychological assessment, psychiatric history and assessment, physical exam, medical history, biopsychosocial assessment, lab test results, employment information, family information, aftercare recommendations and discharge planning.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The QA Coordinator and Facility Director collaborated to correct the template for Release of Confidential Information (ROI) for Employers to remove the options for "information to be released" that are not in accordance with 4 PA Code 255.5 (6). The revised template now contains the sole option of "presence in treatment" for the ROI for Employer.
The Clinical Director provided training(s) to all pertinent staff on the revised ROI template.
Additionally, the Quality Assurance Committee has added "ROI Compliance" as a standing agenda item where a random sampling of 30% of active clients charts will be reviewed to ensure that all ROI's are being completed in accordance with the new policy.
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client that included the dated signature of the witness in thirteen of thirteen client records reviewed on June 23 - 24, 2021.
Client # 1 was admitted June 2, 2021 and discharged June 8, 2021. Consents for insurance, employer, treatment provider, pharmacy and hospital were documented during the intake process and did not include the dated signature of the witness.
Client # 2 was admitted June 8, 2021. A consent for a treatment provider dated June 18, 2021 did not include the dated signature of the witness.
Client # 3 was admitted May 25, 2021 and discharged June 2, 2021. Consents for insurance, treatment provider, pharmacy and physician were documented during the intake process and did not include the dated signature of the witness.
Client # 4 was admitted June 2, 2021. The following consents did not have a dated witness signature: a consent for a treatment provider dated June 23, 2021 and a consent for a pharmacy dated June 22, 2021.
Client # 5 was admitted May 14, 2021 and discharged May 19, 2021. Consents for insurance, government, treatment provider and pharmacy were documented during the intake process and did not include the dated signature of the witness.
Client # 6 was admitted May 19, 2021. The following consents did not have a dated witness signature: a consent for a treatment provider dated June 3, 2021, consents for a government agency dated May 26 and May 28, 2021, a consent for probation dated May 25, 2021 and a consent for a relative dated June 22, 2021.
Client # 7 was admitted January 29, 2021 and discharged February 5, 2021. Consents for insurance, treatment provider, hospital and pharmacy were documented during the intake process and did not include the dated signature of the witness.
Client # 8 was admitted February 5, 2021 and discharged March 4, 2021. The following consents did not have a dated witness signature: consents for a treatment provider and pharmacy dated February 26, 2021 and a consent for a hospital dated February 22, 2021.
Client # 9 was admitted December 2, 2020 and discharged December 9, 2020. Consents for an employer, treatment provider, hospital, physician, parent and pharmacy were documented during the intake process and did not include the dated signature of the witness.
Client # 10 was admitted December 9, 2020 and discharged January 8, 2021. The following consents did not have a dated witness signature: a consent for a treatment provider dated January 7, 2021 and a consent for a pharmacy dated January 4, 2021.
Client # 11 was admitted August 26, 2020 and discharged August 31, 2020. Consents for a treatment provider, hospital, physician, insurance, spouse and pharmacy were documented during the intake process and did not include the dated signature of the witness.
Client # 13 was admitted November 17, 2020 and discharged November 25, 2020. Consents for a treatment provider, hospital, physician, spouse and probation were documented during the intake process and did not include the dated signature of the witness.
Client # 14 was admitted November 25, 2020 and discharged December 21, 2020. The following consents did not have a dated witness signature: consents for a treatment provider dated November 30 and December 16, 2020 and a consent for a pharmacy dated December 18, 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The QA Coordinator and Facility Director collaborated to correct the template for Release of Confidential Information (ROI) to include a required staff signature and date of signature.
The Clinical Director provided training(s) to all pertinent staff on the revised ROI template.
Additionally, the Quality Assurance Committee has added "ROI Compliance" as a standing agenda item where a random sampling of 30% of active clients charts will be reviewed to ensure that all ROI's are being completed in accordance with the new policy. |